Where are all the radiologists?

Sep 25, 2003

By Daniel R. Corbett

Just a few years ago, picking radiology as a specialty was a big no-no among U.S. medical school graduates. It's easy to see why. Dismal starting pay, four years plus to partner, and huge buy-ins were just a few of the things graduating residents could expect.

Radiology was the one specialty where you had to pay your dues to get to parity. Unfortunately, in many cases, real parity was never available. With few options open to them, many radiologists stayed where they were and endured.

But there are certainly options now. Radiologists who were unhappy with their situations have long since left those undemocratic groups. A reshuffling of sorts took place between 1999 and 2002. Radiology groups are now doing it the hard way, competing for well-informed, hard- negotiating, experienced candidates, and are paying top dollar for newly minted residents and fellows.

What happened?

Some say it was Hillary Clinton’s utopian healthcare scheme of the early 1990s. Some say it was the advent of MRI and subsequent procedure-volume increases. Some blame the demise of many of the radiology residency programs. Most radiologists blame the government, Medicare reimbursement, and managed care. It really is all of the above and more.

Let’s go back to the early 1990s and Clinton’s campaign to "Canadianize" the U.S. healthcare system. Even though her plan failed, the managed care era was well underway, which changed the physician balance for a decade. With the emphasis on gatekeepers and primary care, the demand for specialists dried up.

Medical students flocked to family practice, internal medicine, and pediatric residencies. Radiology as well as many other specialty slots went unfilled. This continued unabated for the better part of eight years.

In their drive to put a primary care physician on every corner, hospitals spent millions of dollars buying physician practices at prices much higher than they were worth. Most kept the physicians on as employees, but productivity dropped and revenues could not cover expenses.

Many of these practices were closed or sold back to the physicians at bargain prices, and hospitals took a financial beating. What this political blunder did was change the physician pipeline. Graduates who might have considered radiology changed their match specialties to reflect the paranoia of the time. A large number of radiology slots went unfilled, and many programs closed down.

Don’t need to do this anymore

Many people are unaware that more than 50% of the practicing radiologists in the U.S. are over the age of 50. Of the 31,000 radiologists listed in the American Medical Association's national database, only 24,000 are in clinical practice, with the balance in academics or research. Of the 24,000 in practice, some 12,000 are over the age of 50.

In 1999 the average volume of exams read per radiologist nationally was 12,000. But now, most radiology groups are seeing anywhere from 5% to upwards of 25% annual increases in volume, much of it in MRI. The corresponding increase in volume per radiologist has jumped to more than 17,000 annual exams per physician in 2003. In many groups, physicians are reading more than 20,000 exams annually.

What does this mean? Many older physicians who want to start slowing down, for example by taking less call or working part-time, find they cannot do so. If a group is short a full-time equivalent (FTE) position because two senior radiologists are working part-time, it will need 100% productivity 100% of the time from the rest of the staff. There is just no maneuvering room when you’re that short.

What alternatives do these seasoned, overworked professionals have? If they invested well, they’ll just retire. Let’s face it; the 1990s were good for investment portfolios. Many radiologists are semi-retiring and joining the ranks of locum tenens physicians.

The daily pay for well-qualified locum tenens radiologists has doubled in the last three years. In many areas with poor reimbursement, some groups are paying more for locum tenens coverage than the partners are earning on a cost-per-read basis. This is not the most cost-effective alternative, but it is sometimes absolutely necessary.

Fortunately, the number of high-quality physicians entering this form of practice is improving the locum tenens industry as a whole. The end result is that more productive physicians are leaving full-time traditional practice.

Other factors

Reimbursement and geography play important roles in physician supply and demand across all specialties, but they are even more important in radiology. Partnership pay in radiology groups in metropolitan areas can be half as much as in similar groups in smaller communities with no managed care.

The upper Northeast, Florida, and the West Coast are areas with higher managed care concentration; they also offer less pay to radiologists. However, the fact that a larger percentage of physicians wish to practice in metropolitan areas has kept these city and suburban groups supplied with physicians despite the lower pay.

It has always been a tradeoff: lifestyle over money. With the volume per physician increasing across the board, many physicians are seeking these higher-paying practices. The rationale is: if you’re going to work hard you might as well get paid for it. For the first time, large big-city practices and academic centers are having a very hard time finding enough radiologists.

What will happen?

Unfortunately there is no quick fix. In fact, the problem will get much worse before it gets better. As the pressures increase, more physicians will retire early. The increasing number of physicians doing locum tenens will help, but not enough.

Small rural communities and multispecialty groups will be hurt the worst. Consider a small hospital with a solo practitioner, or maybe two full-time radiologists. Losing one or both with no help on the horizon could force the closure of the department.

Multispecialty groups with radiology departments are being forced to renegotiate contracts with their radiologists in order to stay competitive with single-specialty groups. Many can’t compete and are losing physicians. An alternative is to approach the group at their local hospitals, but many are finding out that these groups are also short-staffed and can’t take on the additional volume. With a shortage of physicians approaching 20% there has to be another alternative.

PACS

PACS will be the immediate champion of the radiologist shortage. A radiologist working on a PACS network is much more efficient, enabling the volume per physician to increase by as much as 30%. The majority of all residents and fellows are being trained on PACS.

After the large initial investment, radiology departments utilizing PACS will see major cost savings over time, both in film and in support staff. Digital archiving takes little space and even less manpower. Rural radiologists can join together and build digital networks of PACS, sharing volume and call.

Remote interpretation

PACS can also offer both short- and long-term relief for any radiology group, large or small, metropolitan or rural. There are many new groups forming that are offering remote PACS interpretation services.

Do not confuse these groups with teleradiology practices. Groups performing primary remote diagnostic PACS interpretation utilize special software and telecommunication links. These groups perform interpretations of examinations in accordance with the standards for telemedicine as defined by the American College of Radiology. They are reading exams via T1 or fractional T1 lines in near real-time.

Any physician licensed in the state where the exam was performed can legally read the exam. These groups take the excess reads from their client groups at prenegotiated prices. In the short term, this service offers a financially viable alternative to finding spotty locum tenens coverage. It also offers a viable long-term solution to those groups unable to attract a permanent radiologist.

When will it get better?

The word is already out about the radiologist shortage, and medical students are flocking to radiology residencies. With every possible slot filled, expect to see an increase in new radiologists entering the market in four to six years. There is no telling how many radiologists will retire within the next decade, but expect the number to accelerate as the shortage gets worse. Based on the projected numbers, this shortage may last at least a decade and maybe longer.

What can a group do to attract a radiologist?

Be competitive. The more you need something, the more you’re willing to pay for it. Starting salaries have nearly doubled over the last two years and partnership tracks have come down to two years or less. Accounts receivable buy-in is disappearing just as quickly. It’s a matter of how bad your group needs someone.

Make decisions based on facts. Candidates who are partners in their current group will weigh the backward step they must take to get to partnership in their new group. If that step is too big, they won’t sign. Pay special attention to those candidates who bring something special to your group. Those with ties to the community are invaluable, as family ties are very powerful and long lasting.

Personality fit and philosophy are extremely important in equal-share partnerships. Consider each candidate on his or her own merits and not by assumptions made by unsubstantiated perceptions of someone in your group.

When you interview a candidate that meets your needs, make your best offer, quickly. Always assume there is a group more desperate than yours that will make a better offer. Do not rely on what has always worked before. It won’t. Seek the advice of a qualified recruiter or colleagues who have recently hired someone, as things change almost overnight.

Most important, gauge the happiness of each member of your group. The best way to avoid having to recruit a new physician is not to lose one.

By Daniel R. Corbett
AuntMinnie.com contributing writer
September 26, 2003

Corbett is recruiting specialist for Davis-Smith, a 56-year-old family-owned and operated physician staffing and consulting company specializing in radiology that is based in Southfield, MI. Corbett was a radiologic technologist as well as a radiation therapy technologist before joining Davis-Smith in 1987. He recruits radiologists for group practices nationwide in addition to consulting on staffing, compensation, and other group-practice issues for radiology groups. He can be reached at 800-541-4672 or at [email protected].

AMGA finds solid radiologist compensation gains, August 12, 2003

Latest ACR data shows solo radiologists, small practice groups remain viable, July 29, 2003

Salary offers to radiologists jump 11%, July 14, 2003

Hunting for recruits, pediatric radiologists take aim at "misconceptions," June 26, 2003