We are a 10-person radiology group seeking a well-trained diagnostic radiologist with a strong interest in neuroradiology. Actually, even a mediocre radiologist with no interest in radiology at all would be acceptable. We require a warm body who mumbles…”
So began a job listing at the American Roentgen Ray Society meeting in Seattle in May. The ad was one of dozens pinned to a job board, all of which went largely ignored. For good measure, Florida radiologist Martin Stern posted a second, more serious version of the neuroradiology listing. Two weeks after the meeting, neither had produced any inquiries. The satiric advertisement, written out of frustration by Stern’s secretary, was beginning to ring truer than he would have liked.
“We started looking for a neuroradiologist two years ago, and now we’re just looking for someone with an interest in it,” he said.
So, it seems, is the rest of the industry. Within the span of a few years, the radiology job market has split wide open. Understaffed practices are grooming their salary and partnership packages to lure anyone they can find. A national task force is weighing multiple options to ease the burden, certain that no one solution will be enough. With imaging volume expected to rise steadily over the next decade, individual practices and the specialty as a whole desperately need more warm bodies to maintain a precarious hold on turf, income, and quality of life.
Depending on where you sit, of course, the situation may look less like a crisis and more like a fabulous opportunity. Newly minted residents and fellows who second-guessed their choices in the gloomy mid-’90s find themselves courted assiduously. Young radiologists who were happy to find any position at all a few years ago can upgrade to better geography, better money, or a better working environment. Others with an entrepreneurial spirit are setting up shop to fill in the void when their overworked peers decide to outsource.
What has become increasingly apparent is that neither the steady trickle of new radiologists nor the seat swapping among veterans is adequate to meet the demand. The demand, in turn, shows no sign of letting up.
The Perfect Storm
Dr. Shireesha Reddy decided to pursue radiology because it was the field she loved most, but the decision wasn’t easy. Finishing medical school six years ago, she felt a not-so-subtle pressure to pursue primary care, predicted to be the boom field in an era of gate-keeping managed care. In radiology, meanwhile, she saw residents coming up empty on job hunts and taking fellowships to postpone the grim job market for one more year.
As she pushed through her residency at Northwestern University, however, the atmosphere changed. In 1995, Radiology and the American Journal of Roentgenology together posted a meager 900 ads for job openings. By 1998, the number had surged to some 2800, and to 3900 by 1999, according to data compiled by Dr. Howard Forman, a Yale University health economist who practices clinical radiology and teaches economics, business, and medicine.
By 1998, the American College of Radiology estimates, there were 500 more radiology positions nationwide than there were radiologists. Every scrap of evidence since then suggests the shortage has grown worse, according to Jonathan Sunshine, Ph.D., the ACR’s senior director of research.
“The change is astonishing,” he said. “In a 1995 ACR poll, 91% of fellowship directors said finding a job was more difficult than typical of previous years. By 1999, only 1% held the same view. Three-quarters said the market was better than in a typical year.”
What happened in between appears to be a unique confluence of demographics, economics, and politics. Imaging volume is growing at an estimated 4% per year, according to an ACR analysis of Medicare data. The figure translates to about a 6% annual increase in radiologist relative value units (RVUs), Sunshine said. Some say the number is higher, in double digits. Fueling the growth is a growing U.S. population that is also aging.
As baby boomers as a group hit their senior years, so do the radiologists within their ranks. No data are available to quantify how many veteran imagers leave the field each year, or why, but the threat, real or perceived, has gained the attention of every recruiter and every practice manager.
“We experienced significant retirements when the stock market was good,” said Dr. David Bern, president and CEO of Drs. Hill and Thomas, a radiology practice in northeast Ohio. “Everyone who had said earlier that they would work into their 60s ended up leaving. We were very short-staffed, missing five to seven out of 40 radiologists. We’ve had limited success in finding new staff, and we’re still short two or three.”
Finally, there is growth potential, or the lack thereof. Each year, 1000 to 1100 people enter the U.S. radiology field, from residency or fellowship, according to Sunshine, who says the number has remained fairly stable over the past decade. Researchers at consulting firm Merritt Hawkins call it differently. By their estimates, between 1994 and 1999, the number of residents dropped from 4236 to 3600. Either way, radiology has a problem: There are few ways to lure more people to the specialty with residency slots limited by Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) regulations.
As a field, radiology is being asked to work harder, work smarter, and look beyond traditional solutions to find new members. For individual practices and departments, the imperative is much the same.
“No one group can solve this problem,” said Dr. Douglas Maynard, cochair of an ACR task force on human resources. “It’s going to require a concerted effort. The solution won’t be one big thing, but lots of little things. We have to decide, as a specialty, that this is a major problem and fix it in lots of ways.”
Warm Body In Every Chair
With a month to go before their report to the ACR is due, neither Maynard nor cochair Dr. Stephen Amis can say with certainty what steps radiology should take to ease the labor crisis. A few recurring themes, however, are worth a look: change residency, draw in colleagues from other specialties, maybe even concede some turf.
With some administrative sleight of hand, Maynard suggested, it might be possible to condense the five years of residency into four, thereby producing a one-time-only doubling of entrants into the job market.
“In theory it would be possible to take the money from those extra years and use it to train more residents, but we don’t necessarily control the money,” he said. “And the clinical year may be taken somewhere other than where the radiology training is done, so there are no guarantees that the other facility would participate.”
Hospitals themselves haven’t perceived that radiology needs more residents and are unlikely to take it upon themselves to change the situation by mixing up the allocations to various specialties, said Yale’s Forman. Neither does the public sector, on the whole, unless a case can be built around a specific issue, such as a shortage of mammographers.
The best prospect, though by no means a sure thing, could be legislation. The Harkin-Snowe bill, S548, and its companion, HR 1354, are primarily aimed at increasing mammography reimbursement but would also provide each radiology residency program with enough extra funds for a one-time addition of three residents. Four years after the bill was passed, the number of qualified radiologists would surge by about 600 before dropping back to the usual 1000 or so.
“What we’re hearing from the experts is that although the bill is generous, many programs don’t have the teaching staff to accommodate the increase,” said Josh Cooper, ACR director of congressional relations. “We’re trying to negotiate to spread the money out over six years, adding one or two residents each year for three years, to still end up with 600 more residents.”
Fortunately, attracting residents hasn’t been one of the problem areas. A handful come from other specialties, and a number of leaders in radiology are starting to eye their clinical colleagues as potential converts. At the 2000 RSNA meeting, Johns Hopkins University radiology chair Dr. Elias Zerhouni advocated offering tailored training under the auspices of radiology to allow pediatricians, for example, to more accurately interpret their patients’ film.
Some, like Dr. Doug Lemley, come on their own. After practicing rheumatology for 10 years in North Carolina, he entered radiology residency at Ohio State University, enduring a long-distance commute for four years. In July, he came home to his family and a musculoskeletal imaging fellowship at Duke University.
The rationale for five extra years of medical training is increased marketability and the chance to meld skills from both specialties. After residency, he’ll consider both academic work and private practice—wherever he has the best chance to focus on musculoskeletal work.
Not every nonradiologist would be willing to endure the course that Lemley set for himself, and it might not be necessary. Zerhouni suggested giving noninvasive cardiologists or internists three years of imaging training followed by limited credentialing.
Technologists, although already in short supply, offer another source of labor for certain tasks, along with trained nurse practitioners and other physician extenders-an approach favored by Dr. James Thrall, radiologist-in-chief at Massachusetts General Hospital. Finally, there’s the option to retreat: Concede a few turf battles, regroup, and focus radiology’s resources on the studies that offer the best reimbursement and the greatest demand for an imager’s expertise.
“We either have to become much more efficient, or by default some of the work will be done by other people,” Maynard said. “We’re going to find that there is very fertile ground for turf battles. Of course, some of those other specialties are short of people too.”
People Who Need People
If there are 25,000 practicing radiologists in the U.S., one, surely, must want to work in Glasgow, MT. It’s a lovely town, with trophy hunting and fishing nearby, a hospital stocked with CT, MR, and nuclear equipment, and plenty of fresh air.
Dr. Martin Kurland loves it. After years in Los Angeles, he and his wife moved to Glasgow six years ago, bought 22 acres and some horses, and became acquainted with small-town America. As the sole radiologist at Frances Mahon Deaconess Hospital, Kurland reads 40 to 100 films per day, with 8 a.m. to 5 p.m. days and very little night call. The pay is good. His practice stretches over hospitals and medical centers in eight towns, however, and he’d like a partner to trade off making those rounds and working at Deaconess. He’s been looking for more than a year.
“You might not make quite as much as at some other places, but you don’t have to work as hard here, either,” he said. “We’re a very safe, low-crime community. Land is cheap, housing is cheap, we have no turf issues and no managed care. Everyone here pays their bills.”
Some prospective partners, he conceded, withdraw themselves from consideration because their spouses don’t want quite so much peace and quiet. Glasgow is 230 miles from Billings and Regina, Saskatchewan, and even with shuttle flights and train service, it’s not exactly cosmopolitan. It might not be much consolation to Kurland, but nearly every practice in the country-rural, urban, and everywhere in between-is having just as much trouble filling positions.
To lure potential partners, practices are sweetening their offers any way they can. Want 16, 20, even 26 weeks of vacation per year? There’s a spot for you. No night call? No buy-in? No worries. Top starting salaries listed at radworking.com have jumped in the past year from $350,000 to $600,000 or more, in some cases with instant partnership.
For many candidates, time to partnership is the strongest bargaining chip, said Dan Groth, CEO of Locum Medical Corp., which recruits and places physicians for both temporary and permanent positions. As job hunters realize they can afford to be choosy, atmosphere and a sense of equity among junior and senior radiologists figure prominently among the intangibles.
“The best offer we’ve pitched is partnership within six months in a six-physician group in Ohio, with $375,000 the first year, benefits, CME, and 10 weeks of vacation,” he said. “Even then, they share call every sixth day, while some groups outsource call entirely.”
If starting salaries are high, they’re still cheaper than paying for a locums—if you can find one. A short-term radiologist can easily command $1500 per day, plus a hefty service charge. Demand has skyrocketed, Groth said.
“I used to get called on May 7 for positions that needed to be filled in August,” he said. “Now I get called to fill positions for May 8.”
For practices that land full-time hires, making partner, once the start of a long marriage between radiologist and group, doesn’t seem to hold its traditional grip anymore. In radiology, as in life, it seems the divorce rate is on the rise, as partners cast a wandering eye for a better climate.
The retirement epidemic at Drs. Hill and Thomas in Cleveland, for example, strained the remaining partners so severely that the practice closed some of its outpatient facilities and put hospitals on notice that it would not be able to renew its contracts. With reading room seats unfilled, the practice had to rely on locums to allow its members vacation time. Fed up, some members looked elsewhere.
“We never used to have a revolving door,” said CEO David Bern. “People came here and stayed. But now with the job opportunities, rather than put up with discomfort they leave at the drop of a hat, even after making partner.”
The practice took a hard look at itself and tried to find ways to relieve the stress and also become more appealing to prospective hires. The time to partner dropped from five years to three. Night call is centralized, averaging less than one night a month. When vacation times dropped from a standard eight weeks to five last year, Bern said his colleagues realized they needed to broaden their recruiting efforts or risk burnout.
“We have always focused on Ohio for recruiting because we think people will stay where they have ties and family, but now we’re taking a national approach,” he said. “We’re not even looking for subspecialists any more. We’ll take anyone qualified and tailor the job to fit.”
That’s just to fill vacancies created by departing colleagues. There’s also the issue of growth.
“We’re more fluid than a smaller group, but a contract with a new hospital or a new outpatient center would hit us hard,” said Dr. Mike Sherman, chair of Advanced Radiology in Baltimore. “We are growing. For a five-person group to add a new person, they need to grow 20%. If you have 80 people, it’s only 2%.”
More practices will also reshape jobs around the needs of their older partners, those who are planning to retire but might consider part-time work for a few more years instead. Forty percent of physicians are older than 50, according to research firm Merritt Hawkins.
Advanced Radiology allows partners to work three-quarter or half-time. Pacific Imaging Consultants in California lured two part-time physicians who had moved to the Bay Area for semi-retirement.
Beneath the day-to-day scramble to fill reading room chairs, broader forces are at work. The old guard may take its live-to-work ethic with it, speculates Merritt Hawkins’ Mark Smith, leaving in charge a younger generation of physicians who care passionately about their specialty but still want to enjoy the lifestyle their profession, in theory, affords them.
The good thing about this philosophical sea change, it seems, is that every practice manager can make a case that it works to his or her advantage. Large, metropolitan practices, such as Advanced Radiology, tout an urban lifestyle and the chance to interact with subspecialty peers. Private practices note that their partners’ salaries may be double or better what an academic radiologist can hope to earn. Academic department chairs, meanwhile, point to the success they’ve had in attracting radiologists who are advanced in their careers and looking to give back to the specialty or pursue research interests that they could not afford to maintain when their families were young. Rural practices like Kurland’s emphasize life’s simple pleasures, like an 8-to-5 work day.
Ultimately, it comes to people: matching the professional and personal interests of an individual with the offerings, both medical and environmental, of a practice.
After an ultrasound fellowship at the University of California, San Francisco, Shireesha Reddy was torn between the satisfaction she found in academic work and the financial advantages of private practice. Ultimately, she chose to practice with Kaiser Permanente, where she would have a chance to teach residents and spend some time in her subspecialty area.
“When I started in radiology, I wasn’t sure I’d find a job,” she said. “Now, though, we have so many options. It’s a nice dilemma to have.”
