SPECIAL EDITION
Perspective

By James H. Thrall, M.D.

Technological advances across the spectrum of imaging methods and the advent of the digital age require changes in the training of radiology residents and fellows. Educational content must be continuously redefined and new digitally adapted approaches developed. In parallel, the leadership and management aspects of radiology are also becoming more complex each year.

From a 20-year perspective as chair of two radiology departments-at Henry Ford Hospital and at Massachusetts General Hospital-I believe the challenges facing radiology's leadership today have changed dramatically. The compelling question is how best to train future leaders.

Each of the categories of management and leadership issues listed in the table fuels increased complexity. In simpler times, a department chair would typically assemble a list capital equipment through informal interaction within the department to determine perceived needs. The list of requested equipment, along with projected purchase costs and a brief narrative, was forwarded for institutional consideration.

Today we monitor service metrics for the hospital administration: in- and outpatient waiting times, percentage of inpatient requests accomplished within 24 hours, and time to next available appointment. We use these to develop formal operational impact statements for each major piece of equipment. Likewise, the department is expected to produce formal financial plans including calculation of discounted cash flows, time to break even, and net present values for incremental equipment.

It could be argued that these efforts in support of the capital plan have always been appropriate, but people were not trained historically to think in terms of quantitative service metrics and formal business planning terminology. The total dollars involved have skyrocketed along with the rigor of the capital process. Nothing in the traditional educational background of practicing radiologists prepares them for this transformed financial environment.

Other examples abound involving quality assurance, patient safety, human resources, and compliance. Twenty years ago, compliance meant exhorting radiology staff to sign their reports in a timely fashion. Today each report in an academic department requires a specific attestation that the material was reviewed by a staff member. Institutions undertake formal periodic audits of departmental performance. The federal government has levied large fines on a number of academic medical centers, including their radiology departments, for failing to comply. Quality assurance now encompasses statistical sampling of individual radiologists' reports to determine their accuracy.

Numerous laws and regulations have been implemented in the last several decades to protect workers, including physicians, from unfair labor practices. Other initiatives, such as the Family and Medical Leave Act, have been adopted to improve the quality of life for workers in the U.S. These efforts are all well motivated, but they create enormous additional regulatory complexity that managers and leaders must understand. The threshold for filing complaints and lawsuits is arguably lower today than in the past, putting an additional burden on managers and leaders.

TAKING CHARGE

Radiology societies have responded with a number of initiatives aimed at training new leaders. The Association of University Radiologists invites promising younger academic radiologists to participate in a leadership training course held in conjunction with the AUR annual meeting. The RSNA convened a three-day leadership training conference earlier this year attended by more than 100 people from both the academic and private practice communities. While these undertakings are valuable, the interest they stimulate in the attendees may be more important than a less-thanthorough examination of the issues in the limited time available.

A number of business schools have begun offering combined M.D./M.B.A. programs. Radiologists would be well served to participate in these programs as faculty and to become alert to the potential of recruiting graduates into radiology training programs. The full impact of such programs will not be felt for 15 years or more at the chairmanship level, however.

Another approach to bringing formal business training to radiology would be to create scholarship opportunities for promising faculty to acquire business degrees. The RSNA, the American Roentgen Ray Society, and the AUR all offer major fellowships aimed at research and research training. Similar fellowships could be established for management training. The track record for major support for research training has been spectacularly successful, but the scholarship approach takes a long time before producing enough people who can influence the specialty.

Perhaps the approach that would provide the widest opportunity for training in leadership and management is action at the departmental level. Each academic department and larger private practice group could facilitate the training of younger and midcareer staff demonstrating interest and capability in administrative activities. Tuition reimbursement for executive M.B.A. programs, support for attendance at society-sponsored leadership training events, direct mentorship, and support for short courses such as the Harvard School of Public Health "Chief's Course" would provide a larger pool of potential future leaders than any of the formal initiatives yet undertaken. Each radiology department chair or private practice group leader should accept the responsibility for identifying talented junior colleagues and facilitating their access to management training.

A number of years ago, we undertook a pilot program in leadership and management development at MGH. We invited seven junior faculty to participate in a 15-month program. The director of the department's quality management group served as the program facilitator. The seven staff met for one entire day each month, and each participant was expected to prepare through assigned readings and selected writing assignments. The final output of the group was the preparation of a strategic plan for selected areas of the department. In addition to the monthly sessions, we contracted with Suffolk University for an 18-hour course on healthcare financing. This course proved to be quite popular and was subsequently offered to other faculty and administrators in the department.

Of the seven people completing the Leadership Training Seminar Series, one serves as a department chair, three serve as subspecialty division heads at MGH, one holds a similar title at another academic institution, and one has become a corporate vice president of a commercial company. One faculty member has received a master's degree in business from the Sloan School at the Massachusetts Institute of Technology.

This undertaking required extraordinary effort on the part of the seven faculty and represented a major financial investment on the part of the department. Nonetheless, the feedback from the participants was extremely positive, and they have moved into management positions where they are using the training they received. If such programs were widely available, the impact could be felt across the specialty in a relatively short period of time.

Another departmentally based approach at MGH and other institutions is to offer fellowships in administration and management. Our administrative fellow spends 50% time on administrative and business issues working with the senior medical and administrative leaders of the department and has a 50% commitment to training in a subspecialty area.

It is easy to see that the development of new technology and new knowledge will continue to require adjustments in how we educate physicians to become radiologists and how we train support staff. The changes affecting managers and leaders are equally important, and we need to mobilize the same creativity in thinking about how to train future leaders that we are mobilizing to restructure and fine-tune the training of radiologists and technologists.

Dr. Thrall is radiologist-in-chief at Massachusetts General Hospital in Boston.

MANAGEMENT AND LEADERSHIP ISSUES

• General management
• Finance
• Regulatory/compliance
• Quality assurance
• Asset management
• Human resources
• Information technology
• Education
• Research
• Entrepreneurism
• Philosophy and values
• Vision