Jennifer Anderson

In pediatric radiology, credentials are important but not always enough. 

Rapport is critical, explained Marta Hernanz-Schulman, MD, radiology vice-chair for pediatrics and medical director of diagnostic imaging at Vanderbilt Children’s Hospital in Tennessee.

Building rapport with pediatricians typically comes through multiple interactions and consistently accurate diagnoses. Radiologists also need to demonstrate a clear interest in the patient and commitment to reducing radiation dose.

Still, there’s that first day on the job, and how do you know the interpretation is correct?  Pediatricians and other doctors may double-check the work of a new radiologist-a strategy Hernanz-Schulman recalled experiencing years ago when she had just completed her training.

A baby was vomiting, and through ultrasound she accurately diagnosed a narrowing of the passage between the stomach and small intestine. It wasn’t until later that Hernanz-Schulman learned that a surgeon had already diagnosed the condition through palpation.

“It happens everywhere,” Hernanz-Schulman said. “Pediatricians are comfortable with a person whom they already know and trust, and when a new person comes on, they may run over to the older person to check the results until they have confidence in the new person.”

So what do pediatricians look for in a radiologist, and what does it take to establish trust?

Adina Alazraki, MD, professor of pediatrics and radiology at Emory University School of Medicine in Atlanta, explained that her initial, five-year career as a pediatrician in urgent care before moving onto radiology gives her a dual perspective on the trust issue.[[{"type":"media","view_mode":"media_crop","fid":"32984","attributes":{"alt":"pediatric imaging","class":"media-image media-image-right","id":"media_crop_5043188604978","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3473","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 167px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Puwadol Jaturawutthichai/Shutterstock.com","typeof":"foaf:Image"}}]]

Pediatricians primarily want radiologists to answer their questions, she said. “Is there pneumonia, yes or no?  If there is a foreign body in the stomach, can they go home and it will pass, or do they need to go to the ER to have it removed?”

They also want radiologists who are willing to contribute to the overall care of the patient.  “Even if we don’t come up with the right answer, they want us to help them along the way to decide what to do next,” she said.  “This builds trust.”

Similarly, Alazraki said, the radiologist wants as much information as possible from the pediatrician. “The pediatrician might say the patient injured a hand while roller skating but won’t say where it hurts,” she said as an example. “Extra information about the exact location of the injuries can change your report.”


At Stanford Children’s Health in California, neonatologist Susan Hintz, MD, medical director of the Center for Fetal and Maternal Health, said trust can be established quickly, given the complexity of the cases and rapport that must ensue between the pediatrician, or neonatologist, and radiologist.

Hintz added that at institutions like Stanford, with its history of and commitment to pediatric and fetal imaging, the burden of assessing the credentials and expertise of the new radiologist largely are lifted from her.

“We know our pediatric and fetal radiologists want to have the best possible colleagues,” she said.  “Their own level of evaluations is high, and they will want to bring on someone who similarly has high expectations.”

Among evaluators at Stanford is Richard A. Barth, MD, radiologist-in-chief at Stanford’s Lucile Packard Children’s Hospital.  He explained that pediatric care, at Stanford and other pediatric-centered facilities, requires close collaboration with  pediatric health care providers given the particular vulnerability of the patients and the difficulty especially young children have in articulating their symptoms.

“Radiologists need to advise and partner and hold hands with their pediatric colleagues,” said Barth, who also is chair of the Society for Pediatric Radiology’s board of directors. 

Pediatricians want to know that the radiologist is highly aligned with best practices, Barth said.   He explained that through specialized training, including a year of fellowship training in an accredited pediatric radiology program, radiologists can earn certification in pediatric radiology through the American Board of Radiology. That certification demonstrates to referring physicians and the public that the radiologist has the knowledge and skills necessary to be worthy of the public’s and profession’s trust, according to information from the ABR.  Maintenance of certification is required and evaluated annually, and a computer-based exam on cognitive expertise is required every 10 years.

Educating the Generalists on Radiation Dose


Radiologists also can demonstrate a commitment to excellence both by offering alternatives to exams that require radiation and by affiliating themselves with organizations such as the Image Gently Alliance, which is dedicated to safe and effective imaging for children.

Barth cited several studies, including a 2014 article that appeared in 

, that reported differences in CT utilization rates for pediatric exams at pediatric-centered facilities versus those that are not pediatric-centered.

In the article, author Thomas L. Slovis, MD, professor of radiology at Wayne State University School of Medicine in Michigan, found that most pediatric imaging-as much as 85%-takes place at non-pediatric-centered hospitals. He further reported that these non-pediatric-centered hospitals are increasingly using CT scans on children, while the use of CT is decreasing at pediatric-centered facilities. Radiation dose on children in several metropolitan centers tends to be “poor,” he states in the article.

But as Barth explained, it would be unrealistic to suggest all children be imaged at pediatric-centered facilities. There are simply not enough pediatric radiologists to go around, and pediatricians are not likely to send families great distances for common conditions or injuries when a general radiology practice is down the road.

An important responsibility is to build awareness. “Part of our role as pediatric radiologists is to educate non-pediatric radiologists on how best to perform pediatric imaging,” he said.


Brian D. Coley, MD, radiologist in chief at Cincinnati Children’s Hospital Medical Center, concurred and added that in most cases it would not be necessary to drive long distances for a radiologist who specializes in pediatrics.

For the more complicated diseases, especially in younger children, possibly involving the growing muscular-skeletal system or conditions unique to children, pediatricians may recommend families seek out specialists in pediatric radiology, he said. 

The most effective pediatric radiologists are those who are engaged members of the patient care team, Coley said. While fielding phone calls may be frustrating when there are images to be read, he said, radiologists who specialize in children need to embrace the increased demand for personal interactions.

In short: if you can’t provide your impressions on what may be going on with the patient, your value is limited.

Pediatrician Janesta Noland, MD, of Burgess Pediatrics in Menlo Park, CA., could not agree more. She said she looks for radiologists who are available and engaged. 

“If they don’t call me back when I have questions, and if they don’t transmit results in a timely way, I can lose confidence quickly,” she said.


Alexander J. Towbin, MD, of Cincinnati Children’s, is among the radiologists interviewed who cited a 2012 study that ran in the 

 that looked at interpretation differences in images of children between general radiologists and those at tertiary care children’s hospitals.

For the study, the authors reviewed diagnostic imaging reports of pediatric patients referred to a children’s hospital between January 2009 and May 2010. Out of the total 773 exams included in the final report, major disagreements in interpretation were found in 168-nearly 22%.

In the paper, the study authors, who include Hernanz-Schulman at Vanderbilt, describe the rate of discrepancy as “substantial.” Hernanz-Schulman told 

 she was not surprised by the results-specialists in all fields tend to be better than generalists at finding abnormalities.

Radiologists trained in pediatric imaging also are generally able to make their diagnoses using radiation doses even lower than acceptable standards, such as those set recently by the National Electrical Manufacturers Association (NEMA).

Towbin suggested radiology practices with a small percentage of pediatric clients might want to have small groups of radiologists consult on the readings. Through group readings, radiologists can gain not only expertise in pediatrics over time but also the trust of the pediatrician.


In addition to having the credentials and skills necessary to succeed in pediatric radiology, personality also is essential, said Sarah Sarvis Milla, MD, acting associate professor of radiology at Children’s Healthcare of Atlanta. 

“We’re very hands on,” she said, explaining that pediatric radiologists often have to go into the room to search for the patient’s pain and help make the diagnosis.

“As pediatric radiologists, you need the personality that lends itself toward gaining trust with both the parent and the child,” she said.  “That ability to create an instant rapport is really helpful and yields trust.”

Articles

Pediatric radiologists need a different skillset and personality than other radiologists.

Building Trust in Pediatric Imaging

After finishing his radiology residency in 2004, Anthony Posteraro, MD, joined several major societies – ACR, RSNA, ARRS, and a few others.  Membership dues were steep, but as a resident, he got a much-appreciated discount. 

Now a diagnostic radiologist in private practice at Saint Francis Hospital and Medical Center in Hartford, CT, Posteraro said he believes society membership is more critical these days than ever due to the healthcare overhaul and medicine moving from a fragmented to more unified system.

He explained that radiologists increasingly are going to need societies for guidance and assurance that they will be integral and well-positioned members of the medical care team.

Many agree that the major societies provide valuable services.  But are their fees worth the benefits? Is there too much overlap?  Are societies keeping up with the pace of change?

Indeed, radiologists are not making as much 

 as they used to and are more cautious with expenses, noted Ronald Evens, past president of ACR and the American Roentgen Ray Society (ARRS). As costs increase, societies may have to look at alternatives to higher dues if they want to hold on to members, Evens said.[[{"type":"media","view_mode":"media_crop","fid":"29204","attributes":{"alt":"Doctor holding piggy bank","class":"media-image media-image-right","id":"media_crop_4388232850428","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3030","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 100px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Already they have lost Bruce Reiner, MD, director of radiology research at the VA Maryland Health Care System in Baltimore and a member of 

During his career, Reiner has been a member of all of the major societies, even once serving as a high-level committee chair for the Society for Imaging Informatics in Medicine (SIIM).

Career shifts prompted some discontinued memberships, he said. Swollen bureaucracies led to other discontinued memberships - notably his decision to leave the American College of Radiology, one of the profession’s staunchest policy advocates.

While Reiner acknowledged that political advocacy benefits everyone in the field, he said he is not convinced that the organization’s successes justify the $875-per-year dues for active, board-certified radiologists. That figure is up 3% from 2013, where it had been steady at $850 since at least 2012, according to Shawn Farley, a spokesman for ACR.

“If I believe an organization like the ACR has excessive bureaucracy, should I be burdened to support it?” Reiner said. “The radiology community has the right to individually choose what organizations they do and do not belong to. In the end, an organization which provides economic and professional value and service to its members will thrive.”

Evens, past president of both the ACR and ARRS, professor of radiology at Washington University School of Medicine in St. Louis, agreed that value depends on individual preference. 

ACR probably does not need to be doing as much education, he said; but that’s a leadership decision. “Economics ultimately will force societies to adhere to their true missions.”

Evens segregated societies roughly into two camps.

There are the large, national societies, such as the ACR, RSNA, SIIM, ARRS, etc. Most have specialized missions, and he said he believes they offer value to members. ACR is primarily policy, while the others focus primarily on education.

Then there are the dozens of specialty societies - twice as many as there needs to be, Evens said. Some of these societies have questionable value and serve primarily as fundraisers, he said. 

Evens suspects economics also will drive closures, mergers, and consolidations as radiologists increasingly use their money more wisely. “Societies ultimately will get down to the right level,” he said. “Many will just die on the vines.”

At least two societies already have merged - the Society of Gastrointestinal Radiology and the Society of Uroradiology are now the Society of Abdominal Radiology, said Gerald D. Dodd III, MD, professor and chair of radiology at the University of Colorado, and chair of the Intersociety Committee of the ACR, established in 1979 to promote communication among societies. Members include the leaders of all 50-plus radiological organizations in the United States, and meetings are held annually.

Another merger, between the ACR and ARRS, failed, Dodd said.  Merging two societies in itself is a daunting task, and with ACR and ARRS, there was the added difficulty of trying to align organizations with different focuses.  “Bringing the two cultures together didn’t happen-at least it didn’t happen quickly enough,” he said.

Dodd said the topic of consolidation comes up frequently at Intersociety Committee meetings.  With consolidation and greater collaboration between organizations, he said, there would be substantial economies of scale, fewer meetings, and coordination of content. Advocacy would likely be more effective with multiple organizations speaking with one voice.

He also noted that many of the societies are supported by radiologists in academia. Sustaining these societies likely will be an increasing challenge as academic departments are forced to make decisions with contracted funding.

“I think the vast majority of attendees [at a recent Intersociety Committee meeting] were in support of consolidation,” Dodd said. “But then you say, ‘OK, which ones are we going to consolidate?’”

“It’s good until you get to the details,” he said.

The ACR’s new chief executive officer, William T. Thorwarth, Jr., MD, a diagnostic radiologist formerly with Catawba Radiological Associates in Hickory, NC, said he has been a member of radiology societies, including ACR, throughout his 30 years of clinical practice.

“Just being a member, I appreciated what the college was doing on behalf of members with respect to reimbursement, medical coding, and how you accurately report the services you’re providing,” he said. “I trusted that the college was taking care of all this.”

Thowarth acknowledged that membership, hovering at about 35,000 and encompassing about 75% of the entire population of radiologists, is growing more slowly than in the past. 

To radiologists who choose not to join, Thorwarth said that any radiologist who can honestly conclude that they are not $20 per week better off because of what the ACR has done on their behalf should not be a member.

As healthcare reform takes place and practices experience decreases in revenue, organizations are going to have to work harder to demonstrate their value to members. Likewise, he said, in turbulent times it’s more critical than ever for radiologists to support societies.

“How we handle the challenges and opportunities we’re confronted with today will have a great impact on the practice of radiology in the future,” he said. “Members recognize that it’s very important to have us working on their behalf.”

Most societies, like the RSNA and the ARRS, which is the nation’s oldest, focus on education. For RSNA, the biggest benefit to members is the annual meeting in Chicago, each year attracting more than 50,000 attendees worldwide, said Ronald L. Arenson, MD, president-elect of the society and chairman of radiology and biomedical imaging at the University of California San Francisco.

The most highly educated radiologists in the world lead the education sessions, there is a large technology display at every meeting, along with scientific sessions and ample opportunity to make connections, and RSNA funds more research grants every year than any other society, he said.

Given the changing economics of radiology, and all of medicine, radiologists will gravitate to those societies that offer the best services for the best value.  Those societies best able and willing to adapt to emerging healthcare models and members’ needs will be the likely survivors.

“Like any business, we have to be in touch with the marketplace,” said Susan Brown Cappitelli, executive director of ARRS. 

With about 21,000 members, ARRS has experienced steady growth over the years, attracting new members primarily through its educational offerings, along with networking and mentoring opportunities,

ARRS regularly surveys members, and with healthcare in flux, radiologists are particularly concerned with being prepared, she said. Not only are the annual meetings packed, but educational content is offered both in hard copy and virtually, she said - “to ensure that the content we’ve developed has the broadest reach.”

Also in response to members, the Society for Breast Imaging is adding more scientific content to its meetings, said Debra L. Monticciolo, a society fellow and chief of breast imaging with Scott & White Healthcare in Texas.

Another push is to engage young radiologists, said Monticciolo, also a fellow with ACR. “We need to make [society membership] appealing for them, to remind them that we’re here, and we value their input,” she said.

Monticciolo noted that with the more than 50 radiology societies, the Society of Breast Imaging is the only one focusing on the breast. “We’re growing,” she said, “and we don’t overlap.”

A look into what drives radiologists’ decisions to join, or not join, radiology societies. 

Worth the Cost?  Weighing Radiology Society Membership

For four months after California’s radiation safety law took effect, radiologists with Pomona Valley Hospital Medical Center verbally dictated dose information from CT scans into each patient’s radiology report.

The manual dictation wasn’t difficult. “But whenever you have to do the same repetitive copy task over and over again, it’s not the best use of any radiologist’s time,” said Johnson B. Lightfoote, MD, medical director of Radiology at Pomona Valley. 

Pomona Valley has since contracted with a third-party vendor who provides software that automatically uploads the dose information directly into patient radiology reports in compliance with the California law, which took effect July 1, 2012.

The software is expensive enough that radiologists at smaller practices continue to dictate the numbers - a task Mark Alson, MD, with Sierra Imaging Associates, described as “extra time, but we’ve got it down at this point.”

He added: “If you spell out the numbers to the nth degree, it would be very cumbersome, but the law doesn’t necessarily require that; just that you give the numbers.”


Either through manual dictation or third-party software, both practices are in compliance with the law - an undertaking radiology practices in other states may soon confront.

Debbie Gilley, government relations specialist with the American Association of Physicists in Medicine, said three states - Arizona, Massachusetts, and Texas--already have regulations in place that are similar to the California law.

Results of a survey conducted in the fall of 2013 identified six states also developing regulations and four other states exploring the possibility of introducing regulations.

More are likely to follow suit, said Lisa Bruedigan, chair of the Conference of Radiation Control Program Directors’ Healing Arts Council.

“I don’t think it’s going to explode,” she said.  But with a new chapter due out this fall as part of the Conference’s suggested state regulations (SSRs), states will have to make only minor edits to the suggested rules rather than re-write regulations from scratch.

Medical Diagnostic and Interventional X-ray and Imaging Systems

 consists of portions of the California law and Texas rules, along with input from other resources, “massaged together for states,” Bruedigan said, describing the guidelines as “meaningful but generic enough for other states to adopt.”

Variations of the California law may even go international, she said, noting that the government of South Korea spent three days in Texas and California asking about CT rules, and the Atomic Energy Commission also has been bringing radiation dose reduction techniques to the forefront.


The California law came about after reports of several hundred people receiving excessive doses of radiation during brain perfusion scans with CT.  At about that time, in 2008, a two-year-old also received excessive amounts of radiation during a CT scan in a case that ultimately was settled in court.

Among other mandates, the law requires dose reporting, which may or may not protect patient safety, especially when the overdose results from operator error - as was the case of the two-year-old.

“Having people report numbers doesn’t take care of human error,” said Alson of Sierra Imaging. 

California Radiological Society Executive Director Bob Achermann likewise disputed the necessity of the law but acknowledged certain benefits.  “Having to record the dose may raise awareness, and initiatives like the ACR Dose Registry provide tools for radiologists to compare dose parameters with their colleagues,” he said.

At UC Davis Medical Center, J. Anthony Seibert, associate chair of informatics, agreed the law has been helpful not only in raising awareness but also in pinpointing trends. 

“We’ve been able to identify situations where we lowered the radiation dose to the head, realizing that it was pretty high on scanners that did not have dose-reduction technology,” Seibert said.  “It allowed us to justify to our purchasing group why we needed iterative reconstruction software on some of our CT scanners.”


The numbers that end up on the patient chart are not the dose the patient received but the amount of radiation the machine emits, explained Scott R. Foster, informatics manager for Radiology at UC Davis.

), a standard measure of radiation emitted from the machine.  It reports radiation doses calibrated for two acrylic “phantoms” -one measuring 16 centimeters in diameter for images of the head and the other 32 centimeters for the body.  Size-specific dose parameters, defined by the American Association of Physicists in Medicine, are estimated based on CTDI

Dose length product, or DLP, the product of the length of the irradiated scan volume and the average CTDI

Foster explained that the third-party dose calculator in use at UC Davis can capture the dose metrics in several ways.  Some of the CT scanners in use prepare a digital imaging and communications in medicine (DICOM) radiation dose structured report (RDSR), which reports the entire dose metric data for all series in a structured format.  This report is often not available or compatible with many informatics systems.

Most CT scanners create a DICOM Dose Protocol page with dose metric data encoded in a grayscale image as a separate series in the PACS.  While easily viewable, Foster said, optical character recognition (OCR) software must be used to convert the data to a usable alpha-numeric format for reporting.

“We need professionals and applications which help radiologists better understand and identify actionable data, and continue to improve dose,” Lightfoote said.

While dose information, including comparisons of the radiation dose from CT scans with natural background radiation, may have the added advantage of discouraging unnecessary exams, he said, on the flip side it also could also discourage patients and doctors from requesting examinations that are necessary.

“Fortunately that’s rare,” he said. “In fact, comparing CT radiation with natural background radiation may be reassuring for patients about to undergo a necessary examination.”

For older CT scanners that do not have dose metric data available, estimates of radiation dose output based upon technique factors (kV and mAs) and analysis of scan parameters can be used to estimate the dose metrics.

The flexibility of the dose calculator software at UC Davis enables extraction of dose metric data for current as well as legacy CT scanner examinations, Foster said.  Thus, improvements in dose utilization, acquisition protocols, and patient safety can be tracked and recorded.

Pomona Valley’s Lightfoote predicted that dose data direct transfer capability may become routinely embedded in applications and integral parts of CT, RIS, and PACS software.  The capability may even be accessible remotely on mobile devices like the iPad.  Direct data transfer also mitigates the error inherent in manual dictation, he said.


Lightfoote cited additional benefits of the law, including the “statistical intelligence” that may result from studying the large volume of data that accumulates. Exploiting this “big data” could support valuable research and development projects, ultimately improving population health and risk management, he said.

While few professionals other than a qualified medical physicist would be able to estimate, based on CTDI

 and DLP, the approximate radiation dose to a particular patient, also on the horizon are technologies that will put the data into context and perspective.

In addition to recording patient dose, other recommendations in the proposed SSRs by the Conference of Radiation Control Program Directors include:

Qualified medical physicists inspect the units within 30 days of installation, every year thereafter and after potentially hazardous maintenance or repairs

Facilities perform phantom testing periodically to ensure the units are running correctly

Facilities create a CT radiation protocol committee, which includes the lead CT technologist, radiologist, qualified medical physicist, along with other appropriate personnel.

Among other tasks, the radiation protocol committee would:

Review existing protocol for CT, focusing on lowering the patient dose, particularly for pediatric and adult head scan protocols as well as chest and abdomen

Develop dose reference levels, notification alerts and alert values, such as those set by the National Electrical Manufacturing Association (NEMA)

Take action, such as patient follow-ups, if dose exceeds reference levels

Set limits on personnel able to access the CT protocols

The last bullet is intended to encourage accountability in cases of human error, explained Lisa Bruedigan, chair of the Conference of Radiation Control Program Directors’ Healing Arts Council.

Other states are expected to adopt variations of California’s radiation safety law, but is the law really protecting patients?

Radiation Safety Law to Expand, But Did It Miss The Mark?

When Muntasir Hoque, MD, decided several years ago on radiology as a profession, the job market was excellent.

“There were numerous job openings for recent graduates and fellows, and relative compensation was excellent as well,” Hoque said. He is now completing his second fellowship, this one in cardiothoracic imaging and intervention at the University of Southern California in Los Angeles.

The market has since turned, forcing many fellows like Hoque to sub-specialize beyond what they might have done in a loose market, as well as consider compromises on compensation, hours and even geography.

For Hoque, there are added constraints. His wife, Kristina Hoque, MD, also is a radiologist and in her third year of residency. The couple has three young children and wants to stay together in Los Angeles, one of the nation’s most competitive locations.

“My whole family’s here,” Kristina Hoque explained. “I think in the back of our minds we know we’re both good radiologists and will find our place somewhere.”[[{"type":"media","view_mode":"media_crop","fid":"27363","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3286178958641","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2646","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 300px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]


If the numbers from the American College of Radiology are correct, Hoque could be among a pool of 1,100 fellows competing for approximately 1,115 open positions in 2014. Adding to the competition is those radiologists already in practice who are looking to change positions.

“There’s a job for everyone but not necessarily where you want to be,” said the ARC’s Edward I. Bluth, MD, head of the college’s Human Resources Commission.

Bluth’s numbers come largely from a survey sent to 1,900 or so radiology group leaders and department chairmen around the country. He calculated a 22 percent response rate representing 35 percent of practicing radiologists.

“Several of the [available] jobs are in areas where they don’t have family or hadn’t thought about living,” Bluth said, citing more openings in the southern and Midwestern regions. Hours worked are also emerging as a factor, with more and more radiology departments seeking radiologists willing to handle nights.

Other market constraints include mergers. There are approximately 1,900 radiology groups today, down from approximately 2,100 just three years ago, he said. Coupled with the decrease in practices, fewer people are retiring, Bluth said. He identified approximately 8,700 radiologists older than 56 who “conceivably could retire,” but for various reasons are remaining in the workforce.

“It’s an international phenomenon,” Bluth said. “People are healthier, and there’s an element of people hit by the economic downturn who have to support their families, relatives and children.”

And then there are those who prefer to work. “They’re living longer and want a more active lifestyle,” he said.


Also crunching the numbers, physician recruiter Craig Fowler said there were 5,009 residents in diagnostic radiology competing for 5,000 advertised positions in 2012.

Adding to that applicant pool, approximately 1,900 of the 27,500 or so diagnostic radiologists already in practice sought to change jobs that year, said Fowler, vice president of Pinnacle Health Group in Atlanta. While the 2014 figures are not yet available, Fowler said he does not have any indication much has changed in the past two years.

“Seven to 10 years ago, the demand for radiology was extremely high,” he said. “There were more jobs than there were radiologists.”

In today’s employer market, job seekers may have to compromise.  “In radiology, vacation is a big deal,” Fowler said. Radiologists may have to lower their expectations and accept salaries below the national average in the more desirable areas.


While it’s difficult to predict who may be the most attractive candidate, Roger S. Eng, MD, president of Golden Gate Radiology Medical Group in San Francisco, said sub-specializing can make a candidate stand out, especially if he or she is capable and willing to perform a range of radiology imaging.

Connections also help - and the combination of sub-specializing and networking could make the difference for the Hoques, who are looking to remain where they have studied, worked and networked.

Traditionally, Eng said, most fellows have been successful at finding positions within an hour of where they trained. Other options are those companies such as NightHawk Radiology Inc., which may not suit everyone, but are hiring.

Southeast Regional Director Richard Steinman, MD, said a distinct advantage is that NightHawk employees can live wherever they want.

“If you want to live in Colorado, but you’re trained to practice medicine in Maryland, you can do that,” he said.


Technology, Eng pointed out, is yet another factor leading to today’s oversupply.

“There was the large technological change from when I got out of training [in 1997] to the 2000s,” he said. “Studies have shown a benefit of the transition [from film to digital] was in our productivity; we were increasingly productive. When each radiologist is more productive, you need fewer.”

Even with the population aging and a growing need for imaging, he said, the increased productivity is greater than the need.

Eng said anecdotally he believes the tight market may be dissuading some medical students from pursuing radiology. While he can understand a graduate’s desire to pay off a student loan debt that could top $200,000, in the end he advises medical students to choose professional fulfillment over economics.

“The job market will go back and forth, and usually balances out,” said Eng, who runs a small, fully staffed practice. “Those I’ve seen who are most professionally satisfied are those who love what they do.”


Among radiology departments hiring is the University of Tennessee Medical Center in Knoxville.  Radiology Associate Professor and Chair Laura K. Findeiss, MD, said she has received “an incredible number of applications” for each of three open positions. All candidates are highly qualified, she said. 

While candidates from the medical center’s residency program may have a slight competitive advantage, Findeiss described qualities she seeks in a hire. These include having subspecialty expertise, but also a willingness to be flexible and behave as a generalist, she said. 

Findeiss said she also seeks candidates who are personable. “I’m very interested in the consultative interaction, talking to the patient, talking to the referring physician and putting the imaging in the context of the patient’s overall care,” she said. 


Findeiss described two competing forces in radiology: teleradiology companies such as NightHawk providing off-site reading and her model of radiologists becoming an integral part of the patient care team. “It will be interesting to see what wins out here,” she said.

Should consultation emerge as the future for radiology, the shift may increase the demand for radiologists, she said.

The ACR’s Bluth also sees the potential for a more open job market as more people without health insurance become insured.

Bluth said he also believes many radiology groups are being conservative about their hiring practices because of the uncertainty of the Affordable Care Act and how it will impact the economics of radiology.

“Uncertainty causes people to pause and see how things shake out,” he said.  “Once people know the rules and what the reality will be, they will be able to accept the changes and make accommodations.”

Are there more radiologists than there are jobs?

The State of the Radiology Job Market

When a radiologist makes a mistake that harms a patient, he or she probably should apologize.

“But in reality - it’s very hard to say to a patient that you’ve made an error, and it’s your fault,” said Leonard Berlin, MD, professor of radiology at Rush University and the University of Illinois, both in Chicago.


Whether radiologists, and indeed all physicians, should apologize has been scrutinized since at least the late 1990s, when the Institute of Medicine published an article that, as Berlin put it: “startled the nation and captured the immediate attention of nearly every newspaper and television and radio news program.”  

To Err Is Human: Building a Safer Health System

 reported that as many as 98,000 people die each year in hospitals as a result of medical errors that could have been prevented.

The article mentioned a five-year goal of reducing mistakes by 50 percent.

“We didn’t even come close,” said Lucian Leape, adjunct professor of health policy at Harvard School of Public Health.  “There was no real national effort, and no federal support to speak of.” 

But even the acknowledgement of errors signified progress, said Leape, also a surgeon and professor of surgery for 25 years at Tufts University School of Medicine.  “It’s long overdue, and thank God it’s happening.”

Leape explained that medicine for the past 200 years has been a conspiracy of silence. Doctors were told in their formal education and from their mentors and lawyers not to admit fault or apologize.

The instruction is well-heeded. “Doctors are reluctant to apologize, and most don't do it,” he said. 

At root is a belief that retaining a patient’s trust required a faÃ§ade of being all-knowing and in control.

In fact, failure to disclose a mistake has the opposite effect, Leape said. When something goes wrong, and the patient does not believe he or she is getting straight answers, trust erodes.


Leape criticized the American Medical Association and other medical oversight and accreditation organizations for failing to take the lead on apology. 

The Joint Commission, which accredits healthcare organizations including hospitals and self-standing radiology groups, encourages but does not require apologies.

Disclosure of unanticipated medical outcomes to patients or their families, however, is required, said Paul M. Schyve, MD, the Joint Commission’s senior advisor for healthcare improvement. Failure to disclose “could be cited as a standard out of compliance,” he said. 

In an e-mail response to a media inquiry, the American Medical Association stated that it does not have an apology policy but supports laws that make apology inadmissible in court.

The American College of Radiology did not immediately respond to media inquiries on apology.


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When a rare mistake of consequence does happen, fear generally drives radiologists to silence, he states in a 2009 report, 

 A “well-founded fear,” according to the article, is of medical licensing board disciplinary action. Indeed, 50 percent of people surveyed believe that suspending a physician’s medical license reduces medical errors. 

“State boards are clearly under increasing pressure to escalate their investigative and disciplinary activity,” the article states.

There also is the fear of losing referrals, hospital admitting privileges and the like, as well as the shame and guilt that accompanies recognition that a mistake has been made.

But perhaps the biggest fear is of a malpractice suit - a “traumatic” experience for any radiologist, the article states, even if he or she ultimately is exonerated.

While the question of whether disclosure and apology will reduce the likelihood of a lawsuit “remains hotly contested,” the article states, transparency policies at several hospitals suggest disclosure and apology, in the end, reduce the risk of litigation.

Risk Management: Extreme Honesty May Be the Best Policy

 describes the unexpected financial benefits experienced by the Veterans Affairs Medical Center in Lexington, Ky. after switching to a “somewhat radical policy” of notifying patients whenever a medical error was discovered.

Malpractice claim payments dropped from more than $1.5 million in 1987 to an average of $190,000 per year after the policy took effect.

In the article, the authors state that they believe the hospital’s “moderate” liability payments - due in part to honest notification of substandard care and help in filing claims - “diminishes the anger and desire for revenge that often motivate patients’ litigation.”

Virginia Ashby Sharpe, chief of ethics policy at the U.S. Department of Veterans Affairs’ National Center for Ethics in Health Care, clarified that the nature of the apology depends largely on the extent of harm done.

“You don’t need to burden patients with things that have no relevance,” she said.

A mistake that leads to death or disability requires what Sharpe described as an institutional approach, in which hospital leadership or members of a risk management committee participate in all communication with patients. 

The leaders express concern and render an apology that includes an explanation of the facts.  “It does not have to say we know everything, but it means we’re sorry this happened on our watch, and we’re doing everything we can to understand how it happened,” Sharpe said.


Similarly at the University of Michigan Health System, malpractice claims dropped from more than 250 at any given time to fewer than 100 by the mid-2000s, after the hospital created a set of principles to address what Chief Risk Officer Rick Boothman said had been a steady increase in malpractice claims and associated costs.

These principles included open disclosure and fair compensation when a mistake causes harm.

“What constitutes a mistake is really key to our approach,” Boothman said. While unanticipated clinical outcomes don’t necessarily mean a mistake was made, determining the difference can be tricky.

“It gets devilish in radiology circles,” he said, “especially with all of the new technologies and the fact that there’s a lasting picture.”

When medical errors are made, should radiologists admit fault?

Jennifer Anderson

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