Vikash Panghaal, MD, MBA

As a younger practicing radiologist with 3.5 years post-fellowship experience, I have seen the partnership track position drying up in radiology.

After coming out of fellowship a few years ago, most of the jobs available were for non-partnership track positions. I interviewed mostly at small and moderately sized radiology practices. After interviewing at a dozen or so jobs, I began to realize that the majority of practices were not interested in offering partnership to new hires. Only a few of the jobs I interviewed at were more accommodating to younger radiologists and even went out of their way to make sure I was aware that the group was looking for radiologists who wanted to have ownership in their practice. Although this was only one of the criteria for looking at potential radiology jobs, I felt that places that offered partnership track positions would be a better fit for me given that they were probably better prepared for future growth and sustainability. 

According to many of my peers recently coming out of residency and fellowship, partnership track radiologist jobs are far and few between. A quick glance at the ACR Career Center confirms the paucity of partnership track positions. Although this may be good for groups in the short term, this may create a dichotomy of practicing radiologists within groups. As the partners continue to get older and eventually retire, there will be no one to carry the torch of running the practice. The newer radiologists will lack the knowledge of being part-owner in a radiology or medical practice. Non-partnership track positions will also lead to increased turnover of radiologists given that employee position radiologists are not committed to any particular group. [[{"type":"media","view_mode":"media_crop","fid":"30086","attributes":{"alt":"partnership","class":"media-image media-image-right","id":"media_crop_114678828207","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3142","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: 121px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

 I read recently said that radiologists are working longer and delaying retirement. According to the article, radiology has experienced periods of severe boom and bust in the past two decades. A surplus of radiologists in 1996 led to a shortage in 2001. According to the article, the current demand for radiologists almost exactly matches the number of new trainees entering the workforce. My interpretation is that although the jobs available equal the supply of radiologists needing jobs, there are fewer jobs for new trainees in desired areas and more jobs in remote areas.

Given the increasing number of senior citizens in America, the demand for radiology services will certainly increase. However, the future demand for radiologists and the ability to obtain partnership track positions is certainly unclear and the rate of senior radiologists retiring will certainly play a role in the balance of supply and demand.

I am skeptical that the trend will change in the near future given the current health care climate.

Articles

Employers are no longer offering partnership to radiologists. 

Partnership Track Is Becoming Scarce in Radiology

When I was growing up “mom and pop” grocery and retail stores were slowly being replaced by bigger chain stores. At first, I remember many people were against the trend of stores getting bigger, but as the bigger chain stores began to slowly replace the “mom and pop” stores, people started to get used to the idea of a one-stop-shop where they can get all of their household items in one store. The lower prices also helped fuel public acceptance. During the past decade, the large retail chain stores, such as Walmart, Target, Costco, etc. still exist and continue to flourish. Despite their success, many individuals are shifting away from the large retail chain stores and the pendulum is slowly moving to the smaller retailers who can provide higher quality and personalization, like local farmers’ markets.

The idea that large stores cannot provide high quality merchandise and services is not necessarily true, but it is not the norm. A low price, low quality store that comes to mind is Walmart. As I walk down the aisles of Walmart, I cannot believe how low the prices are for certain items, including food. In today’s agricultural environment where livestock animals are fed unnatural food and crops are grown using genetically modified seeds with a greater quantity of pesticides, one has to wonder the quality of food that is sold at retailers such as Walmart.

Walmart has its hand in many industries including groceries, guns, pharmacy, cigarettes, and eyewear to name a few. Recently, Walmart has decided to get into the healthcare business.  A few weeks ago I watched a segment of 

 discussing Walmart’s new Care Clinic, which just opened up in Georgia. The Walmart Care Clinic will be staffed by mid-level providers, such as nurse practitioners and will charge $40 for walk-in patients. A recent article in 

 pointed out the convenience of going to this type of clinic and dismissed the importance of having a central primary care physician who knows you and your medical problems. [[{"type":"media","view_mode":"media_crop","fid":"28016","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3504781312779","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2797","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: 75px; width: 165px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Society is consistently pushing towards low cost everything and we are currently in a similar situation in the healthcare industry, that the grocery and apparel industry faced many decades ago. While the push for low cost healthcare is necessary, quality may suffer. The idea that replacing physicians with mid-level providers to cut costs sounds good initially, however, the back end costs of lower trained providers either misdiagnosing patients or ordering more tests will likely end up costing more money in the long run.

It will be interesting to see which large organizations will stay around and continue to keep the trust of patients. Physicians will need to come together in larger groups to compete with these corporations.

A radiologist longs for the “mom and pop” days of healthcare.

Walmartization of Healthcare

Defensive medicine is prevalent in all specialties of medicine. Physicians may not even consciously realize they are practicing defensive medicine since it has been engrained in our thought process early on in our careers, especially over the past few decades. From my experience, physicians-in-training are usually not exposed to defensive medicine until residency, since medical schools usually shelter us from the “real life” thought process.

In medical school, physician mentors or professors stress the importance of physical examination and history and believe the majority of diseases or disorders can be diagnosed without ordering further tests for consultations. It is not until residency, when we are taking care of real-life patients in the real world, far from the ivory tower medical school atmosphere, that we slowly immerse ourselves into the practice of defensive medicine.

Defensive medicine is usually the result of two issues, one is the fear of being sued and the other is the continued decrease in time spent taking care of a patient. Both result in the increased utilization of additional consultation and testing. The increased utilization of mid-level providers such as physician assistants and nurse practitioners have also attributed to increasing costs, given their lower level of training, which likely ultimately leads to overutilization of services.[[{"type":"media","view_mode":"media_crop","fid":"27527","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1630789094776","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2695","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":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

 I recently came across an article in Forbes Magazine – 

Defensive Medicine: A Curse Worse Than The Disease

. This article discusses the issue of defensive medicine and how it is engrained in our health care system. One in four health care dollars is attributed to defensive medicine which amounts to about $650 million annually. The article also addresses the likely worsening of the problem due to the Affordable Care Act creating more insured patients, as well as the decreasing physician workforce due to retirement of baby boomers.

From my personal experiences, I see the practice of defensive medicine in all specialties including my own specialty of radiology. In my daily radiology reading grind, I can think of many situations where I may recommend an additional study, or my non-radiology physician colleague ordered a follow-up of a benign nodule. For instance, one case I read today was a renal ultrasound that demonstrated a likely renal cyst but given the slight debris within it (likely artifact), I recommended a CT abdomen. Since I practice in a litigious state, I recommended the study mainly for the fear of a malpractice lawsuit that this likely cyst may turn out to be cancer in a rare instance. Another example is seeing likely cysts within the kidney on lumbar spine MRIs which usually get an ultrasound or CT scan next to verify that they are cysts. I am sure most of you can come up with examples on a daily basis as well.

Another article I recently came across was in the Journal of American College of Radiology - 

Are Chargemaster Rates for Imaging Studies Lower in States That Cap Noneconomic Damages (Tort Reform

)?  The article caught my attention since it seemed to evaluate the effect of tort reform on health care spending.  However, after reading the article, I realized that the authors may have missed the underlying issue of defensive medicine as the real issue is overutilization of health services not increasing charges of individual tests.

The article addressed the significance of whether tort reform (cap awards for noneconomic damages (NED) influences the chargemaster rates by hospitals and diagnostic testing centers for certain imaging studies. The 

 concluded that chargemaster rates for select imaging services were not lower in states that have capped NED and were higher in some cases. One of the states that had tort reform, but had higher chargemaster rates was California. I am not surprised by this, given the high cost of living in California, which would likely increase costs for all business sectors within the state.  Hopefully, future studies will address the correlation between defensive medicine and overutilization of services.

The solution to combating defensive medicine is not an easy one, especially in a system that rewards physicians for doing more. Decreasing the risk of a malpractice lawsuit for physicians and limiting damages paid to patients while maintaining the right for patients is a difficult balance. The article in Forbes points out that the practice of defensive medicine did not significantly change in Massachusetts after legislatures enacted “Disclosure, Apologize, and Early Offer” as well as in Texas despite a cap on damages related to pain and suffering. Georgia and Florida legislatures are considering “Patients’ Compensation System,” which would eliminate the possibility of any physician or hospital ever being sued again. This system would replace our current system and would have a panel of experts to hear the medical claims of patients.

Although there has been much attention on curbing defensive medicine, I am not sure we will reach the “Patients’ Compensation System,” given the lobbying efforts of trial lawyers in this country. Even if we enact such as system, I don’t think the behaviors of physicians will change much in the short term. It may take decades to reverse the defensive medicine behavior in physicians, including myself. Parallel reform of physician compensation from fee-for-service to outcomes-based may also help align the goals of high quality and efficient care.

Radiologists and other physicians have been taught to practice defensive medicine.

Why Defensive Medicine Will Continue

Doctors are in the driver seat of health care but they mostly do not benefit monetarily from the health care spending in the United States. I recently came across an article in 

The New York Times: Busy Doctors, Wasteful Spending

. This article addresses the issue with physicians seeing more patients and performing more procedures in order to compensate for payment cuts which may, in turn, increase health care costs rather than decrease costs.  

 of health care costs are directly paid to physicians, 50 percent of that is used to pay overhead, including practice expenses and medical malpractice, leaving only 10 percent of the pie for physician salaries. The trillion dollar answer on how to curb health care costs is not by cutting physician salaries, which will only directly address 10 percent of the spending. 

Radiologists are at the center of physician payment 

. Over the past decade we have seen reimbursements for our services drop over 50 percent for many procedures. Currently, Medicare will pay on average $11 for a radiologist to read a chest radiograph. I cannot imagine any more cuts in imaging, as I feel as though I am already feeling the pressure of reading more and more each year. [[{"type":"media","view_mode":"media_crop","fid":"26104","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9714229924138","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2483","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":"line-height: 1.538em; height: 248px; width: 440px; float: right;","title":"Impact on global outpatient payments of Medicare reimbursement cuts for imaging services performed at outpatient imaging centers of Southwest Diagnostic Imaging Ltd. Courtesy of Rodney Owen, MD, FACR. Image Courtesy of Radiology Business. ","typeof":"foaf:Image"}}]]

Cutting physicians’ salaries seems counter intuitive. It would be analogous to placing a mandatory cut on teachers’ salaries to reduce educational costs. In the short term, this would seem logical since by cutting teachers’ salaries, the expenses would decrease, however, the long term effects would be detrimental to the outcome of educating our children. Fewer high-quality candidates would decide to go into teaching, leaving less-qualified or less-educated individuals to teach young Americans, eventually leading to worsening of the U.S. education system.

Similarly, by cutting physicians’ salaries, it would eventually lead to fewer top-tier students going into medicine and would allow middle- to lower-tier students to go into medicine. The perception of choosing a career path in medicine would evolve and would likely not maintain the high level of respect and value it currently receives. Also, the end result of saving lives and improving health care would suffer.

It is interesting to see how many administrators are focusing on the physicians’ incomes when hospitals, ancillary services such as ambulance transportation and durable medical equipment companies, and prescription drug prices are huge factors in the U.S. health care environment. Cutting physician salaries will only plug one of the holes in the sinking ship. A larger overhaul of the U.S. health care system needs to be implemented in order for the industry to continue to move forward and to enhance the lives of our country while maintaining costs.

When it comes to healthcare spending, salary cuts may not be the best approach.

Vikash Panghaal, MD, MBA

Articles

Partnership Track Is Becoming Scarce in Radiology

Walmartization of Healthcare

Why Defensive Medicine Will Continue

Making a Case for Not Cutting Radiologists’ Salaries