Yomi Wrong

During 18 years as a radiologic technologist, Jeff Crowley acknowledged he sometimes thought, "Oh, I can do that," while assisting with procedures.

But since becoming a radiology assistant, a job that allows him to perform certain procedures himself, Crowley's views have evolved.

"You end up gaining a lot of respect for the radiologist. The skill of being able to delicately manipulate catheters and wires-they make it look easy, but it's difficult," he said.

He'd reached the ceiling as a technologist and found that he could advance his career by securing a certificate as a Radiology Practitioner Assistant first. But because he had a bachelor's degree, Crowley was eligible to take an exam to become a certified Radiology Assistant, a new career path that's gaining momentum in imaging, though it is far from reaching its full potential.

For Crowley, the move signaled a dramatic change at Premier Radiology in Tupelo, MS. Not only is he doing work he used to eye from the sidelines, Crowley picks up slack for the practice, allowing time-pressed radiologists to focus on reads and high-end procedures.

A typical day for him starts with a briefing on cases with a supervisor in fluoroscopy. He then checks in with the interventional radiologists to talk about any interesting assignments. And he's rolling.

"The pager goes off, and I go from one thing to another," Crowley said.

Crowley rotates from PICC lines to central venous procedures to fluoroscopy, all in a day's work at North Mississippi Medical Center, where Premier provides imaging services.

"I went back to school at age 40, which was difficult," Crowley said of juggling night school and full-time job responsibilities.

The radiologists at Premier recognized the potential in such an endeavor and invested in his education. Having completed the rigorous program, Crowley has a renewed feeling of career satisfaction. "It took me to this level where I could be content retiring from," he said. "I wouldn't look for anything higher."

Technologists-turned-RAs can see annual salaries balloon from $58,000 to $80,000-plus. But Crowley insists the money isn't the only draw. There are intangible perks, such as the challenge of clinical work and camaraderie with radiologists he admires.

"It took a while for some of the referring physicians to get used to it. But I've been at that hospital for 20 years, so they knew me," Crowley said.

"They'd see me working and say what are you doing? And I'd say, 'I went to school for this.'"

"He's very helpful in doing some of our less invasive interventional procedures," said Dr. Jeffrey Howard, one of 15 radiologists at Premier.

With Crowley on hand, workflow has improved. Radiologists have more time to focus on image interpretations. Turnaround time is quicker. And everyone goes home earlier.

"We notice a big difference when he's not here," Howard said. "We get a lot more work done with him in here."

But for all Crowley has added to the group, Howard said he would not consider hiring a second RA at this time. Rather, the practice is thinking of adding a nurse practitioner.

"The reason is that (Crowley) as an RA cannot function independently," Howard said. "He has no provider number. We need to have a clinic in interventional radiology, and I need someone who can function more independently. He could probably function independently in a lot of ways, but he's not allowed to do so."

And therein is the biggest challenge facing RAs.

By all indications the career path is growing: Academic programs are sprouting, enrollment is up, and radiology groups overall seem interested in adding RAs to the staff.

But until their role is expanded, RAs find their usefulness to a radiology group will remain limited.

Crowley and others must negotiate physician supervision levels and reimbursement guidelines with the Centers for Medicare and Medicaid Services. Unlike radiology practitioner assistants (RPAs), who paved the way for radiology extenders but still struggle for respect and recognition in the field, RAs are well positioned to do this.

RAs, on the whole, have the support of major players. The American College of Radiology is agitating for them. The American Society of Radiologic Technologists has appointed Crowley to its 2007-08 Task Force on RA Membership and Governance Implementation.

"Right now, the RA is perceived to have a limited role," Crowley said. "But I want to broaden it out to fit the practice better."

His newly empowered stance illuminates a second source of tension for RAs: the ongoing turf battle with their RPA counterparts. Efforts to combine the positions have fallen apart and fundamental ideals keep the two divided.

To understand a way around these obstacles, one needs a primer on how the RA model came to be, what's happening now-on the ground and behind the scenes-to bolster its position, and what the future holds for this nascent field.

The radiology assistant was born out of necessity. Confronted with increasing workloads, a growing demand for imaging, and a nationwide shortage of radiologists (as well as technologists), the ACR and ASRT joined forces to carve out this new career path.

In 2003, the ACR council voted in support of the Joint ACR/ASRT Statement on the Roles and Responsibilities of the Radiologist Assistant. The radiologist assistant was designed to be an advanced-level radiologic technologist who works under a radiologist's supervision. RAs have the knowledge and skill to carry out certain procedures but cannot formally interpret images or bill for service. "I'm proud to say that the development and acceptance of the RA concept has occurred more quickly than we envisioned," said Dr. Charles Williams in an editorial in the June 2005 ACR bulletin.

The RA model was touted as a tangible solution to staffing pressures and an attractive opportunity for technologists interested in advancing their careers. The chances for success were greatly enhanced thanks to the concept of an advanced-practice radiologic technologist having already been tried and proven.

According to an ACR white paper posted in 2007, radiology physician assistant programs were initiated in the 1970s at the University of Kentucky, Brown University, and Duke University. Those programs eventually closed due to perceived lack of demand, but the idea was resurrected in 1996, when the Department of Defense asked Weber State University to design a radiology practitioner assistant program to address a shortage of radiologists in the armed forces medical programs.

Weber State continued the program well after the DOD withdrew support due to budgetary cutbacks.

RPAs were mavericks who proved radiologic extenders could work side by side with physicians, not replace them. RPAs blazed the trail for RAs but now stand to be replaced by the fledgling RA enterprise. University programs for RAs are cropping up across the country, enrollment is becoming increasingly competitive, and more practices are inquiring about how to hire an RA or put one of their own technologists through school.

"From the beginning, we were very interested in offering a pathway for technologists who enjoyed doing flouro work or patient contact and wanted a new challenge but didn't want to go into modality," said Dr. Donna Wright, program director and professor at Midwestern State University in Wichita Falls, TX, which offers both an online bachelor's degree in radiologic science and a new master'slevel track for RAs.

University programs are small by design. Midwestern State enrolled just four students into the inaugural year of its master's program.

"We will always have fairly small classes because the clinical component is very intensive," Wright said. "We are definitely not a puppy mill."

All RA programs are at a baccalaureate degree or higher and include a radiologist-directed clinical preceptor component. RAs must also get certified by the American Registry of Radiologic Technologists and fulfill continuing education requirements to maintain ARRT registration.

Though RAs need to have an undergraduate degree at minimum, some schools have created an advanced degree to give students a competitive edge.

"The advantage professionally is they are now standing shoulder to shoulder with other groups that have master's degrees," Wright said of the RAs in her program. "They have an uphill battle for professional recognition as it is." It is too soon to say whether RAs are actually answering the radiologist shortage. But those on the front lines say this is a step in the right direction.

"Even though they may be helping alleviate [the shortage] somewhat, I'm not sure we have enough RAs out there to make a noticeable difference yet," said University of Arkansas professor Rebecca Ludwig, Ph.D. "What I do hear is that these graduates are very helpful, very productive, and a help to their practice."

It helps to have a positive image, but good PR and anecdotal evidence can carry RAs only so far. To validate their utility in a clinical setting, RAs must present a strong case for reimbursement to CMS. It's a long, protracted process. It took nearly 15 years for CMS to recognize physician assistants, said Christine Lung, director of governmental relations for the ASRT.

"We've been working on this for about three years now and are getting ready to gear up [for] a congressional campaign," Lung said.

The ACR is putting some weight behind the effort, too.

But RAs aren't the only ones clamoring for recognition. Remember their predecessors, the RPAs who fell by the wayside when the RA model sprang to life?

Their relative numbers alone make RPAs a force to reckon with. The 400-member National Society of Radiology Practitioner Assistants (NSRPA) is on the move, its leaders determined to fight for members across the country who have more experience than RAs but lack their high-level support and educational pedigree.

"It comes down to power, politics, and personality. We are a bigger entity than the RAs, but they've got rich grandparents," said James Abraham, vice president of NSRPA.

Articles

During 18 years as a radiologic technologist, JeffCrowley acknowledged he sometimes thought,"Oh, I can do that," while assisting withprocedures.

Assistants take on additionaltasks, inch toward payment

A survey of academic radiologists' clinical productivity shows that workload continues to increase, in both exam volume and complexity. Academic department heads could use the survey data to help set staffing levels and evaluate the performance of individual radiologists.

"It's a great tool to decide when to add a new chest radiologist or abdomen imager," said author Dr. Ronald Arenson, chair of radiology and biomedical imaging at the University of California, San Francisco. 

Ying Lu, Ph.D., Shoujun Zhao, Ph.D., and Philip W. Chu contributed to the 

Journal of American College of Radiology.

The authors used data from a 2006 survey performed by the Society of Chairmen of Academic Radiology Departments. That survey collected data for 1134 radiologists in 24 departments, including 10 departments that also reported productivity in an earlier 2003 survey. 

Arenson's group reported the mean clinical workload in 2006 was 9671 examinations, up 15% in 2003. The mean number of work relative value units per full-time equivalent was 7136, a 22% increase over the three-year period. 

The biggest change to radiology productivity occurred because of PACS, to which Arenson attributes a 25% to 30% increase.

Another factor is a surge in the numbers of commonly ordered procedures, such as MR and CT, which have risen for the same patient populations.

"That's due in part to improvements in technique, but also because of the aging population," Arenson said.

The combination of the two factors is driving productivity increases for radiologists at Massachusetts General Hospital, said radiologist-in-chief Dr. James H. Thrall.

"Beyond these factors, many practices in both academics and the private community have found the need to become more productive to maintain income levels in the face of increasing practice expenses not offset by lagging increases in reimbursement," Thrall said.

With the exception of plain films and non-PET nuclear medicine, radiologists at Wake Forest University are also feeling the productivity squeeze. Dr. Allen D. Elster, chair of radiologic sciences, predicts that as more pediatric work is consolidated toward children's hospitals, big academic centers will experience an increase in the total volume of pediatric cases.

"Not many residents are electing to do pediatric radiology fellowships nationwide," Elster said.

He's concerned supply won't match demand for a few more years.

Survey data included the numbers of procedures performed by radiologists, percentage of clinical effort, subspecialty sections, and number of clinical days. The numbers of CPT codes were converted into total work RVUs per FTE faculty member. By grouping the CPT codes into six prespecified examination categories, adjustment factors were created to adjust the RVUs for CPT categories to ensure that the median total adjusted work RVUs from different subspecialty sections were comparable.

For more information from the Diagnostic Imaging archives: 

Productivity tools remain scarce in radiology

Imaging informatics offers key to reshaping radiology's future

Enterprise-wide 3D assists radiology/surgery workflow

A survey of academic radiologists’ clinical productivity shows that workload continues to increase, in both exam volume and complexity. Academic department heads could use the survey data to help set staffing levels and evaluate the performance of individual radiologists.

Rising workload puts squeeze on academic departments

It's been a year since practice manager Lorna Vaughan took out an ad seeking a breast imager to work on the Jersey Shore. To her surprise, a "dream-come-true, fee-for-service, patient-focused, personal and compassionate practice with partnership and ownership opportunity" has been a hard sell.
  

"We're a new company, so we are at our breaking point," Vaughan said of HerSpace Breast Imaging Associates, a spalike facility founded by Dr. Beth Deutch. "We can't accommodate any room for growth without adding another breast imager."
  

She's turned the recruiting task over to professionals, hoping that headhunters will have access to a wider swath of candidates. They do, but problems persist.
  

Breast imagers command "huge deals," said Lauren Krebs, a radiology recruitment specialist with American Medical Recruiters, a company based in Florida. 
  

Women's imaging subspecialists can walk in the door expecting big salaries-anywhere from $200,000 to $500,000, depending on education and experience-along with generous vacations equal to those of partners, no call, no nights, and no weekends.
  

"They don't want to do anything else but 100% breast imaging," Krebs said.
  

Yet supply and demand dynamics prevail across the country. Job ads from Georgia to California, offering everything from malpractice coverage to gym memberships, suggest that no particular region alone is a magical draw.
  

The shortage of fellowship-trained women's imagers plagues hospitals and academic institutions as well. Data on academic vacancies published in the July issue of the Journal of the American College of Radiology indicate this subspecialty is in highest demand.
  

"As of last summer, breast imaging was in the worst shape in terms of not being able to fill academic positions," said study author and ACR research director Jonathan Sunshine, Ph.D.
  

The study found that, in 2007, the largest numbers of vacancies in academic departments were in breast imaging (15% of all vacancies), followed by interventional radiology (13%), neuroradiology (11%), pediatric radiology (11%), research (11%), musculoskeletal radiology (8%), and abdominal imaging (8%).
  

"To state the obvious, academia is the training ground for future radiologists," the study said. "If academic departments cannot staff adequately, that threatens the ability of the radiology profession to provide the volume of imaging and interventional services patients will need in the future."
  

The fact that breast imagers face higher malpractice risks and lower Medicare reimbursement than their counterparts makes it easy to understand why young radiologists avoid this important work.

"Missed breast cancers are the commonest source of lawsuits against radiologists, which makes life as a breast imager uncomfortable,"Sunshine said.

Adding to that problem has been a reduction in the number of mammography facilities. Of all mammography that's done in the country, only one-third of it is performed by radiologists trained in breast imaging, he said.

Though mammography is as demanding as any other field, it has suffered from a reputation as being a less exciting career pursuit. Experts predict, however, that technical advancements and new imaging developments could inspire a shift in that perception, which could in turn increase the pool of qualified breast imagers in the job market.
  

"Some of the high-tech activities are growing, with nonsurgical biopsy and breast MR having become important," Sunshine said.

In a recent article on womensimagingonline.com, Dr. Marcia C. Javitt, section head of body MRI and genitourinary radiology at Walter Reed Army Medical Center in Washington, DC, reported that breast imagers could soon find themselves using new and more advanced tools. These include tomosynthesis and breast CT, CAD for digital mammography, mammography with intravenous contrast, and molecular imaging.

"We are seeing an upswing in fellowships filling up," Kreb said. "Breast MR and PET are making it exciting again."

Ms. Wrong is feature editor of Diagnostic Imaging.
  

It's been a year since practice manager Lorna Vaughan took out an ad seeking a breast imager to work on the Jersey Shore. To her surprise,  a "dream-come-true, fee-for-service, patient- focused, personal and compassionate practice with partnership and ownership opportunity" has been a hard sell.

Mammo benefits improve, but recruiting remains big challenge

Most radiology practices are governed haphazardly, act unpredictably, and tend to succeed in spite of what they do rather than because of it. This evocative statement by Dr. Lawrence R. Muroff touches off an instructive new paper in the September issue of the 

Journal of the American College of Radiology

Taking your radiology practice to the next level

.Radiology groups have benefited over the last decade from favorable market conditions that made it difficult to fail, said Muroff, CEO and president of Tampa-based Imaging Consultants. But the gravy train is over."Things are cyclical," he said. "One only has to turn to the mid-90s to see when radiology was not so fortunate and there were concerns about the future of the job market, for example."The federal Deficit Reduction Act and down economy are among the forces foreshadowing hard times for procedural specialties. Commoditization of radiology services, a burgeoning teleradiology industry, and increasingly fractious contract negotiations with hospitals are also seen as harbingers.Radiologists will need to manage their affairs more diligently, Muroff said."Practice members are going to be expected to spend time after hours practice-building and in other ways protecting their radiology group," said Muroff, who is also a clinical professor of radiology at both the University of Florida and University of South Florida.

The major difference between great practices and the rest is that the great practices have effective governance structures and strong business infrastructures. He offers a dozen differentiators for readers to ponder. For example, great practices:

 Have effective governance structures based on group-developed mission statements and business plans.

 Involve their members in decision making and strategic planning.

 Understand that they also are businesses that require expertise and involvement by practice members to ensure that opportunities will be brought to fruition successfully.

 Are not afraid to deal with their problematic partners and associates.

 Demand that all radiologists in their practices contribute to practice-building activities that, by necessity, occur after routine working hours.

"These groups realize that a 9-to-5 mentality is for shift workers, not the owners of a business," the article said.

But Muroff's list is not meant to be taken as gospel. What he wants is to get radiologists to think about their livelihood in a serious way. For example, teleradiology has had a profound impact on the specialty, but there is salvation in being hands-on."Nothing replaces relationships and service if a group is willing to make an effort to provide that," he said. "Otherwise, I like to say the future for radiology is extraordinarily bright, but the future of radiologists is very uncertain."For more information from the Diagnostic Imaging archives: 

Legal uncertainties linger as teleradiology expands

Medicare fee schedule proposal could force nonrads to close office-based imaging services

Columnist explores impact of healthcare reform on your practice

Most radiology practices are governed haphazardly, act unpredictably, and tend to succeed in spite of what they do rather than because of it.

Author | Yomi Wrong

Articles

Assistants take on additionaltasks, inch toward payment

Rising workload puts squeeze on academic departments

Mammo benefits improve, but recruiting remains big challenge

Thoughtful tactics can lead to great group practices