Surmounting negative perceptions of clinical relevancy of research could prove challenging to ACR initiative
Many transformations taking place in radiology can be seen in both a positive and negative light. Imaging utilization is up, but the number of radiologists is down. Technology has made imaging widely available, but imaging is increasingly being performed by nonradiologists. Nowhere does this dichotomy manifest itself better than in the tension between private practice and academic radiology.
Radiologists are lured to private practice for its high salaries and quality of life. Decreasing reimbursements and an increasing workload, however, threaten this lifestyle advantage. Radiologists pursue academia to enjoy a rich career of clinical work, research, and teaching. The last several years, however, have seen fewer residents opting for an academic career and young faculty making an early exodus. As the faculty shrinks, more clinical workload falls on those who stay behind, and they, in turn, have less protected time to teach and conduct research.
"The attitude develops, 'If I work like a private practice radiologist, why not go into private practice and reap the financial rewards?'" said Dr. Kay Vydareny, a professor of radiology at Emory University.
Vydareny's cardiopulmonary imaging section hired an associate who had recently completed a fellowship at Emory. Eight months after receiving his privileges, he left for greener private pastures. The section is now shy two docs and, like most other sections, the radiologists are performing more imaging procedures with each one more complicated than it was five years ago.
"The pressure to get the clinical work done impacts on resident teaching conferences and availability for academic pursuits," Vydareny said.
An initiative by the American College of Radiology proposes to tap into the pockets and clinical schedules of private practice radiologists to help free up academicians to do research. It's a noble pursuit but one that ultimately may prove to be very challenging. Many private practice radiologists don't see the clinical relevance of much of the academic research being conducted. In addition, they often see academic radiology departments as direct economical and clinical competitors who are training nonradiologists to perform imaging and interventional procedures. How realistic is it to expect private practice radiologists to help academic radiology survive?
"I don't know. I've had more than one intelligent person say I'm wasting my time," said Dr. Thomas Fletcher, a radiologist in the 68-member Austin Radiological Association in Texas and cochair of the ACR academic-private practice alliance committee.
Fletcher, along with cochair Dr. Gerald D. Dodd III, radiology chair at the University of Texas Health Sciences Center in San Antonio, conducted a survey last year of all 126 members of the Society of Chairpersons of Academic Radiology Departments (SCARD) to assess academic radiology's health. About one-third of the chairs responded, and the highlights are telling, Fletcher said.
All respondents agreed that there are academic departments on the brink of failure or functioning at a level that compromises their missions of teaching and research. The SCARD group estimated that 28% of the academic departments in the country operate under such marginal conditions. Revenue and staffing were identified as the greatest challenges confronting radiology departments. Nearly half of the chairs reported having insufficient faculty, and the same percentage reported they were not in a sustainable financial state.
The survey found that clinical revenue makes up 81% of total department income, followed by 9% from the federal government (including grants), 3.6% from the state, and 2.9% from medical schools. Since the bulk of income derives from clinical work, academic radiologists increasingly must forego research to concentrate on generating income.
"There is an idea that the academic enterprise is floated by state or medical school dollars. That's a fallacy," Dodd said.
Three-quarters of SCARD respondents reported critical shortfalls in research, 23% cited clinical problems, and 4% named education as the area of concern. To the surveyors, the SCARD results confirmed earlier publications that academic radiology, in particular radiology research, has been significantly compromised.
To help academic radiology out of the hole, Dodd and Fletcher intend to mount a grassroots campaign aimed at convincing private practice radiologists that their livelihood depends on academic radiology's solvency. Academia is private practice's research and development team, its personnel farm, and its educational source.
"The specialty of radiology is like a corporation, and in order to remain viable, it has to invest in R&D, manpower, and education," Dodd said.
What can private practice docs do? Practices can fund fellowships or contribute as a group or as individuals to large umbrella organizations such as the RSNA or smaller subspecialty groups such as the Society of Interventional Radiology. Private practice radiologists can perform pro bono work at local universities, thus freeing up faculty time to conduct research.
"Personally, I think the idea of doing pro bono work is a very unrealistic expectation," said Dr. Barry T. Katzen, medical director of Baptist Cardiac & Vascular Institute in Miami. "Private practice is geared toward productivity, and many practices are already working at capacity."
Katzen suggested tapping into the increasing pool of radiologists undergoing mandatory retirement. He also said that some technologies such as PACS that result in practice efficiencies could ultimately free up time for private practitioners to do pro bono work. But an important first step is for private practice radiologists to accept that academic radiology has value for them even though they are not directly involved.
More than a few private practice radiologists have commented that much of academic research is clinically irrelevant to them. Clinical relevancy, however, may be in the eye of the beholder. A sampling of useless research complaints includes 3T MRI, studies of CT slice thickness unrelated to the relative quality of the image, MR-guided interventions, and small retrospective studies on obscure diseases. At the top of the relevant research list are cost-effectiveness and clinical efficacy of imaging.
Dr. Frank Yuppa, radiology chair at St. Joseph's Regional Medical Center in Patterson, NJ, is part of the 15-member Imaging Subspecialists of North Jersey. More than 20% of his patients are uninsured, while 16% are covered by Medicaid. HMOs in his area are paying below Medicare rates, and his group is dropping them one by one. Multispecialty groups like Yuppa's can't survive allied with hospitals alone, he said. They need to have outside ventures where they collect more than the professional fee. But in New Jersey, freestanding imaging centers also pay a 3% tax on every $1 million made.
"I think the ACR proposal is unrealistic," Yuppa said. "Radiologists are already struggling to make a living the way it is."
To stay competitive, Yuppa's group consists of a variety of subspecialists, including pediatric radiologists, neuroradiologists, interventional radiologists, and mammographers. Within the last two years, he has hired four radiologists at a cost of $1.3 million, half of which he expects never to recoup because of indigent care, which has increased from 11% in 2003 to 21% in 2006.
Two years ago, the group opened a vascular access center that does well. The radiologists own and operate the center alone, without collaboration from cardiologists or vascular surgeons. Yuppa and colleagues are currently in negotiations to partner with the hospital in a freestanding imaging center that recently acquired a 64-slice CT scanner. Yuppa is lucky in that the hospital pays several hundred thousand dollars annually to cover a nighthawk service. While he has trouble seeing the clinical relevancy of much of academic research, he considers the ACR initiative worthwhile.
"I'm afraid, however, that these people don't see the big picture, that private practice radiologists like us with excellent docs delivering excellent services are struggling," he said.
Dr. William T. Thorwarth Jr., a private practice radiologist with Catawba Radiological Associates in Hickory, NC, has challenged his colleagues to donate 1% of their net revenues to support research, education, and political advocacy. He estimates the effort could garner $100 million annually (JACR 2006;3:248-251). Such a nest egg would bring radiology in line with the American Heart Association, which receives and allocates $130 million per year for research into cardiovascular disease. By contrast, the RSNA Research and Education Foundation has collected $35 million total in its 25 years of existence-and that from fewer than 7% of its U.S. members, with more than 90% of them being academic radiologists.
"Great idea, bad timing," said Dr. David A. Dowe, medical director of Atlantic Medical Imaging in Galloway, NJ, about the Thorwarth challenge.
The bad timing has to do with the 3% tax imposed by New Jersey on imaging centers and the potential loss of income from the Deficit Reduction Act of 2005. Another way to help academic radiology is to fund fellowships. Through a relationship with several radiologists at Thomas Jefferson University, Atlantic Medical Imaging agreed to fund a cardiac imaging fellow. It's purely academic, requiring no New Jersey licensure or dictation. The fellow comes to the imaging center once a week. The association with Jefferson has given Dowe's group some prestige.
"It also has made us better radiologists," he said.
Dowe envisions expanding this type of effort to resemble the farm system in professional sports. The local universities would train certain radiologists who are supported by local private practices. These radiologists would agree to stay in the area for a number of years but not necessarily at the funding practice. After their mandatory stay, they would become like unrestricted free agents.
"By then, most would have fallen in love with the practice and won't want to leave," he said.
Other arrangements can be made as well. Thorwarth and his group funded a musculoskeletal fellow at Duke. They structured it as a loan to be forgiven if the fellow stays with the group for two years.
"Duke got a junior faculty member at no expense. And we got a terrific ambassador for our practice," Thorwarth said. "We've subsequently hired two more radiologists from the Duke program."
For years, Dr. Michael N. Brant-Zawadzki, radiology chair at Hoag Memorial Hospital in Newport Beach, CA, has been flying up to Stanford University once a month to donate his time (and flight expenses) for a day. He reads cases, helps supervise procedures, and interacts with residents. He's an enthusiast for this type of pro bono work. He says it serves both sides extremely well. He enjoys interacting with young residents and former colleagues. He acts as a barometer for research that might not translate well at the clinical level. He sees the latest pool of resident talent firsthand. And the association with Stanford gives the practice competitive differentiation. The university, of course, gets a free radiologist for the day. He said that universities could do a better job of emphasizing these intangible benefits.
"Given the growing load on radiologists in practice to be more productive, giving up an off day to do free work is daunting for many individuals," Brant-Zawadzki said. "That's why universities should emphasize the nonfinancial benefits."
Advocates of the effort to get private practice radiology more involved in academics stress that it is a long-term investment, one that is crucial to the future of the profession.
"With all the other specialties nipping at what we do, what's the eventual endpoint if we don't step up and take charge?" Thorwarth said.
Mr. Kaiser is news editor of Diagnostic Imaging.