Current Perspectives on Radiology Workforce Issues and Potential Solutions

In recent years, there has been a marked change in the daily work life of a radiologist. We all feel it. Workloads have significantly increased. The number of studies, the number of images per study and, concomitantly, the overall complexity have all increased.^1,2 Gone are the days of taking a break for lunch, of leaving the hospital (let alone the reading room), of being able to get some rest while on night shift. Log onto any online radiology forum or talk to radiologists in any hospital in any state, and you will hear about the unprecedented volumes and daunting backlogs of studies, and the concern about what the future holds for our profession.

There is no cavalry on the way. There is no relief on the horizon, not for radiologists or physicians in general. The profession of radiology has certainly braved workforce challenges in the past, but the challenges we currently face seem nearly insurmountable. The burgeoning list of issues includes increasing image ordering, increases in image-guided procedures, decreasing reimbursement, rural and underserved urban area access issues, 24/7 subspecialized coverage, and a graduating workforce that may prefer subspecialized work and more flexible work hours. Unfortunately, this may lead some radiology groups to “outsource” things to non-physician practitioners (NPPs), radiology technicians, or non-physician corporate entities who promise “economies of scale.”

How should we address the current state of radiology and forge a path forward?

We believe there are many practice-level, educational and legislative options to address our workforce concerns, but they will require radiologists to think outside of the box and reimagine some components of the profession.

A Closer Look at the Gravity of the Physician Shortage

Current projected United States physician shortages are estimated to range between 37,800 and 124,000 within the next 12 years per a report issued by the Association of American Medical Colleges.³ This shortage is largely due to the Balanced Budget Act of 1997, which capped federal funding for physician residency training programs at 100,000 spots and placed limits on the number of foreign medical graduates (FMGs).⁴ In the almost three decades since, there has been only a single increase in this number.⁵ In 2021, a plan to add 1,000 residency spots over five years was approved. To put this in context, that represents a one percent increase in 27 years. Meanwhile, in that same time span, the U.S. population grew by 23 percent, according to U.S. Census Bureau statistics.

Since 2010, there has been a mild increase in the number of physicians in the US (see Figure 1).⁶ There has been an even smaller rise in the number of radiologists during this time, a number that is dwarfed by the concomitant rise in imaging volumes, which grow at approximately three to four percent annually, according to some long-term studies.^7,8 In contrast, there has been a shocking increase in the number of non-physician practitioners with 2024 data indicating a 263 percent and 93 percent increase in numbers of nurse practitioners and physician assistants respectively.⁹ Though it varies on a state by state basis, NPPs have enjoyed continuous increases in their legislated scope of practice. This, in conjunction with their well-documented overutilization of imaging services in relation to physicians, suggests that future increases of three to four percent in imaging volumes is undoubtedly a very conservative estimate.¹⁰

Calls for removing the physician residency funding cap and expanding residency training positions are necessary but need to occur on a very large scale to make a tangible difference. Additionally, the impact of more residency spots on the workforce will not be felt until at least three years following expansion. Finally, many medical specialties face even greater shortages than radiology and any expanded residency spots would likely be preferentially allotted to specialties other than radiology. While necessary to address the overall physician shortage, expanding residency training positions (unless the expansion is huge) is unlikely to provide noticeable relief for the radiologist shortage.

These numbers are simply not sustainable and necessitate rapid, decisive changes in order to meet these exhaustive workforce demands.

Potential Solution: Reassessing Our Educational Pathways

While radiologists have experienced multiple changes to our board certification/recertification processes, isn’t it time to reexamine our educational pathways?

Much like the already existing combined six-year baccalaureate/Doctor of Medicine programs, surely there could be options for combining/overlapping some of the medical school/residency/fellowship years with increased focus. Are four years of medical school with eight-week long rotations in general surgery truly necessary for a future radiologist, or could there be a means of focusing a portion of that time on radiology-specific training? Our pathology colleagues successfully changed their training model, shortening overall time in training and subsequently increasing the number of practicing pathologists by removing the clinical intern year and redirecting a greater focus on their chosen specialty.¹¹

Perhaps it is also time to reevaluate fellowship training and address the increasingly common graduate who is ill equipped or unwilling to practice outside of his or her fellowship area. Refocus on development (and celebration!) of the general radiologist, who can cover all the imaging needs of many hospitals and is in extremely high demand in the current workforce.

Identifying and Addressing Practice Level Changes

At a practice level, improving workflow (efficient worklists, improved PACS/dictation software, improved clinical/EMR integration, triage of examinations) and finding ways to increase speed without compromising quality of care would be beneficial on many levels. This can be achieved with technological assistance (artificial intelligence (AI), automated/improved communication systems) and with workforce stratification (scribes, appropriately supervised NPPs, reading room assistants/secretaries) to augment workflow and perform non-medical/non-physician level tasks. Effective assignment of support staff, informatics integrations, and AI tools can all help increase radiology productivity and satisfaction, particularly if radiologists can participate in and lead these point-of-care process improvements.

Removing burdens of answering phones, calling reports, completing documentation for billing, and other administrative tasks allows the radiologist to be more focused and efficient, decreases interruptions, provides more time for direct patient interaction, and ultimately helps ward off burnout and restore overall joy in medicine.

While we provide a referral service and are considered “the doctor’s doctor,” we must also advocate for our patients and “image gently” by addressing inappropriate utilization and over ordering of radiology studies.^7,12 Algorithmic ordering has no place in true high value patient-centered care and is a costly burden on an already overwhelmed system.¹³ Anecdotally, there are hospitals where NPPs have been barred from ordering imaging to decrease overutilization. Historically, minor procedures (lumbar punctures, thoracenteses/paracenteses) were routinely performed at the bedside by other specialties. We may need to relinquish these back to our clinical colleagues.

Radiology work ranks highest in mental demand (see Figure 2) across specialties, and this demand correlates with burnout.^14,15 Nonetheless, current radiology operations often base components of compensation on relative value unit (RVU) productivity. While RVUs are typically utilized as a means of evaluating productivity, this is not necessarily an adequate measure of activity.

The chest X-ray (CXR) is a complex examination requiring expertise but is markedly undervalued in RVUs. Similarly, discussing cases with clinicians is time-consuming without any RVU equivalent. However, as “the doctor’s doctor,” this is yet another way in which we display our expertise to other specialties, continue to have real time input into patient care, and add value, thus remaining an integral part of the team in a team-based multidisciplinary approach. We must lead the charge to promote safe practices in terms of shift length, volume, and time between shifts akin to those in place for nurses, trainees, and pilots. We must recognize outcomes over output and metrics aside from productivity/work RVU.

Also, it is vitally important we maintain a “presence” in the hospital and remain visible to clinicians, referring specialties, and administrators. We must place value on the radiologists who represent us on hospital and society committees, so we have a voice in decision making. If we are not present, others will speak in our stead. We must continue to participate in multidisciplinary conferences, be available for consultation, and to have direct patient contact. All of these actions allow for radiologists to showcase their highly specialized expertise and remain a visible, integral part of the health-care team rather than a faceless report. The more we reduce our visibility, the more we become perceived as an easily replaced expendable commodity.

Lobbying and Honing in on Key Legislative Fixes

We need to continue to lobby for more Accreditation Council for Graduate Medical Education (ACGME) funded radiology residency positions. With the discrepancy between number of graduate medical students and residency spots, we have an untapped resource with the thousands of unmatched physicians each year. We need to consider legislation that would allow us to utilize these physicians in a limited, supervised capacity, perhaps some version of the “associate physician” model, which has already been legislated in several states.¹⁶

While continuing to lobby congress for more residency spots, it is a perfect time to fund our own. For specialty societies that have accumulated hefty war chests, this is the time to use them. Society-funded or sponsored residency spots could go a long way to addressing workforce problems. However, care must be taken to avoid corporate or private equity funding of residency spots as it has introduced a conflict of interest and had a detrimental effect in other specialties, as readily seen with our colleagues in emergency medicine.

Increasing international medical licensure (IML/FML) programs and removing administrative barriers could provide immediate workforce relief in greater capacity than the limited post graduate medical licensure (PGML) noted above.

Federal or state legislation that protects reimbursement, alleviates or forgives student loan debt, incentivizes rural care, removes restrictive legislation (similar to rural pass through for anesthesia) and addresses the Merit-Based Incentive Payment System (MIPS) should all be prioritized. Importantly, protecting individual radiology groups from corporate interference and protecting individual radiologists employed by corporate entities (such as banning corporate non-compete and non-disparagement agreements and protecting whistleblowers) will improve morale and reenergize the workforce.

In Conclusion

The situation is complex.

There is no quick fix but deliberate, meaningful changes, perhaps some variation or combination of the aforementioned recommendations, may allow for radiologists to refocus on patient care and the practice of radiology.

The issues we currently face in radiology have developed and have been compounded over decades, partly as a result of our own success, but also in large part due to legislative burdens, increased corporate involvement in our workforce, and stakeholders with varying motivations. Unless our workforce issues are tackled head on with plans to address and improve this concerning state of affairs, the situation will progressively worsen, negatively affecting the quality of patient care and the health/morale of the radiologist workforce. This will likely result in further reduction in numbers, as medical students may shy away from a specialty struggling to stay afloat with no clear plan to right the ship.

Creative solutions designed to promote long-term stability are necessary to ensure that these problems are solved, not simply patched. There have been many discussions about the workforce shortage in radiology, but not enough discussion of potential solutions. Our aim was to propose numerous viable options for both short-term patches and long-term solutions, some of which have been successfully utilized by other specialties facing workforce issues.

Admittedly, some of these ideas may need to be modified, but we look forward to the shift from “recognition” to true “action” as we dive into the workforce discussion at the upcoming American College of Radiology (ACR) conference next month. It is here that we hope individuals, radiology groups, and other stakeholders band together and collectively act in the best interests of our specialty as a whole so we can, in turn, provide better care for our patients and ourselves.

References

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2. Stempniak M. Use of advanced imaging skyrockets in ED, and radiologists should be ready for more. Radiology Business. Available at: https://radiologybusiness.com/topics/healthcare-management/healthcare-economics/use-advanced-imaging-skyrockets-ed-and-radiologists-should-be-ready-more . Published August 7, 2023. Accessed March 13, 2024.

3. Association of American Medical Colleges. The complexities of physician supply and demand: projections from 2019 to 2034. Available at: https://www.aamc.org/media/54681/download . Published June 2021. Accessed March 13, 2024.

4. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. U.S. residency training before and after the 1997 Balanced Budget Act. JAMA. 2008;300(10):1174-80.

5. Hayes OW, Scaglione J, Hutchinson CP, Zhorzholiani I. Graduate medical education enhancement and the Consolidated Appropriations Act 2021. J Grad Med Educ. 2021;13(5):650-653.

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8. Smith-Bindman R, Kwan ML, Marlow EC, et al. Trends in use of medical imaging in US health care systems and in Ontario, Canada, 2000-2016. JAMA. 2019;322(9):843-856.

9. U.S. Bureau of Labor Statistics. Occupational outlook handbook. Available at: https://www.bls.gov/ooh/fastest-growing.htm . Accessed March 13, 2024.

10. Hughes DR, Jiang M, Duszak R. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175(1):101-7.

11. Mai B, Aakash N, Huddin J, Castillo B, Wahed A. Pathology residency curriculum: time for a change? Ann Clin Lab Sci. 2021;51(3):434-440.

12. Cheng MKW, Telleria-Cano JM, Nath JB. Imaging wisely: an introduction to the ACR Appropriateness Criteria® and analysis of its impact on internal medicine trainees. J Am Coll Radiol. 2023;20(10):1059-1062.

13. Mehan WA, Shin D, Buch K. Effect of provider type on overutilization of CT angiograms of the head and neck for patients presenting to the emergency department with nonfocal neurologic symptoms. J Am Coll Radiol. 2023 Sep 16:S1546-1440(23)00714-7. doi: 10.1016/j.jacr.2023.08.042. Online ahead of print.

14. Harry E, Sinsky C, Dyrbye LN, et al. Physician task load and the risk of burnout among U.S. physicians in a national survey. Jt Comm J Qual Patient Saf. 2021;47(2):76-85.

15. Azour L, Goldin JG, Kruskal JB. Radiologist and radiology practice wellbeing: a report of the 2023 ARRS Wellness Summit. Acad Radiol. 2024;31(1):250-260.

16. Singer JA. Tennessee becomes the latest state to remove barriers to assistant physicians. CATO Institute. Available at: https://www.cato.org/blog/tennessee-becomes-latest-state-remove-barriers-assistant-physicians . Published May 17, 2023. Accessed March 13, 2024.