Supply/demand imbalance taxes imaging services worldwide

September 5, 2003

Hospitals and healthcare centers around the globe are struggling to meet the demand for medical imaging, according to figures disclosed at the August meeting of the International Society for Strategic Studies in Radiology. While radiology staffing levels

Hospitals and healthcare centers around the globe are struggling to meet the demand for medical imaging, according to figures disclosed at the August meeting of the International Society for Strategic Studies in Radiology. While radiology staffing levels and the nature of imaging procedures vary dramatically from country to country, speakers from the U.S., Europe, and the Asia-Pacific region presented compelling evidence that the growing staffing shortage is an international issue. Cross-border and transcontinental recruitment schemes will not solve the problem but will simply shift the burden elsewhere.

Assessing the current level of medical imaging provision in the huge and diverse Asia-Pacific region is an enormous task in itself, according to Prof. Lenny Tan, chair of diagnostic radiology at the National University of Singapore. Standards for training medical professionals can vary considerably, making it difficult to compare individuals who share the same label such as "radiologist" or "radiographer."

China, for example, claims to have 30,000 radiologists and 130,000 radiographers to serve its 1.2 billion population. But personnel in rural hospitals and remote healthcare practices may not meet internationally recognized standards of competence, Tan said.

"In China there are no minimum standards, no regional examination, no national programs, and no national examinations. Every hospital trains to its own needs, and the standards are very uneven across the country," he said.

A simple head count of radiology personnel also hides the great disparity of imaging services within certain countries. The Philippines, for example, has a population of 80 million spread over 5000 islands. Yet 50% of the radiologists and training courses are clustered in metropolitan Manila, leaving the majority of Filipinos without access to medical imaging facilities.

The population of Asia-Pacific is aging, in common with demographic trends in Europe and the U.S., and by 2020, the number of people over 60 will have doubled. Yet many countries are already struggling to cope with their existing radiology workload. Just 49 of India's 162 medical colleges and universities have radiology programs, and an estimated 105 new radiologists graduate each year. This is simply not sufficient to provide a comprehensive imaging service in one of the world's most heavily populated countries, Tan said.

Although the situation in Europe is less extreme, several European countries are losing radiology staff faster than they are gaining new recruits, said Prof. Iain McCall, a professor of radiological sciences at Keele University in Stoke-on-Trent, U.K. This foretells problems for the future, as the increasing complexity of imaging procedures, the spiraling levels of data generated, and a higher proportion of elderly patients add to expanding workloads.

McCall based his assessment on the assumption that each newly qualified European radiologist works full-time for 30 years after completing a five-year residency. His evaluation did not account for the increasing number of women entering the profession, who may take maternity leave or work part-time, or the introduction of working time legislation in European Union countries.

"We need an output of trainees of 3.3% just to cover retirement," he said. "But very few of the countries we have reasonable figures for even meet the 3% boundary. So in a number of countries, we're not even training enough people to replace existing manpower."

One exception is the U.K., where the number of trainee radiologists has doubled over the past five years. This increase reflects proponents' success in persuading U.K. government officials to increase the number of training places, McCall said. Accurate statistics on numbers of radiologists Europe-wide and the anticipated need for imaging services could be used in a similar fashion to lobby other national governments and the EU, he added.

U.S. radiologists can only watch and weep. Radiology training positions in the U.S. are fiercely regulated, and negotiating an increase without robbing another medical specialty could require the magic of Harry Potter.

"To increase the number of radiologists in our current setting, you have to decrease the number of training programs for someone else. It's a zero-sum game," said Prof. Carl Ravin, chair of radiology at Duke University in Durham, NC. "Politically, getting more training slots for radiologists by taking away training slots for internists and surgeons would be very difficult."

Decreasing radiologists' workloads without boosting trainee numbers is not easy, and suggested solutions are generating controversy on both sides of the Atlantic. A number of European countries are experimenting with "supertechnologists": radiographers who are also trained to perform ultrasound, barium enemas, and even angiography. Similar arrangements exist in the U.S., with the emergence of physician assistants, radiologist assistants, or radiology practitioners, depending on which state you happen to be in.

Alternative but no less contentious suggestions include reducing the length of radiology residency programs, certifying residents' competency for certain procedures midway through training, and recruiting clinicians to perform imaging within their subspecialty.

"The fact is that if radiologists don't respond to this growing imbalance between demand for radiology services and our inability to provide, then others will provide this service," Ravin said. "There is no question; if we don't do it, somebody else will, and they won't look anything like a radiologist."