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President's Address |
1 From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27106-1088. Received December 18, 2000; accepted December 22. Address correspondence to the author (e-mail: dmaynard@wfubmc.edu).
Index terms: Radiological Society of North America • Radiology and radiologists
I would like to take this opportunity to thank all of our hundreds of volunteers who make possible not only the Radiological Society of North America (RSNA) annual meeting but also all of the other activities of our society. Without their contributions of time, energy, ideas, and hard work, none of this would be possible. I also thank their departments and colleagues for providing the necessary release time to allow them to participate in the RSNA activities. With the demands of practice today, time to participate in organized radiology is a very precious commodity.
My 8-year term on the Board of the RSNA will end this week. I first attended an annual meeting in 1963 as a 1st-year radiology resident. I have missed only one meeting since then. In 1963, the entire meeting, including the scientific and technical exhibits, was held at the Palmer House Hotel in Chicago, Illinois. I was able to bunk in a room that the Palmer House provided especially for residents. Four of us paid $5.00 each per night! I would never have dreamed the meeting would grow so large that we would occupy most of McCormick Place and nearly all of Chicago’s hotels for the week and that attendance would reach almost 65,000. Of course, in the 1960s no one expected radiology to become such a dominant force in medicine. Our specialty has come quite a long way!
I believe that the future of radiology is even brighter than its past. During the next 10–20 years, we will be faced with many challenges and opportunities. What we will become will largely depend on our collective responses to some of these challenges. I would like to share with you what I believe to be the most important of these and offer my opinion as to how we—and by "we" I mean both the field of radiology and the RSNA—should respond.
As I see it, we are faced with five major challenges:
The first two challenges, maintaining an adequate workforce and expanding our sphere of knowledge, relate specifically to human resources issues. Do we have enough radiologists and associated scientists? Are they being properly prepared for the next millennium? I will focus only on diagnostic radiologists, whom many believe are representative of the entire radiology workforce. I have had the opportunity to travel to many other countries during the past 2 years. Nearly all nations are experiencing similar workforce issues—it is a worldwide phenomenon.
Now let us consider these challenges in more depth.
CHALLENGE 1: MAINTAINING AN ADEQUATE WORKFORCE
From all indications, a shortage of radiologists in the United States appears to be inevitable in both the near and the long term. Results of recent surveys by the American College of Radiology (ACR) Research Department clearly indicate a substantial increase in job opportunities (1). This increase is a result of three factors.
First, the number of resident positions has declined. Two circumstances account for this decrease: (a) a temporary dip in job opportunities in the middle 1990s that discouraged medical students from choosing a career in radiology and (b) a self-imposed, as well as a government-imposed, freeze on positions. Currently, 7% fewer residency positions are available than were available in 1995 (2).
Second, retirements have been accelerating. According to data provided by Jonathan H. Sunshine, PhD, of the ACR research group (oral communication, 2000), the number of retirements doubled, from 400 in 1996 to 800 in 1997. Although the most recent recorded data show that the number of retirements decreased to 600 in 1998, accelerated retirement seems to be continuing. A strong stock market and some disenchantment with managed health care have prompted many radiologists to seek early retirement.
Third, the workload has increased. A projected decrease in the use of imaging procedures as a result of managed health care has not occurred. Total workload, including increases in the number of procedures as well as increases in the mean relative value units per procedure, has actually increased by an average of 4%–6% per year. This trend is likely to continue as we deal with an aging population. James H. Thrall, MD, in his Caldwell Lecture at the 2000 meeting of the American Roentgen Ray Society, stressed the effect of aging on the volume of procedures projected for the future. In the year 2000, radiologists in the United States performed approximately 300 million procedures. A combination of growth in the population, increase in the use of imaging procedures by people over 65 years old (four times that by individuals under 65), and a documented increase in the use of imaging procedures by patients of all ages will result in the performance of more than 450 million radiologic procedures annually by the year 2010.
On the other hand, with the number of radiology residents governed by the Health Care Financing Administration (HCFA) and the retirement rate remaining at a higher level, the pool of radiologists will increase by only approximately 20% by the year 2010. Clearly, the increase will not be adequate to accomplish the job under the present health care system.
During a casual conversation while I was working on this address, Otha Linton asked if I had read articles by John Knowles in the New England Journal of Medicine in 1969 (3,4). Dr Knowles, from Massachusetts General Hospital, reported on the pending shortage in the radiology workforce. When faced with shortages, he wrote, "The strategy inevitably involves expanding the system that produces the manpower, altering the functions of existing workers to enhance productivity, reconstituting or adding sanctions designed to facilitate entry and actively manipulating values, attitudes and beliefs through public education to enhance recruitment" (3). He could have been writing for the next millennium!
What solutions are available to address the anticipated radiology shortage?
First, we must increase the number of trained radiologists. As long as the federal government through the HCFA maintains the cap on the number of residents it will support, no substantial increase is possible. Organized radiology must develop a national strategy and gain more federal support for its implementation. The marketplace, not arbitrary quotas, should determine the number of radiologists that are trained. Market forces will not work unless the numbers can either decrease or increase according to market needs. No method currently exists to increase output.
In 1961, the total number of residents in training was fewer than 1,600. Knowles (3) predicted a need for more than 4,500 positions by the year 1975. Growth occurred, but today there are fewer than 4,100 positions. To handle future needs adequately, we again need major expansions in our programs.
Second, we must become more efficient. Most radiologists are already working hard. The average number of studies interpreted by each radiologist is increasing every year. Academic time for faculty is insufficient as a consequence of the pressure of an increased workload (5). Digital radiology and picture archiving and communication systems, or PACS, will offer partial solutions once the systems become both commonplace and user friendly. However, these systems will not gain widespread use for a number of years. In England and many other countries, physician extenders are often used, particularly in emergency departments. This practice was tried in the 1970s but quickly abandoned. Perhaps organized radiology should seriously revisit the issue. Physician assistants could be helpful in such areas as interventional radiology.
Third, we may be required to reevaluate and prioritize the studies we interpret. Although most of us would prefer not to give up interpreting selected types of studies, in the long term doing a good job on a limited range of patient studies will be preferable to reading such a large volume of studies that we do a poor job at everything. Perhaps the time will come when we must choose to interpret only those studies for which we are best able to add value and leave to other specialists the interpretation of studies for which our added value is marginal. This practice is common in some developing nations that have very few radiologists.
The role of the RSNA in meeting the challenge of a projected workforce shortage will be to work with other radiology organizations, such as the ACR, to develop a long-range plan and to seek federal support for additional residency positions. We must also work with all of organized radiology to provide support for fellowship positions. Through its annual meeting program and educational materials, the RSNA can disseminate new methods to improve efficiency in practice.
CHALLENGE 2: EXPANDING OUR SPHERE OF KNOWLEDGE
Equally as challenging as maintaining the correct number of radiologists will be ensuring that our trainees are properly prepared to work in a constantly changing field. Several think-tank meetings organized by the RSNA, ACR, and American Board of Radiology during the past 2 years brought together all organizations involved in the training of radiology residents and fellows. A constant theme can be identified: (a) The existing training period of 5–7 years is too long. (b) The current curriculum needs considerable revision, particularly to include such topics as leadership, professionalism, ethics, economics, genomics, and computer science. (c) Research training and research mentors are nearly nonexistent. (d) A variety of tracks will be needed to provide the subspecialized training—from general radiology to interventional radiology to research training—that will be required in a highly changeable workplace. (e) General radiology is still very important and must be maintained as an essential core of our programs. (f) Electronic teaching methods should be explored and exploited. (g) We must instill an understanding of lifelong learning and devise a better method of delivering continuing medical education for practicing radiologists.
It will be imperative for radiology to respond to these challenges, and an optimal response will depend upon the cooperation of the American Board of Radiology, the Residency Review Committee, and the remainder of organized radiology.
Let me suggest some starting points for discussion:
-year basic radiology core that includes 6 months of clinical training. years of fellowship training in all programs currently approved by the Accreditation Council for Graduate Medical Education and add accredited general radiology, women’s imaging, and cardiothoracic imaging programs in the future. The role of the RSNA would be multifaceted: to help fund the establishment of the centers of excellence, fund educational materials for use by all the programs, lead the way in the development of expert teachers and methods of implementing lifelong learning, act as a catalyst to move changes in the educational programs forward, and work with other organizations to establish a valid method for measuring continued competence.
Space does not permit me to discuss the last three challenges in the same depth as the first two, but I do want to raise several issues related to each.
CHALLENGE 3: INCREASING THE RESEARCH ENTERPRISE
As the NIH expands support of medical research, it is imperative that radiology expand its efforts accordingly. Organized radiology through the Academy of Radiology Research has successfully lobbied for the establishment of the Institute of Biomedical Imaging and Bioengineering at the NIH. Long without a focus for basic imaging research, radiology will have the opportunity through this initiative to establish itself as a major player in the expanding areas of functional and molecular imaging. To succeed, we must devote more human resources to research, develop more mentors for our trainees, and make research training mandatory for our academic faculty. The RSNA, through its Office of Research Development and the RSNA Research and Education Foundation, can be a critical link in the success of this initiative. We must support centers of research excellence and research training for fellows and junior faculty and continue to provide pilot research funding. The Academy of Radiology Research must remain active and provide a strong unified voice in Washington, DC, in support of our interests.
CHALLENGE 4: MANAGING THE INFORMATION NETWORK
Management of the information network will be vital to radiology’s success in the new millennium. No other specialty matches radiology in its requirements for managing image, text, and voice information. Proper integration of advanced communication technology into our practices not only will improve our diagnostic accuracy and communication with our patients, colleagues, and referring physicians but will also provide efficiencies needed to meet the data overload that already exists. Many challenges must be overcome; some, such as standards, speed, storage, and display, are technical. More difficult, however, are the nontechnical challenges, such as confidentiality, access by referring physicians and patients, legal issues regarding which data should be retained, and teleradiology. All of these concerns will be addressed and overcome in the next century, and we must actively participate in their resolution to ensure the patient’s right to quality radiology services. The RSNA, through its cooperation with the Healthcare Information and Management Systems Society, has begun to develop relationships with those industries, which will make the integrated hospital (health care) enterprise a reality. We must, as a field, be part of developing the systems.
CHALLENGE 5: PARTICIPATING IN THE GLOBALIZATION OF MEDICINE
Globalization of medicine is inevitable. Evidence of globalization is everywhere. The 2000 RSNA annual meeting was a perfect example. Attendees from non–North American countries made up 25% of the total attendance; they presented 48% of the scientific papers and 63% of the exhibits. Altogether, 85 countries were represented. Medicine is universal, and as the world keeps getting smaller because of the World Wide Web and other advances in communication, radiology and the RSNA must be prepared to participate in a meaningful way. Through its annual meeting and publications, the RSNA must provide our field with the best science from all over the world. At the annual meeting and over the Web, the RSNA must provide meaningful, innovative, timely educational programs, not only for our North American members but for anyone who seeks this information, regardless of location or nationality. Radiology organizations in the United States must join with their counterpart societies around the world to help developing nations raise the level of their radiology services. The RSNA, through its relationships with such organizations as the Interamerican College of Radiology and the European Society of Radiology, has pledged to be an active player. Someday we will have worldwide standards for training and practice. We must start now to lead the way.
All five of these challenges—maintaining an adequate workforce, providing appropriate training, increasing our research enterprise, managing the information network, and meeting the needs of the globalization of medicine—are vital to radiology’s continued leadership in diagnostic imaging and interventional radiology. A concerted, collaborative effort involving all of radiology will be required if we are to achieve our goals, but history has certainly shown that we are up to the task. Our future is bright. Eric Hoffer, the American philosopher, said, "In a time of drastic change, it is the learners who inherit the future" (6). I am confident that radiology will be prepared, and the RSNA pledges to fulfill its role to ensure that we are!
In closing, I want to thank all of the members of the RSNA for their support this year. I appreciate the efforts of our superb staff, particularly Roberta Arnold, Dana Davis, Steve Drew, Susan Thomas, and Mark Watson, who kept us moving forward in a very stressful year marked by the untimely death of our Executive Director, Mr Stauffer. And I especially thank my wife, Mary Anne, for her constant encouragement, support, and participation in this incredible adventure.
ACKNOWLEDGMENTS
I acknowledge Jonathan H. Sunshine, PhD, of the American College of Radiology and Donna Garrison, PhD, for their help in preparing this material.
FOOTNOTES
Abbreviations: ACR = American College of Radiology, HCFA = Health Care Financing Administration, NIH = National Institutes of Health, RSNA = Radiological Society of North America
REFERENCES
This article has been cited by other articles:
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  S. Chan The Importance of Strategy for the Evolving Field of Radiology Radiology, September 1, 2002; 224(3): 639 - 648. [Abstract] [Full Text] [PDF]
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