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Perspectives |
1 From the Department of Radiology, Children’s Hospital-Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115. Received January 28, 2005; accepted February 2. Address correspondence to R.T.B. (e-mail: robert.bramson@childrens.harvard.edu).
In November 1972, John Holt wrote an editorial in American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine (1) in which he said there were too many pediatric radiologists in practice, there were too many radiology residents entering pediatric fellowship training, and radiology at that time had a crop of pediatric radiologists that was too young to make it a wise career choice for large numbers of radiology residents. What a difference a generation makes!
Try to hire a pediatric radiologist. They are in short supply. One hundred one positions for pediatric radiologists went unfilled in 2003, and by the end of 2004 the number had reached 117 (S. Royal, Society of Pediatric Radiology Committee on Physician Workforce 2004, personal communication, January 2005). That number represents about 15% of the total number of pediatric radiologists who practice in North America. For the past 5 years, the number of new pediatric radiologists that annually enter the working pool has fluctuated between 20 and 35 (S. Royal, Society of Pediatric Radiology Report of Membership Committee, personal communication, January 2005). At that rate, it will take 3–5 years just to fill the available positions if no one retires. The mean age of pediatric radiologists is the oldest of the radiology subspecialists—by 10 years in some cases (2). Retirement looms closer for a large percentage of pediatric radiologists with each passing year.
On the basis of our own experience and what we have learned from others, the number of applicants for pediatric radiology fellowship positions either remains stable or, in recent years, has had several periods of decline. No new fellowship training programs are being added, and many existing programs risk losing their accreditation because they have had no trainees in several years. In addition, an increasing percentage of pediatric radiologists are women. The percentage of women who work part time is greater than the percentage of men who work part time, resulting in fewer "full-time equivalents" in the active workforce (2,3).
Most radiology groups, including our own, have seen an annual workload increase of about 4%–6%. Academic institutions, where the majority of pediatric radiologists practice, also report that the workload for their radiologists continues to increase annually by about 5%–6%. Pediatric hospitals report a similar steady increase in radiology workload, as measured in relative value units (4,5).
At the same time, many third-party payers are contracting with companies that manage radiology benefits and costs to health plans. According to one of these companies, National Imaging Associates, "about one third of advanced imaging tests are either inappropriate for the medical problem or don’t contribute to a doctor’s diagnosis or a patient’s outcome" (6). These efforts in controlling medical imaging costs have resulted in complex requirements for preauthorization and the diversion of more expensive imaging examinations, such as computed tomography (CT) and magnetic resonance (MR) imaging, away from academic or specialty centers toward less expensive providers. That, however, does not always reduce work demands for pediatric radiologists, although it may decrease costs to the third-party payer. For example, at our pediatric institution we interpret or provide a second opinion on CT or MR images obtained outside our institution approximately 3000 times each year. The studies are performed at other locations either because third-party payers referred them there, as a part of a program like National Imaging Associates, or because a pediatric radiologist was not available at that location to obtain and interpret the images. These two trends reinforce the concern about an absence of pediatric radiologists and also point out how an overworked staff of pediatric radiologists ends up doing extra work with little or no financial compensation because of the quirks in the system. We will say more about financial inequities later in this article.
Great! Rejoice! Fewer workers and more work means more money for the remaining supply of radiologists. Alas, the workplace does not work that way. In 1994, Apple Computer controlled 14% of the marketplace with its Macintosh operating system (7). The Macintosh arguably was a very user-friendly computer operating system. Its future potential to capture the majority of customers and businesses buying computer systems was enormous. Software developers wrote new software for both the Macintosh operating system and its rival the personal computer, or PC, operating system. For a variety of reasons that had nothing to do with the quality of the Macintosh operating system, by 1996 the percentage of market share owned by the Macintosh had dropped below 6% (7). Apple Computer had crossed a critical threshold; it had reached a "tipping point." As the market share of the Macintosh operating system dropped below this critical level, a chain of events occurred that made the demise of the organization imminent. In Apple Computer’s case, independent software developers wrote their software for the 92% of the market share that the Macintosh operating system did not control (7). Software engineers did not write software for the Macintosh system or wrote it only as an afterthought. Customers who wanted to use Macintosh operating systems could not get the type and quality of software for their desktop computers that they wanted. The end for the Macintosh loomed near.
Apple Computer did not die, but it had to reinvent itself, and it lost the battle for who controls personal computer systems. Macintosh computers are still sold throughout the country, but when the percentage of market share dropped below the tipping point, Macintosh lost the ability to dominate and control the world of computers. Similar examples exist throughout the business world.
When a company or organization crosses a certain threshold and its market share drops below a certain percentage, it loses its relevance, and the marketplace looks for alternative solutions to the problems that the organization was solving. The exact percentage for any one type of organization is not known; for Apple Computer and Macintosh it was somewhere below 10%. For other types of businesses and organizations it may be another number, but the concept is recognized and makes perfectly good sense. When a company cannot provide the services that its customer base needs, customers find a different way to satisfy their needs.
If pediatric radiology is not able to supply the needs of its referring physicians because of an inadequate workforce supply, pediatric radiology could cross its tipping point and become irrelevant. Customers would find a different method to satisfy their needs. The truth of this is apparent to almost all radiologists. Those locations that do not have pediatric radiologists—and the numbers are increasing—today find the workload shifts to radiologists who interpret adult images and who may be uncomfortable handling pediatric patient cases. That is one potential scenario as the demand for pediatric radiology services continues to increase faster than the supply. The authors are not screaming that the end is near. The authors think pediatric radiology can be saved. But radiology leaders must recognize the impending crisis and take actions to preserve an important subspecialty of radiology. If radiology does not meet the demand for pediatric radiologists, pediatric radiology could quickly reach its tipping point. In the best of the bad-case scenarios, the marketplace will force adult radiologists to perform pediatric radiology studies. In the worst-case scenarios, the various pediatric clinical specialists will fill the vacuum and perform the pediatric imaging. Even today in pediatric radiology there are nephrologists and urologists who want to perform their own renal ultrasonographic (US) studies, orthopedic surgeons who want to interpret their own musculoskeletal MR images, and emergency room physicians advocating their use of US for abdominal trauma. Radiology’s history of holding on to specialized turf has not been good. Cardiologists, obstetricians, and others have slowly captured market share that once belonged exclusively to the radiologist. Why? The inability to provide the services wanted by the referring base ranks as one of the leading reasons. Others might argue that money also is a factor, but let’s be generous and say that perhaps the absence of radiology services available around the clock might at least be a contributing factor.
How can pediatric radiologists retain control of their market share? How can they expand their ability to do the increasing amount of work? How can they capture new market share and do more of the pediatric work that, by default, their adult radiology colleagues are performing and may not want to perform? We propose several strategies. Although we make no claim about the originality of these various strategies, all of them probably need to be implemented, and some of them may even help. By calling the impending crisis to the attention of the radiology community, we hope that there are additional ideas and strategies that others can conceive that we have not even dreamed possible. The critical point is that all of organized radiology must recognize the impending crisis and take actions to remedy the situation prior to reaching that critical level where market share rapidly disappears.
We will discuss several potential strategies that, if implemented either individually or together, may have a substantial positive effect on pediatric radiology.
Increase the Number of Pediatric Radiologists
Radiology must demonstrate that pediatric radiology is an exciting, attractive career choice for young physicians in training—the earlier in their training they get this message, the better. Pediatric radiologists need to aggressively move into the lecture circuit for medical students and radiology residents. They should participate in the development of a national medical student curriculum in radiology (8). The frequent exposure to pediatric radiologists keeps the topics of pediatric radiology in front of the potential recruits on a daily or weekly basis. It allows them to see the effect pediatric radiologists have in the care of children, the ways in which they are useful and respected by their colleagues, and the wide array of interesting problems that they encounter on a daily basis.
The younger generation of physicians makes career choices with a value system and set of goals that may not be exactly the same as those of their predecessors. The younger generation expresses concern over the effect that career choices have on family life. These trends and value choice differences are nicely discussed in Geeks and Geezers: How Era, Values, and Defining Moments Shape Leaders, an insightful book by Warren Bennis and Robert Thomas (9). It is important for the older generations to understand these differences in motivation, since many of the leaders qualify as older members of the radiology profession. The key is for the leaders to recognize that younger members of the medical profession may have very different goals and ideas about what they want to do with their career than did the current leaders when they were just starting in the field of medicine. Engaging trainees in a meaningful discussion of lifestyle and financial and work flexibility can have a very positive effect on the career choice of a physician in training at several different time points. It is especially important to address any potential misconceptions about pediatric radiology, including the need to practice in a rigorous academic environment, the limited supply of positions, and financial discrepancies (10). At worst, physicians in training will learn more about pediatric radiology. At best, they will learn the unique and exciting things that make pediatric radiology fun. Hopefully, some will decide that a career in pediatric radiology excites them.
Reduce Barriers to Entry in the Subspecialty
The educational pathways leading to a career in pediatric radiology need to be carefully examined, with the goal of reducing the amount of training required to reach certification. Is each step necessary? Is there a better way? This may require some radical thinking rather than adherence to a tradition that has, historically, simply added years to the training process at each step. Some thought needs to be focused on what it is in the way of training we want to require for physicians to be pediatric radiologists. Changes might be accomplished in a number of ways, such as the development of a focused "pediatric track" during radiology residency. The American Board of Radiology has approved an experimental pathway called Pediatric Emphasis Diagnostic Radiology Alternative Pathway, or PEDRAP. With this plan, radiology residents would spend half of their time during residency training focused on pediatric radiology and the other half focused on adult radiology. The radiology resident who follows this training pathway will likely have come from a background in pediatrics (11). Some leaders have suggested a variation on the procedure, such as identifying pediatricians interested in radiology and building a special training program for them.
It is not clear how the problem of board certification with special qualification in pediatric radiology will be handled with either of these two suggestions, but that is a topic that needs to be solved. If the fellowship year could be eliminated, that might make the field attractive to some pediatricians who discover that they really prefer practicing radiology to pediatrics but abhor the long training required by both residency and fellowship in radiology.
In response to marketplace pressures, some institutions have changed the length of time required for a pediatric radiology fellowship. The Children’s Hospital in Boston, Massachusetts, once required each radiology fellow to commit to a 2-year fellowship. Now many of their fellows spend only a single year in the fellowship and move on to positions elsewhere. This change met considerable resistance on the part of some staff radiologists at Children’s Hospital, but it was implemented with the intention of trying to meet market demands and the rising shortage of pediatric radiologists.
Increase the Workforce in Pediatric Radiology
In any industry, a disruptive innovation sneaks in from below. While the dominant players are focused on improving their products or services to the point where the average consumer doesn’t even know what [he or] she’s using (think overengineered computers), they miss simpler, more convenient, and less costly offerings initially designed to appeal to the low end of the market. Over time, the simpler offerings get better—so much better that they meet the needs of the majority of users. (12)
This quotation from the Harvard Business Review succinctly summarizes one viewpoint that applies equally well to radiology as it does to other forms of specialization. People working in a specialized field tend to develop a very narrow focus on how to improve their products or services. Radiology needs to take a serious look at the ways in which pediatric radiologists add value to the diagnostic process. Does it really take someone with full residencies in pediatrics and radiology, a 2-year fellowship in pediatric radiology, and 20 years of clinical experience to interpret follow-up fracture images or the fifth scoliosis series? If we add no meaningful value to the care of the child, then let’s not do it, or let’s delegate the activity to a more appropriate level of training or expertise. A provocative article by Christensen et al (12) in the Harvard Business Review proposes that the health care industry focus on "enabling less expensive professionals to do progressively more sophisticated things in less expensive settings" as a potential solution to the current health care crisis. This radical proposal touches on the controversy of the potential role of a physician extender. Other specialties have used physician extenders or physician assistants (13). Why not radiology?
For example, many technologists have years of experience but have a limited career pathway beyond promotion to a higher grade level or into more complex imaging techniques. We should explore the possibility of using technologists in expanded practice models. Specific sets of tasks would be identified as appropriate for a technologist to perform. A course of instruction would be organized. Selected technologists would complete the course, be tested initially and on a periodic basis, and then perform those tasks under the supervision of a radiologist. This would not be an independent practice of radiology, but merely the use of a highly skilled and experienced technologist to perform more routine tasks in a highly supervised environment. The American College of Radiology is currently discussing these possibilities. Perhaps pediatric radiology is the right environment and gives us the opportunity to test this experiment (14).
Increase Efficiency
All radiologists need to leverage the power of technology (eg, picture archiving and communications systems [PACS], voice recognition systems) to make work more efficient. The data do not yet convince everyone that PACS make radiologists more efficient, but the evidence is accumulating. There is a suggestion that PACS allow subspecialists like pediatric radiologists to extend their expertise beyond the geographic borders of their institutions. This could, in theory, supply needed services to some remote locations or to those without a pediatric radiologist available. Clearly, this will only help with the maldistribution of pediatric radiologists. There still needs to be a sufficient number of pediatric radiologists available to actually perform the work. New technology systems will evolve that may allow radiologists to operate more efficiently. Leaders in radiology need to become especially alert to experimenting with new methods to leverage technology to improve workflow processes. This will require leaders with the mind-set to experiment and the ability to fail.
Economic Incentives
Compensation for pediatric radiologists has historically lagged behind that for their adult radiologist counterparts. Third-party payers have paid less for pediatric admissions and procedures than for similar adult admissions and procedures. Pediatric radiologists do not perform the same percentage of high-technology studies, such as CT and MR imaging, and highly compensated studies as their colleagues in adult radiology. It generally takes longer to perform the same type of procedure on a child than on an adult. Therefore, pediatric radiologists usually generate a lower volume of images than do their adult colleagues, and their work consists of lower relative value units. All of these factors account for less pay to pediatric radiologists than adult radiologists.
Radiology needs to make a convincing case to third-party payers that a premium should be paid for subspecialty work done by pediatric radiologists. This may require a joint educational effort to persuade parents that a study performed by a pediatric radiologist is more likely to satisfy the needs and consider the peculiar demands of children and their parents, intuitively resulting in a better study for the child. Third-party payers need to understand this. Parents and pediatricians jointly may need to help persuade insurance companies that pediatric radiologists add value to the care of children (15).
Improving customer service to referring physicians will make the skills and talents of subspecialists more attractive to clinicians. All radiologists could benefit by this, but pediatric radiologists have a unique relationship with their referring physician base. In general, the desire for consultation with radiologists is greater among pediatricians than among adult internists and surgeons. Pediatric radiologists should therefore make a compelling case to parents as to how much value the radiologist adds to the care of the pediatric patient. Showing pediatric specialists the new technology available to help them diagnose and care for their patients should be a coordinated marketing strategy of the pediatric radiology community. It may be necessary to increase ties with subspecialty pediatricians to provide new technology to help them.
Geographic Maldistribution of Pediatric Patients Needing Radiologists
Most pediatric radiologists practice in academic institutions. The opportunities for pediatric radiologists to practice their skills in rural locations or even private practice groups are few. As with any specialty, a certain critical mass of patients is needed to generate enough business to make it financially worthwhile. There are many radiology groups where there are not a sufficient number of pediatric patients for one or two radiologists to focus entirely on pediatric patients during the workday. At those locations, the pediatric work is distributed among the various radiologists, or a single radiologist spends 50%–60% of the time doing pediatric work and the remaining workday is spent doing adult radiology work. Several groups in the same geographic location may have the same situation, but because those groups are competitive rivals they do not share their pediatric workload. Thus, the efficiency of caring for pediatric patients in an optimum manner takes a backseat to the practicalities of the workplace and competitive marketplace. Can we somehow solve this problem? Can we develop methods to transmit images for specialty interpretation without the fear that the sending organization will lose revenue or that the receiving organization is doing work for no compensation?
Leaders need to acknowledge that a problem exists and take bold innovative steps. We need to try different, unique, and innovative methods. As mentioned, we need to not be afraid to fail when trying out new ideas. The end result is too critical to simply wait for a solution to evolve. Letting things evolve on their own represents a conscious decision not to do something with a looming crisis. Radiology needs to learn from other business and management failures and from its own failure in retaining market share; experience with cardiology and some obstetric imaging comes to mind. Unfortunately, leaders are often the most resistant to trying new experiments in how they practice and administer radiology. As Hamel succinctly phrased it, "most management processes are controlled by defenders of the past" (16). Experience in businesses demonstrates that to survive, an organization must adapt. An organization will not adapt unless someone steps up and provides some direction that the organization can take. Who is going to provide that leadership? Can we save pediatric radiology? Do we want to expend the energy, try the experiments, suffer the failures, and find a way to avoid the tipping point that spells the demise of pediatric radiology?
REFERENCES
This article has been cited by other articles:
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  D. R. Kirks, R. T. Bramson, and G. A. Taylor "You can see a lot just by observing," but ... Radiology, April 1, 2006; 239(1): 301 - 303. [Full Text] [PDF]
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D. J. Grunz, R. T. Bramson, and G. A. Taylor Pediatric Radiology Radiology, March 1, 2006; 238(3): 1072 - 1074. [Full Text] [PDF]
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R. R. van Rijn, C. M. Owens, F. Avni, for the European Society of Pediatric Radiology, R. T. Bramson, and G. A. Taylor The Future of Pediatric Radiology: A European Point of View Radiology, March 1, 2006; 238(3): 1074 - 1075. [Full Text] [PDF]
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