Radiologist sightings drop around the world

The world is running low on radiologists. This much all concerned parties agree on. But when it comes to putting hard numbers on just what the shortage means-or figuring out what to do about it-that agreement falls apart.

"If anybody gives you a straight, clear answer," said Otha Linton, executive director of the International Society of Radiology, "you shouldn't believe them."

The first problem is that radiology is practiced differently throughout the world. In Germany, about 70% of imaging studies are done by nonradiologists. In Italy, only ultrasound studies are performed by general physicians, while 90% to 95% of all other imaging studies are performed by or under the authorization of a radiologist.

Similarly, radiographers play a greater or lesser role depending on the country. In medically underserved countries, radiographers are the main imaging workforce. But industrialized countries with a limited supply radiologists, such as the U.K., also depend heavily on radiographers to do the basic work.

THE BIG PICTURE

If 10 experts are asked what is behind the global shortage of radiologists, they'll give at least 12 answers. The shortage is most acute in the developed world. No, it's the developing world that suffers the greatest deficiency. Technology can help relieve the scarcity. No, technology is a big part of the problem. Market forces will ease the strain. No, market forces can't be trusted to handle such a complex problem. Governmental policies need to be put in place. No, government interference got us into this mess in the first place.

"The appetite for imaging is bottomless," said Dr. Pablo Ros, a professor of radiology at Harvard Medical School and former chair of the Committee on International Relations and Education of the RSNA.

Workloads are heavier across the board. Imaging volumes increase faster than new radiologists enter the field. In the U.S., for example, the rate of imaging utilization is increasing by 6% each year, while the number of new radiologists is increasing by only 2% per year, according to Dr. Charles Williams, chair of the American College of Radiology's Commission on Human Resources.

"It's becoming impossible to meet coverage demands," he said. "We're seeing an increasingly overworked and unhappy workforce."

That situation prevails across the developed world. In Sweden, imaging volumes are increasing by 2% to 5% per year. The U.K. and Canada are both seeing demand for imaging gowing by 5%. The demand isn't likely to fall.

"Most of these countries are facing the problem of an aging population," said Dr. F. L. Chan, head of the department of radiology at Queen Mary Hospital in Hong Kong. "The shift to more chronic illness and cancers in the older population results in not only a special demand on clinical management in general, but also a higher demand on radiological services."

INCREASED COMPLEXITY

But the story doesn't end there. The complexity of the imaging being done also continues to intensify dramatically.

"Years ago, the American College of Radiology was willing to say that a full workload for a radiologist was 10,000 cases a year, reading stacks of film and doing flouros on the GI system," Linton said. "If we produce 100 images from a CT or MRI study, there's no way that doesn't take longer to look at than the five or six x-ray films of 25 years ago."

Even though it's clear the developing world is facing a fundamental lack of even the most basic radiological services, nailing down firm numbers is no easy task. Missionary hospitals and other health facilities that operate outside of the government's purview, for example, tend not to be counted in official statistics.

"Statistics are difficult to obtain, and they should be regarded with some cautiousness," said Dr. Harald Ostensen, coordinator of Diagnostic Imaging and Laboratory Technology for the World Health Organization in Geneva. "If you ask a health minister in a certain country how the condition in his or her country is, you get one story. If you travel around in the country, you will see a totally different story."

Whatever the numbers, radiologists agree the situation is dire. About two thirds of the world's population has little or no access to radiological services. In South Africa-one of the better staffed countries in Africa-most hospitals in the public sector have never seen a radiologist, according to Dr. Peter Corr, a professor of radiology at the University of Natal. The 20 francophone countries of Africa have about 117 radiologists among them, Linton said. Some countries in Asia have as few as one radiologist per million population, said Dr. Lenny Tan, a professor of diagnostic radiology at the National University of Singapore and president of the Asian Oceanian Society of Radiology.

Government mismanagement of all stripes has contributed to the problem. Many capitalist countries, including the U.S. and U.K., predicted that their populations would suffer from a shortage of general physicians and cut training positions for specialists. Unfortunately, governments have been wrong in their predictions over the last four decades, said Dr. E. Stephen Amis Jr., cochair of the ACR Task Force on Human Resources. Meanwhile, countries with socialized medical systems don't offer enough incentives to increase productivity, according to doctors in those countries.

"There is no gold standard of productivity. Consequently, the average productivity of a radiologist in Italy is, to my knowledge, lower than in other countries," said Dr. Roberto Passariello, chair of radiology at the University of Rome. "In our services, we need many radiologists to take care of issues that are usually taken care of by a lower number of radiologists but probably a higher number of radiographers in other countries."

But governments are almost exclusively responsible for funding training positions. Uniformly, radiologists say the number of these positions just isn't enough.

"We had over 600 applications for seven positions," said Dr. Barry Goldberg, associate chair of research and director of ultrasound at Thomas Jefferson University Hospital. "Out of those 600, at least 100 were the top of the top. We could easily have accepted 100 people, but we can't. There certainly is a desire to go into radiology, but you need training. The bottleneck is the radiology training programs."

ECONOMIC FACTORS

Another factor contributing to that training bottleneck in many countries is the decrease in numbers of academic radiologists. In the U.S., doctors in private practice can make more than twice as much money as their academic counterparts, Ros said. In Germany, academic radiologists don't face the same hurdles.

"Since other radiologists don't earn so much more money, academics are quite happy to stay at the university," said Prof. Bernd Hamm of the University of Berlin.

Market forces in the U.S. play out in other ways as well.

"Our shortage keeps contributing to the shortage everywhere else," Linton said. "There is a desire for bright young physicians who come to this country for training to stick around when they finish."

This trend can hit the home countries of those young doctors especially hard. South Africa, for instance, has fewer than 400 radiologists for a population of more than 42 million, Corr said. But because salaries are low and crime is problematic, many radiologists and radiographers trained in South Africa choose to look for work elsewhere. Countries with stronger economies facing their own shortages take advantage of this factor: About 30% of Australia's overseas radiologists come from South Africa. Canada recruited South African radiologists so aggressively that the country complained to the United Nations that Canada was poaching its educational resources.

Practices designed to help the developing world, such as training programs that ship radiologists to major Western academic centers, can actually do more harm than good, Ostensen said.

"If these people are taken out of their own countries, they will not go back home," he said. "If they do go home, they haven't learned anything that they can use in their small district hospital with one x-ray machine and no CT and no MRI. The only way to help these people is to train them onsite."

Surprisingly, the movement of radiologists to more lucrative countries tends not to be a problem in Europe. Although doctors can move freely throughout the European Union, borders of language still exist, said Dr. Holger Pettersson, president of the European Association of Radiology (EAR). English is a common language, but a doctor must be able to speak the national language in order to practice effectively in another country.

IS TECHNOLOGY A SOLUTION?

Some experts look to technology to help ease the shortage of radiologists. Canada, facing a projected shortfall of at least 500 radiologists by 2006, began replacing much of its outdated imaging equipment in 1999, said Normand Laberge, CEO of the Canadian Association of Radiologists.

"A short-term way of increasing capacity is having better equipment," he said. "Instead of taking 20 minutes to complete a scan with an old CT, you have a multislice scanner that takes two minutes to scan."

Other doctors are pinning their hopes for the future on teleradiology, PACS, and other innovations that they hope will increase the efficiency of imaging facilities-eventually.

"PACS will be fine once it's 100% rolled out, but it's far from 100%," Amis said.

When ask if a solution is on the horizon or what can be done to ease the shortage, the experts, predictably, disagree. Some in the U.S. advocate the creation of a "supertech" to perform more of the basic work. At the moment, however, radiographers are in shorter supply than radiologists.

Another idea, which Ros acknowledges is somewhat heretical, is simply to cede the studies that don't produce much income to other specialists or even general practioners. Canada's Laberge protests, however, that this idea could put the quality of the reading in peril.

A controversial proposal in the U.S. is to reduce the time spent in training from five years to four years. At the same time, however, many European countries are discussing adopting the U.K.'s five-year training protocol.

In the developing world, the practice of "training the trainers" onsite or in regional centers may help increase the number of radiographers, but the equipment shortage is still critical.

"There is no magic bullet," Amis said.

Sarah Jersild is a freelance writer in Chicago.