Radiology Veers Off the ROAD

Thirty years ago, radiology had a good reputation. Salaries were high. Hours were short. Providers vacationed in exotic locales. Life as a radiologist was nearly storybook.

Today, the perception of radiology is quite different. The picture painted for medical residents and early-career radiologists includes declining reimbursement, nearly around-the-clock work hours, and more complicated imaging studies.

They’re signs the specialty has changed, said Richard Gunderman, MD, PhD, professor of radiology in Indiana University’s Center for Bioethics.  

“The perception for a long time was that radiology was a great lifestyle specialty. You didn’t have after-hours duties except for being on call. Patients weren’t calling you with problems or questions about their health. You worked short hours and were relatively well compensated for it,” he said. “That situation has changed considerably.”

But, changes and a movement away from the lifestyle specialty moniker aren’t necessarily bad things. Overall, radiology has simply assumed a new role within the health care system.

Technological Advancements
One of the biggest shifts affecting radiology has been the rapid expansion and improvement of modalities. Over the last two decades, the advent of advanced imaging machines, including MRI and PET scanners, have made imaging not only ubiquitous, but also a more integral part of diagnosis and treatment.

“As medicine has moved forward, radiology has been a part of that. That’s the exciting thing about radiology,” said Linda Dew, MD, medical director and diagnostic radiologist at the Center for Diagnostic Imaging in Illinois. “Although we get less sleep than we used to, and it’s not as much a lifestyle specialty as before, we’re a much more integral part of the health care system.”[[{"type":"media","view_mode":"media_crop","fid":"42827","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2362124569473","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4657","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 148px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

When radiology dealt mainly with X-rays, it wasn’t uncommon for emergency room physicians to read images themselves before securing a radiologist’s interpretation. Today, however, increased advanced imaging options make diagnostic studies possible at all hours, and most require a radiologist’s purview, which means a provider must be available at all times. 

James Rawson, MD, chair of the American College of Radiology (ACR) Patient Experience Commission agreed. The growth of more complex technologies has made it easier for referring physicians to request – and expect – imaging services at any point with a more rapid turn-around time.

 “When I entered clinical practice more than 20 years ago, we did some CT scans on the weekends, but they were mostly emergency cases,” he said. “Now, we do CT scans 24/7, and it’s the same with our MRI scanners.”

Referring physicians anticipate rapidly-available radiology reports in order to make effective, accurate diagnoses and to design appropriate treatment options. That means providers are reading more, analyzing faster, and working longer hours. The extended hours are necessary to compensate for the drop in reimbursement rates, he said. However, it’s unlikely that concerns over flagging payments are still contributing significantly to provider happiness within the specialty.

“The uncertainty of reimbursement rates for radiology and all of health care has been there for years. So, I’m not sure it’s a big driver in terms of selecting a career,” Rawson said. “I think people who are attracted to radiology are people who like to solve problems and who enjoy technology and clinical decision making. They like to be engaged in the improvement of patient outcomes.”

More Options
As a whole, more scans and truncated turn-around times are requiring greater time investments from radiologists. This situation has required some radiologists to work longer hours, but it’s also presented additional employment options. Rather than being relegated to working in hospital departments or private practices, radiologists willing to work nights and weekends have opted to work for teleradiology companies.

These types of outfits give radiologists greater flexibility in choosing where they live and when they read imaging studies. And, over the past decade, the number of teleradiology companies has ballooned.

“Many smaller hospitals and practices were getting to the point where radiologists were up all night on call and, then, working into the next day. That’s a long time to work,” Dew said. “Using advanced technologies, hospitals can send images anywhere and have radiology experts read studies. This way, the hospital-based radiologists can get the sleep needed to do a proper job.”

In addition to offering radiologists lifestyle choices, outsourcing imaging reads can protect patients, she said. Just as pilots aren’t allowed to fly when they’re tired, radiologists give patients much better care by using teleradiology when it’s needed.

Impact on the Provider
The increased presence of advanced technology and growing number of diagnostic images doesn’t always mean a radiologist’s focus stays on the patient, however. In many ways, a radiologist’s concentration and attention goes elsewhere – a change that can impact his or her professional happiness and fulfillment.

“The hospital systems in which we work have grown more complex. Radiologists, today, spend more time thinking about compliance and regulatory issues, information technology, ICD-10, and other billing and coding issues,” Gunderman said. “The amount of what you might call bureaucracy and red tape is greater than it used to be.”

And, having to concentrate on so many issues outside patient care can wear away at a radiologist’s ability to provide quality care. Consequently, physician wellness and provider burnout have become common topics at professional meetings in recent years.

“These weren’t hot topics 10 to 15 years ago, but they’re more prominent now. It’s because of the change in work responsibilities and the impact on work-life balance,” he said. “It’s made radiology practice much more difficult and challenging in many respects. It’s more tiring, more frustrating, and less fulfilling than it used to be.”

The ACR is actively combatting these professional pitfalls. Its Imaging 3.0 initiative focuses on cultivating the relationship among provider, patient, and referring physician. The ACR isn’t alone in its efforts, however, Gunderman said. Indiana University offers a program called FIRM (Finding Inspiration and Resilience in Medicine) Symposium that’s designed to capture and nurture career satisfaction.

Currently for fourth-year medical students, the initiative addresses daily struggles and gives students the opportunity to discuss their professional concerns. The goal, Gunderman said, is to help early career providers see beyond RVUs and daily productivity and identify strategies that will play up the most satisfying aspects of providing radiology services.

In most cases, he said, positive points are directly related to increased patient contact. In addition, radiology departments and practices can make the field more enticing by allowing providers to work more flexible schedules with irregular hours or less than full-time loads.

Making this effort is critical to the specialty’s future, he said. The perception that radiologists spend all their time shackled to an isolated viewing station will repel people from choosing the specialty at a time when industry leaders are trying to make the field more attractive.

“We radiologists need to seek opportunities to interact more frequently with patients,” Gunderman said. “But, we should be prepared to accept some decrease in our productivity to become more connected with patients and with our referring physicians.”