AJR 2000; 174:3-8
© American Roentgen Ray Society
ARRS Presidential Address |
Education in Radiology:
Challenges for the New Millennium
Theresa C. McLoud1
1
Department of Radiology, Harvard Medical School, Massachusetts General
Hospital, P. O. Box 9657, 55 Fruit St., Boston, MA 02114.
Presented at the annual meeting of the American Roentgen Ray Society, New
Orleans, May 1999.
Address correspondence to T. C. McLoud.
Introduction
Education is indeed the third pillar, one of the major components of the
tripartite mission of the specialty of radiology, which also includes clinical
practice and research. Although it may be traditional to consider education as
the primary responsibility of academic and training institutions, it in fact
affects all of our careers as radiologists. The future of our specialty is
determined by the quality of education in our residency training programs and
by our ability to recruit bright, young medical students into our field.
Education is indeed a lifelong endeavor for the practicing radiologist. Issues
of continued competence and time-limited certificates, now given by the
American Board of Radiology (ABR), make it even more compelling for the
practicing radiologist to maintain his or her skills and to acquire new
knowledge and expertise as the field advances.
Education and training in radiology occur at three levels: in the medical
schools, during residency and fellowship, and in the form of continuing
medical education (CME) for the practicing radiologist. I will focus most of
my address on residency training issues because as a program director that is
my main area of interest and expertise.
Perhaps the most compelling question for us to ask is the following: Are we
really preparing today's residents for both today's and tomorrow's practice
This issue was most recently addressed at the American College of Radiology
(ACR) Intersociety Commission meeting in 1998
[1]. Although most residency
training programs are situated in academic and university departments, we
prepare only a small minority of our residents for academic practice.
Approximately 80% will eventually practice in large or small private-practice
groups. We must therefore train and prepare residents adequately to meet the
needs and wants of these two different career situations. They must be
prepared to respond to the needs and requirements of clinicians, whether
generalists or specialists, and most importantly, to fulfill the needs and
requirements of our patients.
As I see it, radiology training programs face four major challenges in the
new millennium: recruitment, funding, the development of a model curriculum
that will prepare our residents adequately for the challenges of different
marketplaces, and finally, employment. Our ability to recruit bright and
successful medical students to radiology is of course related to their
perception of radiology as a specialty. In the early 1970s, most medical
students entering radiology residencies ranked in the bottom 20% of their
class. Radiology was then perceived as an unattractive and
less-than-challenging specialty. However, radiology is now regarded as a
highly successful medical specialty that has advanced from being a scientific
curiosity to being an integral part of health care. Technologic advances and
improved diagnostic imaging techniques have led to the dramatic development of
interventional radiology, sonography, CT, and MR imaging, thus creating new
subspecialties within radiology
[2]. The growth of diagnostic
and therapeutic interventional techniques as well as functional and molecular
imaging have continued to place radiology in the forefront of medical
advances. These developments have permitted our specialty to recruit some of
the most talented individuals into radiology during the 1980s and early 1990s.
However, there are other important components that determine whether radiology
is attractive to the budding medical student. These include the job market and
opportunities for employment after the completion of residency and fellowship,
financial compensation, and lifestyle. Health care reform and the growth of
managed care have affected both financial compensation and lifestyle for the
radiologist. Demand for 24-hour service for interpretation of imaging
procedures, the decrease in fee-for-service rates, and lower compensation from
capitation have also made an impact on financial compensation and lifestyle. A
national consensus has determined that there is a need for more generalists
and primary care physicians and that the number of specialists should be
decreased until the physician workforce is composed of about 50% generalists
[3]. This consensus has led to
policies at many of the medical schools in the United States that have worked
toward ensuring that 50% or more of the graduating class will enter generalist
areas. Both persuasion and pressure are applied to influence medical students
to choose primary care and generalist residencies.
Employment
Despite what might be perceived as a number of negative factors affecting
recruitment into the field of radiology, statistics regarding employment and
recruitment over the past 2 years show reason for considerable optimism. A
survey of program directors reported that the unemployment rate for diagnostic
radiology graduates over the past 3 years has been less than the 1.1%
unemployment rate for all United States physicians in 1997
[4].
Finding suitable jobs in the field is getting easier. The decline in hiring
of radiologists noted in the early and mid 1990s has been reversed or at least
has ceased for now. Figures 1
and 2 show the employment rates
for diagnostic radiology resident graduates and fellowship graduates
[5]. Most residency graduates
seek fellowship positions, and only about 20% proceed to a permanent job
situation. Residents who were unable to secure a position constituted only 1%
and 1.2% in 1997 and 1998, respectively. Perhaps more important are the
results for fellowship graduates, the largest group of radiology trainees
seeking permanent positions. Figure
2 shows that in 1996, 95% of graduates of fellowship programs had
secured a permanent position within 6 months after completion of their
fellowship and that this percentage had increased to 98% in 1998. In addition,
an ACR study found that 85% of the 1997 graduating fellows had found jobs that
reasonably matched their training and goals
[6]. A survey of radiology
program directors in 1997 showed an even higher rate of satisfaction, with 96%
of graduates reported to have secured jobs that reasonably matched their
training and career goals
[4].
View larger version (15K):
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Fig. 1. —Employment statistics for graduating radiology residents for years
1996 (gray bars), 1997 (white bars), and 1998 (black
bars). Only 1.2% of residents were unable to obtain employment in
1998.
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View larger version (28K):
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Fig. 2. —Employment statistics for graduating fellows in radiology from 1996
to 1998. Number of unemployed fellowship graduates has steadily declined. In
1998, only 2% were still seeking positions 6 months after completion of
training. White = unemployed, light gray = private practice, black = academic,
dark gray = other.
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Recruitment
Similar optimistic observations can be made regarding recruitment. The
percentage of national match positions that were filled in diagnostic
radiology in 1996 and 1997 were 60% and 70%, respectively. This represents a
decline from 80% in 1995. The decline in residency applicants and the
perceived decline in the quality of residency applicants in 1996 and 1997 were
felt to be attributable to the forces that already have been cited: the
attraction for careers in primary care and generalist areas such as internal
medicine, the perceived lack of opportunities in the job market, and changes
in lifestyle and reimbursement. This trend appears to be reversing, with 86%
of the match positions filled in 1998 and recent results from 1999 indicating
that 86% of positions have been matched. An almost 40% increase in the
applicant pool between 1998 and 1999 (from 1520 to 2297) was also seen.
However, it is important to note that there was a slight decline in the
percentage of United States medical graduates relative to international
applicants.
Despite the improvement in recruitment and the increase in number of
graduates in the applicant pool, it may be getting more difficult to find a
place to do residency training in radiology. The number of first-year or PGY2
(post-graduate year 2) training positions available in diagnostic radiology
declined from 1024 to 990 between 1995 and 1997, and the number of programs
declined from 206 to 197 [4]
(Fig. 3). In addition, the
percentage of diagnostic radiology residency first-year positions filled by
graduates in medical schools outside the United States and Canada is
increasing. About 22% of the positions in 1997 were filled by IMGs
(international medical graduates), compared with 17% in 1996 and 15% in 1995
[4].
Funding
Regardless of some of these reservations, trends in recruitment and
employment appear promising. Radiology faces another major challenge in the
new millennium in regard to funding for training programs. Such funding now
comes from the federal government through the Medicare program, which provides
both direct and indirect funding to training institutions for the education of
its residents. The federal government is now debating the appropriateness of
federal government support for medical education. The Balanced Budget Act of
1997 limits the number of house staff that will be funded by Medicare in a
given hospital, and it also has reduced the indirect medical education
payments over the next 5 years by 29%
[7]. The federal government is
also debating whom it should support. Medicare currently supports resident
training by payments to the training institution for salary support, benefits,
and the indirect costs of training programs. Historically, when the federal
government offers support for education, it supports the trainees directly
through scholarships and loans. If federal funding were to shift from
hospitals to trainees, the negative impact on the bottom line for most
hospital budgets that provide residency training programs could be as much as
10%. The government also has considerable concerns regarding the
ever-increasing number of international medical graduates. The federal
government is funding such graduates at a time when there is concern about an
excess supply of physicians. Proposals for alternate sources of funding have
been suggested, including an education tax on managed care and health
maintenance organizations and the establishment of an educational trust fund
that would be supported mainly by radiologists in private practice. Neither of
the two options appear practical or likely, at least for the immediate
future.
Adequate training in subspecialty areas has become mandatory over the past
decade. Such training is usually provided in 1- or 2-year fellowship programs.
Fellowships include both ACGME-accredited (Accreditation Council for Graduate
Medical Education) and nonapproved training programs. The issue of funding for
the fellowship programs is more immediate and critical than that of funding
for radiology residency programs, which is currently from hospital or
department funds. HICFA (Health Care Financing Administration) and Medicare
fund ACGME-approved fellowships at only a 50% level, and a minimal amount of
funding may come from grants. Sources for alternative funding must be
aggressively pursued over the next decade. Possibilities include having the
trainees pay for at least a portion of their education. This is an unlikely
and quite unattractive option because many of our trainees sustain heavy debt
from their medical school education. It is expected that federal government
support will continue to decrease. An educational tax on health maintenance
organizations has been suggested but will likely be resisted. Establishment of
a national or educational trust fund to which all radiologists would
contribute would allow training programs to be independent of other funding
sources, but it would probably be necessary to raise more than $1 billion from
United States radiologists over a 10- to 15-year period to accomplish the
necessary goal.
Manpower Requirements
Despite the optimistic situation in the market-place for employment of
radiologists at the present time, we as a profession must ask ourselves
whether we will actually produce a large surplus of diagnostic radiologists in
the new millennium. The growth in managed care and plans to reduce the numbers
of physicians have focused attention on the possible oversupply of physicians,
particularly non-primary care physicians. One widely publicized government
analysis projected a 60% oversupply of non-primary care physicians by the year
2000 [8]. There has been much
discussion about the possibility that diagnostic radiology may be facing such
a surplus in the near future. It is difficult to make a precise assessment of
the future need for radiologists, although efforts should be continued to
estimate that need. Multiple factors may affect changes in demand for
diagnostic radiology service. These include factors that increase demand, such
as population growth; the aging of the population (elderly persons use more
medical services); universal health insurance (which may be a prospect for the
coming millennium); the increasing employment of female radiologists, a
certain proportion of whom tend to work part time; and the increasing
complexity of imaging examinations
[9]. These are balanced by
factors that decrease demand, including health care reform and more efficient
radiology service. In 1995 there were approximately 24,000 diagnostic
radiologists in the United States. Assuming that the rate of attrition is
steady at 2.5% of the total and that 900 residents complete their training
each year, the total number of radiologists by the year 2010 would be 28,000.
Rosenquist has suggested this number may be 1500 in excess of estimated needs
[9]. However, although precise
estimates of future manpower requirements are often inaccurate, it appears
reasonable that a slight reduction (10-15%) in the number of trainees may be
warranted.
Curriculum
Are we indeed preparing today's residents for tomorrow's practice? More
flexibility in our training programs is required because the market has
changed and subspecialization within our field has changed. We are often
producing trainees who are all much alike, but the job market may be totally
different depending on their choice of careers, the degree of
subspecialization required, and the choice of academic versus private
practice. Radiology training programs may not be adequately preparing
residents to meet these demands. It may be necessary to produce multiple
tracks with different curriculums within training programs to address these
needs. These are times when the academic and educational mission of training
programs is under siege. Declining revenues have been accompanied by
increasing clinical volume. This creates a unique challenge for resident
education. Most practicing radiologists have been trained in programs in
academic departments in which there was ample time for the resident to preview
cases at either the viewbox or the workstation and to review studies in a
somewhat leisurely manner with the staff. This created a situation of
intensive one-on-one teaching. Unfortunately, this is a model that has become
outdated. Creative approaches are needed to ensure the quality of our resident
education and to motivate faculty to teach in difficult circumstances. These
could include financial incentives for teaching efforts as well as for
clinical productivity. Many medical schools now require documentation of
teaching accomplishments and efforts as a prime criterion for promotion.
A well-defined curriculum also helps ensure the quality of resident
education. The ACGME has defined specific program requirements for the
curriculum. These include educational goals and objectives with respect to the
knowledge, skills, and other attributes residents must acquire at each level
of training and for each major rotation or other program assignment. The
Association of Program Directors in Radiology has recently solicited the help
of each of the subspecialty organizations in radiology in an effort to develop
a well-defined curriculum for each level of training in subspecialty areas
such as chest, bone, neuroradiology, and so on. These curricula include a
listing of interventional techniques, algorithms, specific disease entities,
and a detailed bibliography, among other items. Documentation of such a
curriculum must be provided to the ACGME and circulated to all the residents
before each rotation. This approach will provide both internal and external
monitors to ensure that the objectives and goals of the curriculum are
met.
Both resident training and the curriculum must be flexible and prepare
residents for the job markets they will enter. The wants and needs of the
academic as well as the private practice community must be taken into
consideration. Many of the needs and wants of these two communities intersect.
The primary mission of both communities is clinical service and patient care;
however, each group has some unique requirements.
Academic Radiology
Academic radiology is a dynamic and evolving field that needs to respond to
new developments in research and scholarship. It is perhaps helpful to review
the traditional roles of the academic radiologist and how those roles must
change for the new millennium. Steven Chan
[10] has recently published a
provocative essay addressing this issue, which I will summarize. The emergence
of academic radiology was characterized initially by the age of the general
radiologist; during this period, the clinical usefulness of radiologic
techniques in everyday medicine was established, as was the role of the
radiologist in general medical care. This was followed by the age with which
most of us are familiar and which exists in most of our academic departments,
that is, the age of the sub-specialist radiologist. These radiologists
established, maintained, and expanded the role of imaging in every domain of
medicine. Sub-specialty radiology has developed and matured over the past two
decades and now forms one of the major pillars of both private practice and
academic radiology. The new millennium, however, will demand some changes in
this academic model. The discipline of radiology has never enjoyed such a wide
array of clinically relevant diagnostic technologies or such a plethora of
emerging imaging technologies and developmental advances. We now possess the
tools to image specific molecules, reconstruct three-dimensional images of the
body, and visualize cerebral function in real time. It has become clear even
to many observers outside organized radiology that diagnostic imaging is a
field to which greater attention and resources should be devoted in the near
future. These developments in our field make it clear that it is necessary to
develop a core of academic radiology faculty with a variety of
interdisciplinary capabilities and backgrounds who can respond to the
challenges proposed by these new developments in imaging and who can perform
the cutting-edge research that is required to maintain growth in our field.
The new academic model must include the clinician scientist who has training
and expertise in other fields, including biostatistics, epidemiology,
technology assessment, and outcomes research. Such clinician-scientist
radiologists will be actively involved in establishing in a rigorous fashion
the clinical usefulness and societal benefits of imaging. Another model for
the future not only encompasses the needs of academic radiology but also those
of community practice—the model of the physician manager. A physician
manager has knowledge of the managerial and social sciences and can connect
technology and imaging with the organizational arena. Such an individual can
maximize the benefits of imaging relative to available resources and can
integrate radiology into the health care system.
Radiologists must have the skills to participate in the frontier fields of
science that affect imaging. These include molecular biology, physics, optical
imaging, radiochemistry, tissue engineering, and computer science. Frontier
fields also include the social sciences, technology assessment, health
services research, operations research, medical informatics, decision
sciences, and financial management. It is clear that the academic radiologists
of the future will need an extended portfolio of skills to meet these
challenges. How do we prepare the academic radiologists of the future to
contribute meaningfully to such frontier fields? The solution probably lies in
the development of alternative educational pathways in other academic
educational programs that will allow the academic radiologist to function as a
full-fledged practitioner of another discipline. This approach will usually
involve the attainment of an advanced degree in another discipline. It is
clear that traditional radiology training programs will not provide the entire
solution. The answer may lie in medical schools with joint programs. In the
past, academic radiologists have pursued advanced degrees, usually a Ph.D.
degree, in the biologic and physical sciences, either as part of an M.D./Ph.D.
program or as a separate educational pursuit. Recently, masters degree
programs in public health or business administration have increased in
popularity among academic radiologists. A common characteristic of each of
these alternative educational programs is the identification of a core body of
knowledge and a set of key skills that usually differ from those learned
during medical school and residency training. Other pathways include
postdoctoral research fellowships and sponsored training programs. All of
these efforts should extend the boundaries of academic radiology to encompass
other academic efforts with respect to the basic sciences and the social
sciences. Interdisciplinary work beyond radiology should become the norm for
academic radiology departments. Modifications in the traditional residency
training program can also help accomplish these goals. The ABR has recently
implemented a research or academic track—the Holman research
pathway—that will allow close to 2 years of research time as part of a
modified residency model. Such a track may benefit those who enter our
specialty with the requisite alternative pathway already completed, such as
M.D./Ph.D., M.P.H., or M.B.A. degrees. The development of critical thinking
skills and instruction in noninterpretive issues are also critical to the
development of both the academic and private-practice radiologist.
Generalists
Specific wants and needs of the private-practice market can be identified.
The resident skills in these areas apply equally to private and academic
practice. Radiology practices place a high emphasis on communication skills.
Residents must learn how to dictate effective reports, consult wisely and
effectively with clinicians, and be able to multitask and interpret large
numbers of cases. Although the age of the subspecialist has occurred in the
community practice as well as in academic radiology, the resident must develop
a strong base in general radiology. This is necessary because interpretation
of studies outside the subspecialty area will occur frequently and will often
be the norm. Interpersonal skills and the development of professionalism are
also critical factors. Professionalism includes those attributes that are
necessary for the consummate care of the patient, in other words, being there
to do the job when there is a job to be done. To succeed in private practice,
residents should have comprehensive knowledge of a number of noninterpretive
skills. How can training programs change so that these wants and needs of
community radiology are effectively addressed? First of all, training programs
must evaluate skills such as effective dictation. These should meet the ACR
standard. Residents should be placed in situations where multitasking is
required, such as outpatient training and primary care activities. Emphasis
should be placed on interpersonal skills. Ideally, only those residents should
be selected to enter training programs who have the requisite interpersonal
skills. The problem resident should be identified early, and remedial guidance
and assistance should be available if personality problems arise. It is
extremely important that the faculty serve as role models in the development
of professionalism among residents. Faculty members may have to evaluate their
own professional behavior to teach these attributes to the residents. Finally,
a curriculum should be provided for the development of noninterpretive
skills.
Communication Skills
We must also train residents to be capable of meeting the wants and needs
of specialists, generalists, and most importantly, our patients. Communication
with clinicians and patients is important, and these skills need to be
emphasized and taught to residents by faculty. The resident should be taught
to be an effective consultant and to interact effectively with referring
physicians. Mechanisms for accomplishing this task could include supervised
rotations where the resident is exposed to the gatekeeper role and provides
advice on the sequencing of examinations. Residents should participate in
clinical conferences with those in other disciplines. Radiologists need to act
as physicians and must not forget that the patient is the reason for our
efforts. Patient focus groups or direct communication with patients under
faculty supervision may be helpful training approaches.
Noninterpretive Skills
The teaching of nonclinical and noninterpretive skills to our residents is
an integral part of the residency training curriculum. The ACGME requires that
all institutions provide their residents with a curriculum that has a regular
review of ethical, socioeconomic, medicolegal, and cost-containment issues
that affect medical practice. In fact, the program requirements for diagnostic
radiology published in January 1999 clearly state that diagnostic radiology,
radiologic physics, radiation biology, radiation protection, computer
applications, radiology practice management, and pathology are required
elements of the curriculum
[11]. In response to the
critical need to teach nonclinical and noninterpretive skills to residents,
the ACR and the Association of Program Directors in Radiology have formed a
working group to devise a curriculum to teach these skills that could be made
available to all training programs. Such a curriculum would include practical
business issues in radiology, ACR standards for accreditation of programs and
appropriateness criteria, service orientation and interpersonal skills,
medical organizational politics, critical thinking skills, ethics, and job
search and contracting. Because it may be difficult for many programs to
develop curricula dealing with all of these issues, the ACR and the
Association of Program Directors in Radiology are developing videotapes that
will consist of short, live sessions with residents and a 30-min faculty
presentation followed by live interaction with the resident audience. Such a
videotape could be shown at local sites, and the local program director could
facilitate more discussion in response to the faculty presentation.
Radiology Review Commission and ABR
Some radical changes in the way we train residents may be required to
prepare them for the new millennium, either in the field of academic radiology
or in community radiology practice. How are we going to ensure that this
occurs? Perhaps the most effective instruments for change in residency
training programs are the Radiology Review Commission and the ABR. Their
approach is, "If we test for it, residents will learn it," and the
ABR is currently reviewing the content of its examination. It may consider
reengineering the examination to address such issues as critical thinking
skills and knowledge of noninterpretive and nonclinical issues ranging from
standards of practice to the business aspects of radiology. It has approved
the new Holman research track to better train residents for academic
careers.
Continuing Medical Education
Education is a lifelong endeavor and continues throughout our careers as
radiologists. CME has recently become a more compelling issue because the ABR
issues time-limited certificates. Recertification is on the horizon, and even
those currently in practice may be required to obtain recertification to
obtain licensure in other states. Changes in the health care scene have also
affected CME. Many university-based postgraduate courses are affected by
limited financial resources and less time for faculty participation. The new
millennium will certainly witness the continuation of very traditional
vehicles for CME, such as annual meetings of national societies like the
American Roentgen Ray Society, professional journals, audiotapes, videotapes,
and syllabi of courses presented at national meetings. However, there is no
question that we have already moved into the era of electronic education.
Electronic media such as CD-ROMs, but more particularly the Internet, are
growing in popularity among radiologists. The burgeoning electronic delivery
of CME is being used across all specialties. In the new millennium,
radiologists may choose to go no further than their computers to learn about
new tools in radiology and to brush up on imaging techniques. This shift is
not surprising. Most physicians today have less time and money to allocate for
travel and in most states must still fulfill CME requirements for licensure
renewal. The electronic future provides unique opportunities for societies
such as the American Roentgen Ray Society to distribute educational products
and materials from annual meetings online to all its members via the World
Wide Web. The Society is also considering the development of an education
center at its new property in Leesburg, VA, although this has not officially
been decided. The center could offer courses in computer education,
particularly in picture archiving and communication systems and virtual
reality.
In summary, the new century will provide us with fewer resources and some
unique challenges in the field of education at all levels—medical
student, residency, and CME. However, the developments in our field and new
advances in technology and exciting new areas of research provide us with
unique education opportunities. I am convinced that our specialty will
continue to attract the best and the brightest. It is up to us to provide new
recruits into the profession with the necessary education and tools to ensure
the future of radiology as a specialty.
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Radiology Review Commission and...
Continuing Medical Education
