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From the Editor's Notebook |
It is proving to be a very tough day for Dr. R. in the ER at Mount Saint Elsewhere. What with the two MVAs added to the usual acute medical and surgical emergencies, the place is a madhouse. Thank God, they installed that ultra high-speed, multidetector helical CT and the PACS is up and running so Dr. R. can get some help with the subtleties when needed. The ability to get an on-line consultation from more knowledgeable associates in the main department is certainly a godsend!
Dr. R.'s discomfort is compounded by the fact that he is usually off this week, attending his favorite scientific meeting, the annual ARRS meeting. But not this year! As one of the senior partners and a long-time mammographer, he is usually posted in one of the two outpatient facilities operated by the group. Under normal conditions, his assignments to the ER are limited to occasional off-hour weekend coverage. But the group is short of staff and could only afford to have one radiologist out this week. And unfortunately, Dr. R. lost the coin toss with his long-time partner, Dr. T.
Dr. R.'s wife wasn't too pleased either. She always looked forward to the trip. In fact, for many years Drs. R. and T. and their wives had attended Roentgen Ray meetings together. It was great fun. The venues are varied and delightful and the meetings themselves are always enjoyable as well as educational.
However, Dr. R. has been promised, if all goes according to plan, next year will be different. Both Drs. R. and T. should be able to go to the Roentgen Ray meeting in Seattle. Their group has hired two new radiologists to join them this July upon completion of fellowships at State University Hospitals; one is a musculoskeletal radiologist with a good background in MRI and an interest in bone mineral density testing, which should answer their needs in orthopedics, and the other is a vascular and interventional radiologist, who should give some relief to the two interventionalist partners presently stretched to the breaking point with the ever-increasing demands for their services.
The group had felt pretty comfortable until 2 years ago, when the demands of off-hour coverage prompted the unexpected early retirement of one of the senior partners. With all the buzz at the time of coming managed care and federal initiatives to control utilization of medical services and to decrease expenditures by reducing payment to hospitals and physicians, the group was reluctant to hire a replacement. Of course, the decision not to hire a replacement required everyone to work longer hours. And despite all the talk about controlling utilization, the workload continued to rise. But at last, after all this doubling up and increased call and reduced vacation and denial of attendance at meetings, help is on the way.
Sound familiar? This same or a similar scenario has occurred in radiology groups throughout the country.
The preceding is brought to mind by two interesting and informative articles in this issue, one by Crewson and Sunshine [1] and the other by Goodman et al. [2], both of which explore the relationship of fellowship training and subsequent employment. I commend them to your attention.
For the past 40 years, diagnostic radiology has been played out in the midst of two competing themes: constant technical innovation and inexorable improvements in imaging capabilities countered by intermittent initiatives of the federal government and other payors to control utilization and limit increases in expenditures for health care.
Forty years ago, imaging was considered adjunctive and optional. However, since then, as a result of technical advancements, imaging has become essential to the practice of medicine and surgery. Yet those who would control health care costs are quite willing to overlook the benefits to patients from the introduction of new technologies and are quick to seize on the cost of imaging, particularly the seemingly high cost of advanced imaging equipment, as an obvious example of needless expenditure. To them, the frequent use of such equipment is often held as a clear example of overutilization.
Periodically the forces of containment introduce new measures to curtail demand for physician services and to restrict physician income. It is assumed that such initiatives should result in a reduction in the demand and payment for imaging examinations: the introduction of Medicare in the mid 1960s, the implementation of DRGs (diagnostic related groups) in 1984, the Hsiao study and adoption of the RBRVS (resource-based relative value scale) in the late 1980s, the Clinton administration's health care reform initiative early in its first term, and, more recently, the introduction of capitation and other such measures by corporate entities (i.e., HMOs and hospitals) to exert control over the practice of medicine. Radiology groups have reacted to each initiative by shelving plans to hire.
But eventually the effort to contain recedes or, if implemented, does not prove to be as onerous as initially feared, and as new technologies are introduced and others improved, and their value in the care of patients is recognized, demand for imaging services continues to increase. It then becomes obvious to many groups that more radiologists are required and while the groups are at it, they recognize the opportunity to shore up one area of imaging expertise or another, whether it be breast imaging, musculoskeletal radiology, or MR imaging to go along with their planned expansion of MR facilities. And they hire accordingly. The job market for radiologists opens up.
In turn, residents in radiology, concerned about their future, recognize that added training in a particular technology or specific subspecialty increases the opportunities for employment and, at the same time, increases the chance to spend more time doing that which they enjoy. And they act accordingly.
With this in mind, we hope that your group is successful in hiring this year so that should you have missed the ARRS Centennial celebration in Washington, DC, you will be able to join us for our 101st annual meeting next year in Seattle, April 29-May 4. Make plans now. We hope to see you there.
In the meantime, until help arrives, good luck in the ER.
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