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1 Research Department, American College of Radiology, 1891 Preston White Dr.,
Reston, VA 20191.
2 Department of Diagnostic Radiology, Yale University, New Haven, CT.
3 Department of Radiology, Wake Forest University School of Medicine,
Winston-Salem, NC.
4 Department of Diagnostic Radiology, Economics Department, and School of
Management, Yale University, New Haven, CT.
Received November 28, 2003;
accepted after revision December 5, 2003.
Address correspondence to J. H. Sunshine
(jonathans{at}acr.org).
Abstract
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MATERIALS AND METHODS. Four sources of information are available, and we present their data: first, the number of jobs for diagnostic radiologists advertised in Radiology and the American Journal of Roentgenology; second, vacancies in academic radiology departments as of July 1, 2003, ascertained by a survey of these departments; third, the ratio of job listings to job seekers at a major professional placement service, the Professional Bureau of the American College of Radiology (ACR); and fourth, diagnostic radiologists' self-reported workload burden, from the ACR's 2003 Survey of Diagnostic Radiologists.
RESULTS. Jobs advertised in September–November 2003 (latest data available) were 28% fewer than in the same months of 2002. Vacancies per department averaged 3.9 in 2003, compared with 5.4 in 2001 and 5.1 in 2002. Listings per seeker were 1.4 in 2002 (latest data available) compared with 3.0 or more in 1999 and 2000. Responses to a question directly tying changes in workload to changes in income indicated that reported desires for workload reduction and workload increase were approximately equal.
CONCLUSION. All four information sources have important limitations, but all indicate that the shortage has considerably eased. We plan to study the causes of this easing and continue to monitor the situation.
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Recent projections call for the shortage to become even more severe because the total workload of radiologists in the United States is expected to increase much faster than the number of radiologists in practice [1]. However, the authors of the projections have warned that a number of factors could render the projections incorrect. Such factors range from the development and deployment of productivity-increasing technologies such as PACs (picture archiving and communication systems) to a possible revival of managed care that would, for the first time, affect patterns of care in a major way. Also, for more than 30 years (the longest time horizon for which information is readily available to us), a series of shortages of diagnostic radiologists have alternated with a soft employment market, and most predictions have—at least in the long term—eventually proven incorrect [1, 3–10]. The possibility of developments that would render predictions incorrect plus this history of fallibility make it crucial to carefully monitor the shortage, which the ACR-convened task force recommended doing.
We present here the most recent information available on the shortage. We have identified four types of such information and believe these sources represent the full body of systematic recent information that can be obtained. Each of the four information sources has important limitations, but we judge that in combination they provide a highly useful picture of the most recent trends in the shortage. In the Discussion, we not only review these findings but also speculate on possible reasons for the trends observed.
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Job Advertisements for Diagnostic Radiologists
Measuring the quantity of help-wanted advertising has long been a technique
used for gauging the overall economy
[11]. One of us (the fourth
author) developed the technique of tracking help-wanted job advertisements for
diagnostic radiologists as a way of measuring the job market for the
profession [11]. The first
author, together with the fourth, showed that this is a valid measure of the
employment market [12]. Under
the fourth author's leadership, they and more junior colleagues have been
publishing an annual update and detailed analysis of the employment market as
measured by these advertisements
[13–15].
The method used in these previous publications has been to tally advertisements in the American Journal of Roentgenology (AJR) and Radiology according to a carefully specified protocol, analyzing them by such categories as academic versus community-based practice, subspecialty, region of the United States, and so forth. For this study, the third author simply counted the number of jobs advertised in the most recent 3 months (September–November 2003) and counted in identical fashion the number in the corresponding period in 2002. Because job advertising is highly seasonal, comparison with the corresponding months of the previous year, rather than with earlier months of the same year, is required. Because the count was performed by the same person in identical fashion for the two 3-month periods, our comparison is consistent. However, because this study did not use the protocol that was used for previously published data on 2002, and because of interobserver variability, its findings may differ slightly from previously published statistics [15].
Vacancies in Academic Radiology Departments
Since 2001, the second author has been conducting an annual survey of
academic radiology departments regarding their number of vacancies.
Departments were contacted by mail in the summer and asked the number and
fields of vacancies they had as of July 1 of that year. Follow-up was by
telephone and, in 2003, also by e-mail. The departments surveyed numbered
approximately 120. These consisted of all departments whose head was a member
of the Society of Chairmen of Academic Radiology Departments (SCARD; the
mailing list for these was obtained from SCARD) plus the small number of
medical school departments that were not SCARD members. We present summary
data for 2003 and compare these with earlier years.
Ratio of Diagnostic Radiology Job Listings to Job Seekers at a Major Professional Placement Service
Since 1990, the American College of Radiology has been tracking this ratio
at its placement service, the ACR Professional Bureau, during the week of the
annual meeting of the Radiological Society of North America (RSNA), which has
been the peak week of the year's activity for the Professional Bureau. The
first author has published these data and, together with the fourth author and
others, has shown that this ratio is a valid measure of the employment market
[12]. Indeed, we have shown
that this ratio "magnifies" changes—that is, changes in the
ratio are two to three times as large (in percentage terms) as true changes in
the employment market.
We present here the latest available data (from 2002), comparing them with trends over the preceding decade. In all years, the counts underlying the ratio include jobs and job seekers in subfields of diagnostic radiology, such as interventional radiology and nuclear radiology; and the data include both registrations and listings made in advance of the meeting and registrations and listings that took place on-site. No data are available for 2001 because the Professional Bureau had no on-site presence at the RSNA meeting that year.
Diagnostic Radiologists' Self-Reported Workload Burden
In major surveys conducted in 2000
[16] and 2003, the ACR asked
radiologists how their workload compares with that which they would like.
Radiologists' responses provide a direct measure of the extent of the
radiologist shortage. As well, a comparison of 2003 responses with those of
2000 provides information on the trend in the shortage in the most recent
years.
The 2000 survey has been described in detail in a previous publication [16]. In brief, it was a mail survey of approximately 3,000 diagnostic radiologists (including those in subspecialty fields such as interventional radiology and nuclear medicine) and achieved a response rate of 74%. A question it asked was "How would you rate your individual workload relative to what you would like, recognizing that income largely depends on work done?" One of five answers was to be checked: "much too much work," "somewhat too much work," "about right," "somewhat too little work," or "much too little work."
The 2003 survey was a mail survey of approximately 3,200 diagnostic radiologists, again including those in subspecialty and related fields. The response rate was approximately 65%. It asked the same question, but the answer options provided were deliberately quite different. The alternatives to "about right" as an answer were "I'd like my work and my income reduced by about ____%" and "I'd like my work and my income increased by about ____%." (Respondents were to place a number in the blank before the percent symbol.) We judged that by explicitly including a reference to the change in income that would be expected to accompany a change in workload, the 2003 survey would obtain a much more realistic indication of the likelihood that a practice would, in fact, seek to hire additional members (or, alternatively, would seek to contract its size or increase its workload). The disadvantage of changing the answer options was that answers would not be comparable. Specifically, because we included a much more overt reference to reduced income in 2003, we anticipated that fewer radiologists would report a desire for reduced workload.
Responses to the 2000 survey were weighted to make them representative of what responses would have been if all practicing radiologists in the United States had been surveyed and had responded. Analysis of data from the 2003 survey is at a preliminary stage. Perhaps most important, we have not yet weighted responses to make them representative of all radiologists.
Using the 2003 survey results on the percentage of radiologists who sought workload decreases and increases and the mean percentage of decrease or increase sought, we computed how the total workload of all radiologists compared with the desired total workload. Because the 2003 survey data are in a preliminary state, two assumptions were required for this computation: First, that all those desiring a decrease or an increase sought, respectively, approximately the mean desired decrease or increase; and, second, that all radiologists desire approximately the same workload.
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Academic Vacancies
With intensive telephone follow-up, the surveys achieved a response rate of
more than 85% in all 3 years they were conducted
(Table 1). As
Figure 2 shows, vacancies
averaged 5.4 per academic department in 2001, 5.1 in 2002, and 3.9 in
2003.
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Ratio of Job Listings to Job Seekers at a Major Placement Service
As Figure 3 shows, the ratio
stood at 1.4 in 1990, fell as low as 0.2 in the mid 1990s when the job market
was softest, and reached 3.8 in 2000. In 2002, the ratio was 1.4, far below
the level in 1999 or 2000.
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Radiologists' Self-Reported Workload Burden
In 2000, radiologists' responses indicated a work overload
[16]
(Fig. 4). Specifically, 51% of
posttraining, professionally active radiologists said they had too much work,
and only 5% said they had too little work. In 2003, the desires for change
were almost exactly evenly balanced, with 17% reporting a desire for a
decrease in workload and 16% reporting a desire for an increase in workload.
Those desiring a decrease sought, on average, a 21% decrease; those desiring
an increase sought, on average, a 26% increase.
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Our computations show these responses imply that the total workload desired by all radiologists is within approximately 1.2% of actual workload. The computations are performed as follows: A radiologist saying he or she seeks a 21% decrease in workload (the average decrease sought) is saying his or her current workload is 100% / (100% – 21%) of a suitable workload. Because 100% / (100% – 21%) = 127%, these radiologists are reporting an excess workload averaging 27% of a suitable normal load. Similarly, a radiologist seeking a 26% increase in workload is saying he or she is working 100% / (100% + 26%), which is 79% of a suitable workload. The 17% of radiologists working at an average of 127% of a desired workload are overworking by 4.6% of the suitable total workload for all radiologists (17% x 27% = 4.6%). Conversely, the 16% working at an average of 79% of a suitable workload are seeking additional work equal to 3.4% of the suitable total workload for all radiologists (16% x [a 21% shortage] = 3.4%). Relative to the suitable total workload for all radiologists, the net of the 4.6% overload and 3.4% "underload" is approximately 1.2%.
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As regards academic vacancies, the academic job market is distinct from that in community practice, and although the two move broadly in parallel, previous research has shown some differences in trends [15]. Moreover, in unstructured conversation that took place during telephone follow-up in the 2003 survey, a number of respondents said their academic departments had developed new revenue sources and were using these to increase salaries. To the extent that similar changes have not taken place outside academia, trends in academic practices would be expected to be somewhat different from those in other practices. Finally, although the response rate to the annual surveys of academic vacancies is extremely high, the departments that actually respond are somewhat different from year to year, and this may cause some minor fluctuations in the data.
The ratio of job listings to job seekers at the ACR Professional Bureau should be relatively little affected by a move toward electronic media because both numerator and denominator of the ratio should be approximately equally changed. Recently, however, operation of the bureau has been contracted out rather than conducted by the ACR and, instead of a large on-site presence at the RSNA annual meeting in 2002, a much smaller staff was present and interviews were scheduled electronically through the regular, year-round mechanisms of the bureau. Thus, data from 2002 may not be comparable to those from previous years.
Self-reported workload burdens, as noted in Materials and Methods, were expected not to be comparable between 2000 and 2003 because of changes in survey response options, with the 2003 survey expected to show less overload. Also, data from the 2003 survey are preliminary; final weighted results may be different. As well, the assumptions made in estimating the net excess or shortage of work in 2003 are certainly not literally true, although they probably produce approximately correct answers.
Overall Conclusion
Despite their limitations, all four sources of information point to the
same conclusion— namely, that the shortage of diagnostic radiologists
has considerably eased. Because of this similarity of findings across four
independent lines of evidence, we judge it to be a sound conclusion that the
shortage has, in fact, considerably eased. Indeed, the preliminary analysis of
the 2003 data on radiologists' desired workload indicates that the overall
total of workload is approximately what is desired.
Why Has the Shortage Eased?
A number of developments that are at least conceivable might, in part or in
whole, account for the observed easing of the shortage. The following list
includes those we have identified and our thoughts about some of them. Except
as otherwise indicated, the listed developments not only are plausible but
also have been anecdotally reported. However, we do not presently have good
systematic empiric evidence about them and do not know whether the anecdotes
reflect frequent situations or rare events.
Because the shortage is a major concern of the profession, we plan to undertake empiric, quantitative research on most of these possible developments. The relevant data will come predominantly from the ACR 2003 survey of radiologists. We expect to obtain an informative picture of the extent to which each development has, in fact, occurred, with the exception of the last two, for which we have not identified sources of quantitative evidence.
We will also continue to track the shortage using all information sources available. Because developments in individual subspecialties sometimes differ considerably from the overall situation [11, 13–15], we will continue to follow subspecialty-specific developments.
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