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Original Research |
1 LAMA Consulting, Chevy Chase, MD 20815-3940
(merewitz{at}post.harvard.edu).
2 Research Department, American College of Radiology, 1891 Preston White Dr.,
Reston, VA 20191.
3 Department of Diagnostic Radiology, Yale University School of Medicine, New
Haven, CT.
Received April 15, 2005;
accepted after revision April 19, 2005.
Address correspondence to J. H. Sunshine
(jsunshine{at}acr.org).
Abstract
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MATERIALS AND METHODS. We tabulated data from the American College of Radiology's 2003 Survey of Radiologists, a stratified random sample survey that achieved a 63% response rate with a total of 1,924 responses. Responses were weighted to make them representative of all radiologists in the United States. We compare information about pediatric radiologists with that for other radiologists.
RESULTS. Approximately 3% of radiologists, some 800-900 physicians,
are pediatric radiologists. Depending on how pediatric radiologist is defined,
two thirds to three quarters of them spend 70% or more of their clinical work
time doing pediatric radiology. Unlike other radiologists, a greater
percentage of pediatric radiologists desire a reduction in workload (with a
corresponding reduction in income) than desire an increase in workload.
Pediatric radiologists who spend 70% or more of their clinical work time in
their field are older than radiologists in general (average age, 55 vs 51
years), and the fraction of pediatric radiologists younger than 45 years is
lower than for other subspecialists (
20% vs 37%). Pediatric radiologists
are disproportionately women (one third or more, depending on definition, are
women, vs 19% for other subspecialists and 15% for nonsubspecialists),
hospital-based, in academic practices (approximately half vs one fifth for
other subspecialists), and in the main cities of large metropolitan areas.
CONCLUSION. A shortage of pediatric radiologists exists and is likely to intensify. Access to pediatric radiologists is probably a problem except for children in large metropolitan areas who connect readily to academic hospitals. Means to overcome these problems need to be actively sought.
Keywords: pediatric imaging • practice of radiology
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The American College of Radiology (ACR), as part of its mission of providing important and useful information to the professions it serves, periodically conducts large-scale, multitopic surveys of the members of these professions and their practices [1-12].
In response to the concerns of pediatric radiology, the ACR's 2003 Survey of Radiologists, the most recent of these periodic surveys, was designed with a special focus on pediatric radiologists. The survey's special focus on pediatric radiologists consisted of having a design that included more ways of recognizing and defining pediatric radiologists than almost any other field within radiology. This article, an in-depth portrait of pediatric radiologists, is one of the first full-scale papers to be produced from the 2003 survey.
This article first shows how many pediatric radiologists there are under each of many possible definitions of who is a pediatric radiologist, the relationship among these definitions of pediatric radiologists, and the demographics of pediatric radiologists (Tables 1, 2, 3 and Table S1). It then details the work activities of pediatric radiologists, such as types of procedures performed and work hours (Tables 4, 5, 6 and S2-S5), and the characteristics of the practices in which pediatric radiologists work (Tables 7, 8, 9 and S6-S10). (Tables S1-S10 appear in the electronic supplement to the AJR and provide more detail than the tables in this hard-copy version.) Throughout, comparisons with other categories of radiologists are made.
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The Society for Pediatric Radiology (SPR) has conducted a number of in-depth, highly informative surveys of its members and has published data from one ([13]; Jennifer Boylan, personal communication, February 2005). Researchers have also published results of surveys of SPR members [14-16]. The advantages of this article relative to those studies are that it has more recent information, contains systematic comparisons with other radiologists, and is based on a systematic sample of all radiologists in the United States, meaning that it includes radiologists active in the pediatric field who are not SPR members.
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The questionnaire for the 2003 survey consisted of 36 items; many items in turn contained multiple subitems. Questionnaire items and topics were elicited from two rounds of canvassing ACR physician and staff leaders, winnowed according to priorities indicated by top leadership, and pretested in two large pretests conducted in autumn 2002, with refinements made after each pretest.
The survey sample, a stratified random sample composed of four strata, was taken primarily from the American Medical Association's (AMA) Physician Masterfile [20], a reasonably complete listing of all allopathic physicians in the United States, whether or not AMA members, but also included a sample of osteopathic radiologists obtained from the American Osteopathic College of Radiology. The sample included residents, fellows, and retirees, not merely posttraining, professionally active physicians.
The survey was administered by our contractor, the Center for Survey Reasearch, University of Virginia, by mail between March and August 2003, with nonrespondents being sent up to four remailings as necessary and other steps taken to boost the response rate. The response rate achieved was 63%, with 1,924 usable responses. Responses were weighted so that the weighted statistics would be representative of the answers that would have been received if all physicians in the United States in the four strata had been surveyed and had responded.
Our leading tool to minimize data deficiencies was the designation of the 12 items on the questionnaire judged most crucial as core questions. When questionnaires were returned, our contractor checked that these 12 items were indeed answered and made three designated consistency checks involving them. If any problems were found with the core items, the Center telephoned the respondent to obtain the missing response(s) or to resolve the consistency problems. In addition, data used in this article have been cleaned and edited to further minimize deficiencies.
Definition of Variables
The definition of most variables has been detailed in a previous article
[18] and also is apparent from
the Results section and the tables. We detail here only the definitions of
pediatric radiologists that we used.
To provide the fullest picture of pediatric radiologists, this article contains information on a large number of definitions of who is a pediatric radiologist. The definitions are as follows:
Analysis Methods
All information presented in the remainder of this article, unless
otherwise noted, is based on weighted data and refers to physicians from all
strata combined. Where numbers of physicians are given (in
Table 1), an adjustment was
made for item nonresponse— that is, for the failure of a limited
percentage of respondents to answer each question— so that the numbers
are, as always, representative of what the answers would have been if all
physicians of interest in the country had responded.
Reported standard errors (SEs) and tests of statistical significance are
calculated taking into account not only the weighted nature of the data but
also the complex survey design— that is, the fact that responses come
from distinct strata. The SEs are calculated with the Statistical Analysis
System software procedure "surveymeans" (SAS Institute). All data
analysis was conducted with SAS software, release 9.0 (SAS Institute). Because
most comparisons are made between pediatric radiologists and five comparison
groups of radiologists (Tables
3 and S1), we use a two-tailed
z-test with a p value of 0.01 or less as the criterion of statistical
significance, in keeping with the Bonferroni inequality
[21]. In two instances in
which visual inspection of the data showed relatively large differences
between pediatric radiologists and other radiologists but the differences were
not significant at p 
0.01, we applied the more common criterion
of p 0.05; these instances are explicitly noted in the text. SEs
for percentages in the tables can be approximated by the formula:
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Table 2 shows the relationship between pairs of characteristics of pediatric radiologists. Each row of the table refers to those radiologists with the characteristic listed at the left of the row, and each cell tells what percentage of these radiologists also have the characteristic listed at the top of the column in which the cell appears. For example, the table shows, in its third row, that of those who did a fellowship in pediatric radiology, approximately 70% have the CAQ, a similar percentage spend 30% or more of their clinical work time performing pediatric procedures, and approximately half spend 70% or more of their clinical work time in the field. But one sixth are not currently doing any pediatric radiology. Other highlights of the table include the following: Of those who reported on the 2003 survey that pediatric radiology was their primary specialty, five sixths have a CAQ, four fifths did a fellowship in the field, four fifths spend 30% or more of their clinical work time performing pediatric procedures, and two thirds spend 70% or more of their clinical work time in the field. Of those who spend 30% or more of their clinical work time in pediatric radiology, five sixths have the CAQ, 70% did a pediatric fellowship, and four fifths spend 70% or more of their clinical work time in the field. Of the half dozen respondents who reported pediatric radiology as their secondary specialty, only one third reported spending as much as 30% of their clinical work time in the field and none reported having done a fellowship, having the CAQ, or spending 40% or more of their clinical work time in the field.
Tables 3 and S1 present the
demographic characteristics of pediatric radiologists and the corresponding
demographics of five comparison groups of radiologists. Pediatric radiologists
in general are, on average, about 51-53 years old, not significantly different
from other specialists or radiologists overall. But those practicing 70% or
more of their time in the field are significantly older (averaging 55 years)
than other subspecialists. Also, although more than one third of all radiology
subspecialists are younger than 45 years, the fraction is considerably smaller
for pediatric radiologists. Specifically, the percentage of pediatric
radiologists who are 35-44 years old is generally smaller than for comparison
categories, but the difference is significant only at the level of p
0.05.
More than 40% of radiologists who spend more than 30% of their clinical
work time in pediatric radiology are women, compared with half that percentage
or less for other subspecialists and for nonsubspecialized radiologists. As is
true for radiologists in general, more than 95% of pediatric radiologists are
board-certified. The proportion of pediatric radiologists in the Northeast is
somewhat lower than the proportion of nonpediatric radiologists, and the
proportion of pediatric radiologists in the Midwest is correspondingly
elevated (results significant only at p 0.05).
The Work of Pediatric Radiologists
Pediatric radiologists average performing approximately four and one half
of the seven major types of procedures (mostly technique categories) into
which we have divided radiology (Tables
4 and S2). This is about the
same as for other radiologists. Pediatric radiologists are more likely to
perform CT than other radiologists, more likely to perform radiography or
fluoroscopy and (to some extent) sonography than other subspecialists, and
much less likely to do breast imaging.
Pediatric radiologists work at an average of two distinct locations versus an average of almost three for other subspecialists and for nonsubspecialists (Tables 5 and S3). On average, full-time radiologists who are pediatric specialists report working approximately 56-57 hours in a typical full week, not significantly different from other radiologists. Similarly, the percentage of pediatric radiologists who are part-timers is not significantly different from the percentage for other radiologists. With an average of 25 or fewer vacation days by a number of definitions of who is a pediatric radiologist, full-time pediatric radiologists have less vacation than other full-time radiologists, who average approximately 35 vacation days. In contrast, both full-time pediatric radiologists and other full-time radiologists average approximately 10 days annually for professional education and society meetings.
By most definitions of who is a pediatric radiologist, approximately 15% of pediatric radiologists would like less work, even though that means their income would decrease proportionately, and a smaller percentage would like more work with a corresponding increase in income (Tables 5 and S4). In contrast, although the difference is not significant, largely because of the limited number of pediatric radiologists in our survey, for other radiologists, the percentages desiring more and less work are more even. Pediatric radiologists are like other radiologists in reporting, on average, a level of enjoyment of their work approximately halfway between "enjoy very much" and "enjoy somewhat."
Virtually all pediatric radiologists report spending part of their work time in clinical practice at hospitals, although only about 90% of subspecialists who are not pediatric radiologists and 86% of nonsubspecialists do so (Tables 6 and S5). Conversely, only approximately one fourth of pediatric radiologists do clinical work at nonhospital sites compared with half of other subspecialists and half of nonsubspecialists.
Practices in Which Pediatric Radiologists Work
Approximately half of pediatric radiologists work in primarily academic
practices (Tables 7 and S6).
Surprisingly, this is greater than the 6% for radiologists who do not
subspecialize, but it is also far greater than the 20% for other
subspecialists. Conversely, approximately 20% of pediatric radiologists are in
private single-specialty radiology practices, which is about half the level
for other subspecialists and for radiologists who do not subspecialize. Two
thirds of radiologists who spend at least 30% of their clinical work time
doing pediatric radiology work in practices located primarily in the main
cities of large metropolitan areas (area population > 1 million), a much
higher percentage than is true for other subspecialists (Tables
8 and S7).
Like radiologists generally, about two thirds of pediatric radiologists work in practices that serve both hospital and nonhospital sites (Tables 7 and S8). The rest of pediatric radiologists work in hospital-only practices, whereas, in contrast, some 10% of other radiologists work in nonhospital-only practices.
The practices in which pediatric radiologists work are significantly less likely to perform breast imaging than the practices in which other radiologists work (Tables 9 and S9). These tables refer to the categories of procedures performed by the practices in which radiologists work, not to the work of the individual radiologists themselves, which is shown in Tables 4 and S2.
Pediatric radiologists work in practices with an average size of 21–28, larger than the size of 12 for nonsubspecialists but similar to that for other subspecialists (Tables 9 and S10). Depending on the definition of who is a pediatric radiologist, about 75–90% of pediatric radiologists have coverage from a member of their group who is in the same subspecialty when they are away, which, at the upper end, is higher than the percentage for other subspecialists.
By most definitions, 30–40% of pediatric radiologists are in practices entirely owned by members of the practice. This is less than the 65% for other subspecialists and the 69% characteristic of nonsubspecialists.
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More than 25 years ago (in a 1979 survey), a prominent concern was that pediatric radiologists were lagging other radiologists in using new imaging techniques (which then were CT and sonography) [14]. A decade later, pediatric radiologists were found to be more involved in newer techniques [15], and this was even more true in 1998 [16]. In this study, we have presented the first systematic comparison of the average number of techniques pediatric radiologists and other radiologists perform. We find equality.
The surveys of SPR members confirm our finding that pediatric radiologists are heavily hospital-based. Only roughly 10% report some other main location of their practice [13, 16]. (Because questions on our survey did not have the wording of those on earlier surveys, findings on this point and subsequent ones are not fully comparable.) Recent surveys of SPR members conducted in 1998, 1999, and 2002 report that almost half of SPR members are based in freestanding children's hospitals ([13, 16]; Jennifer Boylan, personal communication, February 2005). In addition, about one third are based in nonchildren's academic hospitals [13].
As we do, Forman et al. [16] and Goske et al. [13] find high percentages of pediatric radiologists have the CAQ (74–81%) or did a pediatric radiology fellowship (85%).
Goske et al. [13], as we do, find pediatric radiologists spend a high percentage of their time doing pediatric work. They report an average of 82% of time, but note that this average may be biased upward because the response rate to their survey was only 37% (because of budget constraints, there were no remailings) and responses came disproportionately from pediatric radiologists at children's hospitals, where the statistic was 96% of time. At the other end of the spectrum, in community hospitals with only a small pediatric practice, they found the statistic was 19% of time. The unpublished 2002 SPR survey, which possibly has the same bias, shows that approximately 70% of pediatric radiologists have more than 75% of their practice in pediatric radiology.
Goske et al. [13] and Forman et al. [16] both report, as we do, that a relatively large fraction of pediatric radiologists—about one third—are women. Goske et al. find that the women are, on average, younger than the men, and Forman et al. report that the younger half of respondents are almost half women and the older half are almost three fourths men. Thus, both find that the heavy representation of women in the field is increasing rather than decreasing.
Goske et al. [13] and we both find approximately half of pediatric radiologists practice at more than one location. Forman et al. [16] find subspecialization within pediatric radiology is fairly common, both based on organ system and based on imaging technique. We gathered no information on this phenomenon.
Although pediatric radiologists are approximately 3% of all radiologists (Table 1), Saketkhoo et al. [22] find 4.6% of all radiology job advertisements in 1999–2002 in the two leading radiology journals were for pediatric radiologists. For 2003–2004, the corresponding statistic was 3.6% (Nwanze C, personal communication, January 2005). These findings that advertisements for pediatric radiologists were more frequent than expected (4.6% vs an expected 3%) reinforce our conclusion, based on there being more pediatric radiologists who feel overworked than there are pediatric radiologists who would like less work, that there is a relative shortage of pediatric radiologists.
Substantive Findings
Our best estimate is that about 800–900 radiologists in the United
States, or 3% of all radiologists in the country, are pediatric radiologists.
Thus, pediatric radiology is a relatively small subspecialty.
Its practitioners differ from other subspecialists in a number of ways. A far greater percentage of pediatric radiologists are women. A far greater percentage of pediatric radiologists are in academic practices. Probably as a result, pediatric radiologists are more hospital-centered and more concentrated in the main cities of large metropolitan areas.
The Shortage of Pediatric Radiologists
Our findings cast light on two important problems facing pediatric
radiology. One, we find evidence there currently is something of a shortage of
pediatric radiologists. Moreover, an analysis of the 2003 survey that is
focused on the radiologist shortage found more of a shortage of pediatric
radiologists than of other subspecialists or nonsubspecialists
[23]. However, because of the
small sample size, the differences generally were not statistically
significant.
More troubling, we find indications that this problem is likely to become worse in the future. The workload of the radiology profession is increasing rapidly, fueled largely by scientific advances (new imaging techniques and advances in existing techniques) that allow radiology to do more for patients [17]. Our findings indicate the number of pediatric radiologists is not likely to expand to meet this growing need. To be more specific, the finding that relatively few pediatric radiologists are young means that newly trained radiologists are entering the pediatric subspecialty in less-than-proportionate numbers. And the finding that those working 70% or more of time in the field are relatively old (average age, 55 years) means that a disproportionate number of those who currently do the most work in the field will be retiring relatively soon.
Radiologists for whom pediatric radiology is a secondary specialty are not a promising reservoir from which to fill the gap. They are few in number and few of them have the advanced credentials—the CAQ or a fellowship— that are generally indicative of the desired skill level of a subspecialist.
Nor is increasing the percentage of their work time that pediatric radiologists spend on pediatric radiology, a large potential reservoir. Most radiologists who report pediatric radiology is their primary specialty are already spending 70% or more of their clinical work time in pediatric radiology, and the same is even more true for radiologists who report spending 30% or more of their time doing pediatric radiology. Thus, there is little opportunity for pediatric radiologists to cut back on nonpediatric clinical work to make time for more pediatric work. This situation of very widespread near-fulltime work in one's main subspecialty is not true of all subspecialties [18].
A more promising reservoir from which to fill the gap consists of the one sixth of those who did a pediatric fellowship who report they currently are not doing any pediatric radiology. Relatively brief refresher training for them might sharpen rusty skills and teach needed new skills so that they would be well qualified to function as pediatric radiologists.
It is not surprising that a sixth of those who did a pediatric radiology fellowship are not currently doing pediatric radiology. Radiologists may have done their fellowship 20 or more years ago, and a considerable number of radiologists change their field of emphasis over a time span that long. We found a broadly similar fraction not practicing at all in their fellowship field for radiologists who trained as interventionalists [18].
Speculation suggests two reasons relatively few residents enter pediatric radiology. The first one is financial. With a relatively large part of the work of pediatric radiologists paid for by Medicaid, the low payment levels characteristic of Medicaid mean pediatric radiologists produce less practice revenue than other radiologists. Moreover, with a relatively large part of the work of pediatric radiologists consisting of radiography and sonography, pediatric radiologists produce fewer relative value units (RVUs), and therefore again less revenue, than most radiologists [24, 25]. As a consequence of this double financial handicap, in practices in which pay is at least partly by revenue produced or by RVUs produced, pediatric radiologists are relatively low-paid. This is not an attractive situation. In practices that do not differentiate pay by revenue or RVUs produced, pediatric radiologists may be resented for taking a full share of pay although they do not generate a full share of income. Again, this situation is not attractive.
Second, disproportionately few women enter radiology— to be specific,
approximately half of current U.S. medical school graduates are women, but
only one fourth of radiology residents are women
[7]. To the extent sex role
stereotyping has an effect, the relatively large fraction of women among
pediatric radiologists ( one third) may make pediatric radiology a
relatively unattractive choice for the three fourths of radiology residents
who are men.
If reasons such as these are important in residents' tendency not to choose pediatric radiology, much work will be necessary to attract larger numbers of them to pediatric radiology and to attract back into the field that sixth of radiologists with pediatric fellowship training who are not now practicing in the field.
Access to Pediatric Radiology
Our findings that pediatric radiologists are concentrated in large cities
and in academic practices indicate that access to pediatric radiology services
is likely a problem for children who do not live in large metropolitan areas
and for children in such areas who do not readily connect to academic medical
centers. The problem is not merely one of expertise in interpreting images, a
problem that might be overcome through teleradiology. Expertise in patient
management, particularly in sedation and minimization of radiation dose, is
also a problem. Given the limited number of pediatric radiologists, which
means there will never be a pediatric radiologist in most practices, solutions
seem to lie in the direction of more links between pediatric radiologists on
the one hand and physicians outside their practices and their hospitals on the
other hand. Such links might include mini fellowships in pediatric radiology
for radiologists from other practices, increased referrals to pediatric
radiologists, and telephone advice by pediatric radiologists to radiologists
in other practices who have a pediatric case that presents challenges. With
such links enhanced, it might be useful to further centralize pediatric
radiology interpretation to more efficiently use pediatric subspecialty
expertise.
Study Strengths and Limitations
Like other studies, ours has both strengths and limitations. These have
been discussed in detail elsewhere with respect to the overall 2003 survey
[17,
18]. In brief, major strengths
include the following: The data are from a large, carefully conducted survey
that achieved a high response rate through intensive follow-up. Weighting
adjusted for nonresponse bias—that is, differences between respondents
and nonrespondents—in the characteristics used in the weighting.
Multiple steps were taken to improve data quality. Multiple definitions of who
is a pediatric radiologist are used to present a rounded and in-depth portrait
of the subspecialty.
Nonetheless, as with almost any survey, statistics drawn from our survey may have inaccuracies from at least three sources: sampling variability (the likely size of these inaccuracies is measured by the SE); nonresponse bias (but only with respect to characteristics not considered in the weighting); and incorrect or illogical responses (some still remain despite careful and extensive data cleaning). Sampling variability is particularly a problem in this study. Because pediatric radiologists are only approximately 3% of all radiologists, the survey had a small sample of pediatric radiologists, and modest-sized phenomena therefore often do not attain statistical significance.
Also, as with any survey, aspects of the questions on our survey affect the answers given and hence the findings. Most notably, this is true for the question about how respondents divide their clinical work time among radiology fields. This question included as answer options both technique-defined fields, such as interventional radiology, and fields defined by organ system or patient population, such as pediatric radiology. Respondents were instructed that the reported percentages should total 100. If there had been one question for techniques and another for organ systems and patient categories, with directions that each was to total 100%, then the number of radiologists reporting time spent in any field and the reported amounts of time spent would have been larger. This is unlikely to have produced substantial bias with respect to radiologists who spend large amounts of time in a field, and these are the radiologists on whom this study concentrates. However, the number of radiologists who, in fact, perform small amounts of pediatric radiology may be twice or more the number reported [18].
The involvement of representatives of individual subspecialties in the design of the survey was limited and, because our survey was a survey of all types of radiologists, it necessarily had fewer questions relevant only to pediatric radiology than a survey of only pediatric radiologists would have had.
Conclusions
Our detailed portrait of pediatric radiologists shows that theirs is a
small subspecialty and that most practitioners of this subspecialty spend most
of their clinical time doing pediatric work. Something of a shortage of
radiologists exists, the shortage is likely to grow worse over time, and ready
remedies to the shortage are not at hand. Thus, the problem of a shortage
needs concentrated attention. Similarly, the problem of access to pediatric
radiology services needs thoughtful action to resolve.
Acknowledgments
Stuart A. Royal, president of the SPR, and David C. Kushner, chair of the
board of the SPR, provided valuable insights and suggestions and made SPR
information available to us. Jennifer Boylan, executive director of the SPR,
assembled and transmitted to us the studies the SPR has conducted. We thank
all those who responded to the 2003 Survey of Radiologists. By contributing
the time needed to complete the questionnaire, they have helped make important
information available to the entire profession.
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