How Will the Generalist Survive?

As Subspecialization Surges, Here’s How Radiologists—in General—Can Avoid Getting Left Behind 

More than half of U.S. radiologists practice mainly as generalists, yet those who fit this description dedicate, on average, a third of their worktime to a single subspecialty. The paradox was uncovered by researchers at the Harvey L. Neiman Health Policy Institute who examined data from more than 33,000 Medicare-billing radiologists. The team had its findings published in the Nov. 2017 edition of Radiology (Rosenkrantz et al., “Generalists versus Subspecialists: Characteristics of the U.S. Workforce”).

Two years later, the numbers still have ramifications for reimbursement, as CMS’s Quality Payment Program continues working with metrics based largely on subspecialty-level activities. 

Given radiology’s development into a subspecialist-rewarding profession—and the slowness of payment systems to recognize the nuances therein—is there pressure on radiology residents to choose a subspecialty or two and, in turn, aim to make generalized practice a side job?  

Should even established rads concentrate on one area as a way to remain relevant? 

RBJ asked these questions of five experienced radiologists who’ve seen the fields of subspecialization sprout, bloom and, in cases, overgrow their operational ecosystems. While the experts’ perspectives on some particulars vary, most agree that the demand for generalists remains strong. 

Our sources also tend to subscribe to the counterintuitive proposition that rads who brand themselves as subspecialists don’t, in the process, discourage referrers from sending general cases their way. It might even be said that those who go this route get to have their cake and eat the entrée too. Or vice versa. 

Personalized Pressure 

Radiologist Mahmoud Al-Hawary, MD, whose clinical practice at the University of Michigan includes subspecialization in bowel and pancreatic diseases, believes there is indeed pressure on radiology residents to subspecialize. But the push comes primarily from the trainees themselves, he says. He’s observed that many Michigan Medicine residents are driven in this direction by a desire to work at one of the many larger radiology groups taking shape as private practices consolidate.  

Mahmoud Al-Hawary, MD, Michigan Medicine

“Almost all of our residents still go for a subspecialty, since these larger groups can now afford to have members focus on certain domains—usually one or two—to meet demands from large hospitals,” Al-Hawary tells RBJ. “Residents know the ability to handle more complex patients improves hiring prospects.”

He points to another possible, perhaps less personal, incentive for radiology residents to pursue subspecialization: a recent change in the American Board of Radiology’s certification process. In keeping with this change, certification testing occurs 15 months after the completion of residency training rather than during the last month. 

“Many residents prefer to continue training for at least one additional year to be better prepared for the certification exam,” Al-Hawary explains.

At the same time, he points out, generalists will continue to have plenty of work simply because the demand for their services isn’t mutually exclusive with the services of subspecialists. 

Moreover, he notes, established generalist radiologists who have opted against subspecialization can ensure a solid future for themselves as long as they keep up with advances in the field through courses, literature reviews and regular attendance at continuing medical education (CME) sessions and participation in self-assessment module (SAM) offerings. 

Al-Hawary is among those who see no reason for subspecialists to avoid branding themselves as such based on concern that referring providers may be thrown by the label and, in turn, send general work to other practices. “Subspecialists can still cover general work if it aligns with their interest,” he says, “and the general work should not be referred elsewhere.” 

Subspecialist—Who, Me?  

Nearly all residents feel pushed to complete a subspecialty fellowship—even those who plan to work primarily as a generalist. However, most soon realize the paths before them can be both/and rather than either/or choices. 

That’s the observation of Andrew Rosenkrantz, MD, MPA, who focuses on abdominal imaging for NYU Langone Medical Center in New York City and is one of the most widely published researchers in academic radiology. 

Andrew Rosenkrantz, MD, MPA, New York
University Langone Medical Center

“We will continue to see graduate residents complete fellowships and become the ‘go-to’ person in a practice for their subspecialty or become highly subspecialized in their future practice. But in many instances, there won’t be a clear definition,” Rosenkrantz says. “For example, we may have a radiologist who did a fellowship in one area, but only a fraction of the studies they read are related to that area.”

Nonetheless, Rosenkrantz says, generalists’ critical role in patient care warrants far more attention than it’s gotten to date.

“To preserve patient access to important, basic, invasive image-guided procedures, the radiology community must continue to train a robust pipeline of future generalists and other diagnostic radiologists who are skilled and comfortable offering such services,” write Rosenkrantz et al. in “Invasive Procedural Versus Diagnostic Imaging and Clinical Services Rendered by Radiology Trainees Over Two Decades” (JACR, June 2019).

Rosenkrantz shares with RBJ that it is incumbent on residency programs to recognize that the bulk of interventional procedures are being performed by generalists. Consequently, he contends, these programs must be structured to include a more comprehensive basic radiology curriculum.

“There’s an enormous role for generalists. They’re not going away,” he emphasizes. “It all depends on many variables, like the structure of the individual practice or the geographical area. Maybe everyone has a subspecialty, but we still need a robust generalist workforce everywhere so that everyone receives the proper care.”

Help Wanted: Generalists 

What advice might a deeply experienced radiologist offer to first-year residents in 2019-20? “Pick a subspecialty that reflects what you do best,” says Catherine Everett, MD, MBA, president and managing partner of Coastal Radiology in New Bern, N.C. “But in your fourth year, do a mini-fellowship in your weakest area. Keep your skills broad, because you’re a radiologist first and a subspecialist second.” 

Catherine Everett, MD, MBA, Coastal Radiology

Everett, whose special practice interests are breast and musculoskeletal imaging, agrees with Rosenkrantz that, when it comes to radiology curricula, greater emphasis must be placed on general radiology. Academic programs shouldn’t give it short shrift, she says, and the same goes for fellowship programs teaching highly subspecialized procedures. 

“Right now we’re not training radiologists for the future,” Everett says. “I’m not saying subspecialization shouldn’t happen—that horse is out of the barn. But the reality is, practicing general radiology is a must, except maybe in the largest radiology groups.”

With the exception of radiology departments in large hospitals and health systems, most groups cannot afford to support a high degree of subspecialization, she maintains. 

“A small hospital needs one radiologist who can put in a peripherally inserted central catheter, perform a breast biopsy and perform a shoulder arthrogram,” she says. 

As Everett perceives it, the ideal scenario is one in which a majority of radiologists accept that they do general work with a bit of their subspecialty mixed in. “There are huge opportunities for subspecialists who maintain general radiology skills,” she says. “They can add value in their subspecialty as needed.” 

In Everett’s experience, most referring physicians neither actively seek out subspecialists to whom they refer patients nor funnel cases elsewhere simply because a radiologist is a subspecialist. 

An “elite physician” might look for a subspecialist, and some referring physicians may have relationships with those whose subspecialty closely aligns with their own, Everett allows, citing an orthopedic surgeon and an MSK radiologist as an example of the latter. “But your typical family practitioner, for instance, doesn’t know what to ask for, and the label doesn’t matter.”

Make the Market 

Richard Duszak, MD, of Emory University has a slightly different take on the branding question. 

“It comes down to messaging, along with communication and radiologists’ availability to meet the needs of referrers’ patients,” says Duszak, who was senior author of the 2017 Neiman Institute study mentioned above and is one of the country’s most sought-out researchers working in radiology economics and payment policy. “If you say you’re a subspecialist in ‘x’, but you trained 20 years ago and/or only 10% of your reads are in ‘x,’ referring physicians looking for a particular subspecialty—especially if they are doing so in a major market—would quickly recognize that you probably don’t qualify as one.” 

Richard Duszak, MD, Emory Healthcare

Similarly, Duszak continues, a radiologist may subspecialize 100% of the time, but if he or she is unavailable to take referring physicians’ calls, “there’s not much value in the label. A radiologist who does 50% of his or her work in the subspecialty and is a generalist the rest of the time probably provides a higher level of service and would become the provider of choice”—subspecialty shingle out front or not.

Along with the research, daily observation in practice has shown Duszak that labels sometimes don’t matter anyway, simply because many referring physicians tend to default to their established routines. Depending on how this plays out, it could mean, for example, that a hospitalist prefers a single radiologist for almost all reads while a neurologist has two or more radiology practices he or she feels confident working with.

Asked how radiologists can secure a good future for themselves without overdoing the marketing on subspecialized skills, Duszak suggests, in so many words, acting locally while thinking globally. 

“Continue to build on skills through continuing education, and make certain that the environment supports more of a generalist function,” he says. “If you really like breast imaging, but want to participate in general call, an academic setting may not be for you.” 

The same fundamental applies to radiologists who are subspecialized and want to stay that way. “If your wish is to do 100% neuroradiology or 100% interventional radiology,” Duszak says, “don’t train for the specialty and then join a small rural practice.”    

Educational Essentials 

One radiologist with a view from the academy says academic institutions themselves are fueling the subspecialization fire. 

“Over the past decade, many teaching institutions have restructured programs to facilitate an even greater focus on subspecialization,” observes Eric Friedberg, MD, who practices general, vascular and interventional radiology at Emory. “Well north of 90% of trainees in the U.S. get fellowship training, and some do two fellowships. It’s a growing trend, supported by what the academic institutions are doing.” 

Eric Friedberg, MD, Emory Healthcare

Like other radiologists interviewed for this article, Friedberg notes that this heightened emphasis on subspecialization is producing many new radiologists with highly specific skillsets—yet the typical business model for radiology does not support limiting one’s work to using that skillset in a vacuum. 

“The most common exceptions are large academic settings,” says Friedberg, who chairs the ACR’s certification task force. 

Friedberg describes the most tenable radiology model as one in which practitioners simultaneously hone and leverage their generalist skills and keep up the skills they learned during one or more fellowships, using the latter less than half of the time.

“It’s generally the best way to best meet the needs of hospitals, communities and individual patients, particularly in smaller and rural communities,” he says. “The highest demand in most private-practice settings for the near future will be for those whose generalist skillset is well-rounded”—and presumably supported by better generalist imaging education in the near future—“complemented by a fellowship or fellowships.” 

In Friedberg’s view, subspecialists who brand themselves as generalists are unlikely to discourage referrers from sending cases. “Referring physicians appreciate the ability to speak to one radiologist rather than track down several subspecialists to get the answers they seek,” he says.

Eyes on Patients 

Moreover, where the work of pure generalists intersects with that of subspecialists, there’s often room for both. Al-Hawary of Michigan Medicine commented on such scenarios in an opinion piece, “Subspecialist Reader Reinterpretation of Referred Imaging Studies,” published in the July 2018 edition of Academic Radiology

“Typically, patients referred to tertiary centers have already had imaging performed that led to the diagnosis and initiation of the referral,” he writes, adding that these examinations are often protocoled and interpreted by general radiologists who don’t see many uncommon tumors. As a result, tumors may be inaccurately staged and incompletely reported. 

“The effort and time spent in the reinterpretation is identical to any other examinations performed at the referral center, and logic would require that the radiologists be compensated equally for their efforts,” Al-Hawary writes. 

To this he adds for RBJ that the two practitioners can work cooperatively—not only with one another but also with referring physicians.  

“Subspecialists’ role, particularly in academic practice, is to make sure education and updates are delivered to all radiologists who need to keep up their skills,” he says, “and to establish a form of partnership with their local referral base to make sure the best patient care is offered at all levels.”