Practicing Radiology in the 21st Century

There was a time, not long ago, when radiologists were either organized into private practices or employed by academic medical centers. Today, they have more options. Representatives of different practice models—from teleradiology to hospital employment to megapractice/multispecialty-practice membership—vary in their views of increasing service and performance demands (and their business, clinical, and lifestyle implications). These five panelists agree that more options exist today, but they warn us that jobs in radiology are currently scarce, and a newcomer might have to take whatever’s most immediately available. They urge radiologists to keep their skills current (and broad) so that they will be able to take advantage of unforeseen opportunities at any point in their careers. RBJ: What practice choices does a newly qualified radiologist have today? ZUCKERMAN: Today, a graduating resident has many more choices than when I was graduating. That’s primarily due to the electronic revolution that made everyone mobile, as well as to the upheaval in health care. The former allows studies to be read at sites physically remote from patients. The latter has led to greater emphasis on efficiency, which has led to more entrepreneurship. Graduating residents now have choices besides just academics or private practice. We have to add teleradiology to the list, and that’s a markedly different model and different job. You don’t associate as much with other medical people, you can work at home, and you don’t have the interaction. NORBASH: Demand for radiologists is cyclical; when I was finishing my training, I was interested in interventional neuroradiology, but I wasn’t sure I would be able to get into that—and you still see that same anxiety that I experienced 20 years ago because of the contracting job market. I wanted an academic position at an academic center where I could practice my subspecialty, so I considered expanding my range of specialization to increase my chances of employment at such centers. A graduating resident will need to consider regional preference, type of practice, and subspecialty, and the individual will have to prioritize all of those choices. Today, teleradiology positions let you work from home; as a new development, there’s in-house or off-site emergency imaging that can take place at night. I didn’t have those options when I was completing training—that degree of flexibility—but we’re not seeing as many traditional positions open in academic settings now. KAYE: My son is a third-year radiology resident, so this hits close to home. Residents have the same choices in practice venues that they had before—and more. Now, there are private practices, outpatient imaging centers, and academic departments—but there are fewer of those positions and more opportunities in teleradiology. There also are more frequent employment opportunities with hospitals and multispecialty medical groups. I would tend to shun teleradiology positions because you’re not a part of a team; it’s a piecework lifestyle. I would go to the more traditional patient-care models at a community hospital, a multispecialty group, an academic department, or an outpatient imaging center. For me, the satisfaction of radiology comes from being part of a team and having contact with other medical providers. BRESLAU: Job availability is currently low. Opportunities lie mainly with large health-care systems and radiology companies, academic departments, and independent practices, which are much larger, on average, than they used to be. There will be changes as radiologists retire, but lately, they’ve been delaying retirement because of the uncertain financial picture. ZINN: Teleradiology has to be an option for anyone. It bespeaks a lifestyle. Do you want a traditional commute or a job that’s more flexible? Unless you’re doing procedures and other activities that force you to be at a facility, the science and technology of radiology are similar, no matter where you practice. Certainly, night-shift workers will dominate the teleradiology scene because much of daytime radiology is still a cottage industry, but this is changing. It may not happen for some time, but traditional daytime radiology providers are using teleradiology more, and you have to provide teleradiology as an extension of a traditional practice. The difference between teleradiology and traditional practices is that the image comes to your home office, rather than you commuting to the image. Teleradiology becomes more pervasive as we become more economical with manpower. RBJ: What market forces are driving interest in your practice model? BRESLAU: You have to consider income, lifestyle, and location: That hasn’t changed. Radiologists’ expectations for income have gone down, but lifestyle expectations have not. Location is the same consideration that it always has been. Job security is hard to assess or compare (opportunity with opportunity). Those coming right out of training often don’t have a sense of how to weigh that as a factor. People approaching a job opportunity 15 or 20 years ago, especially in private practice, hoped it would be a job for their career. Today, that assumption is diminishing; instead, the assumption is that they might have several jobs. ZINN: One driving force is the need to economize; another is to have a presence where there would normally not be a presence, as in an underserved area. If you’re a patient and want to know why teleradiology is a good thing, that’s one reason. You will realize savings in moving images and not moving radiologists. Quality of care also increases, as multiple specialist opinions can be obtained with the press of a button. Radiology is based on images, so it’s tailor-made for remote practitioners. There are other areas of telemedicine that are not quite as advanced—such as telecardiology, in which ECGs are sent to a central location where a senior physician can make centralized decisions, which could be executed in multiple locations. KAYE: My practice model is a hybrid. We have two community hospitals in this area, and a multisite outpatient imaging practice. We have 30 radiologists in three venues. The most unusual thing about us is that we have our own residency program as well. Otherwise, our model is not uncommon. Historically, this has been the most desirable practice type—or at any rate, the most popular—because we have the best of both worlds. This model provides the intensive patient-care aspects of a hospital, close contact with your fellow physicians, the teaching of residents, and control of one’s own success through private imaging offices. NORBASH: Small and medium-sized private practices are suffering from financial reform. As much as academic practices have been affected, it’s worse for other practices, so they’re looking to us as a safe haven. Payment reform has served both to hurt us in certain ways and to help us in other ways, but from the academic perspective, it principally has hurt private practitioners. RBJ: What are the risks of choosing one practice model over the others? BRESLAU: The risk of not having a job is the greatest risk of all, and there are not many job opportunities in general, so you can’t always weigh the risks of different options. Weigh the kind of career path you want instead. Look for stability, how the organization is positioned for the future, and who will be your mentors. If you start in a nonspecialized practice, might you eventually lack the skills required for a much more specialized practice—or vice versa—if you want to move to another job? For example, you might only do mammography, but you might want to try for a job that requires musculoskeletal expertise. There are hazards of overfocusing or underfocusing. ZINN: Traditionally, there’s a model for private practice in which you work your way into a partnership position, and you will usually stay in that practice until you retire. The lack of security in teleradiology is more perceived than real—because the medical community does need you. As radiologists, we’re capable of flipping in and out of different businesses, carrying our skills with us. Some radiologists who object to teleradiology say they don’t want the uncertainty of a nonpartnership job. Granted, when you’re an independent contractor, you don’t have that kind of security—but in exchange, you have the nimbleness to multitask. You just have to have confidence in your skill set. To go into teleradiology, you have to be willing to thrive in an uncertain world and be entrepreneurial. In many private practices, you’re bound by their laws, some forbidding you to multitask. You’re forbidden to pursue certain medical endeavors on the side, and if you’re the kind of person who wants to grow your practice, you are not incentivized to increase revenue, as you will have to share it with all of the partners. On your own, you can seek other opportunities aggressively, without the feeling that you are subsidizing others. KAYE: I would not have gone into radiology if teleradiology had been my only option, but as a teleradiologist, you do have a flexible schedule; you’re paid by your productivity (you eat what you kill). There has been a lot of competition among teleradiology companies, and (combined with the slow job market) that has made compensation decrease. Teleradiology suits people who want to set their own hours, but the downside is that you’re not part of a team. The academic setting holds a lot of advantages if you like to teach, do research, and write papers. It’s generally viewed as more prestigious, although you don’t necessarily make more money at it. There is a great need for more information about the scientific, clinical, and business aspects of imaging, and much of that will come from academic research. That is exciting and can be professionally satisfying, but compensation in academia has been significantly less than in private practice. Many academic departments have a dean’s tax, to use the euphemistic term, whereby the revenue generated by the radiologists’ activities is shared with the medical school for its own purposes; the rest of the compensation is divided among members of the department. In private practice, the revenue is divided among the practitioners; there’s no institutional tithe. NORBASH: Our model is lower paid, typically, and time off can be lower—and there’s the additional need to do teaching, writing, and research, which not everyone enjoys. You might think academia is safer, but if those teaching and research interests aren’t there, there could be resulting performance issues. You might be a competent radiologist, but you also have to be competent in those other skill sets. If you’re not, you might not advance as you had hoped, and you might become unhappy or unfulfilled. There has to be a match of skills and ability. ZUCKERMAN: Any job has risks. For private practices, there’s the risk of consolidations (such as mergers and acquisitions), and you could be made redundant. For teleradiologists, there’s the risk of being viewed and valued as a commoditized employee who can be perceived as not having any value to add to a health-care community. For academics, there’s the risk that as 30 to 50 million more people become insured, there may be increased emphasis on just taking care of patients, at the expense of academics. RBJ: How do you see your practice model evolving? BRESLAU: To quote Lawrence Muroff, MD, “The future for radiology is great; the future for radiologists is uncertain.” There will be a robust demand for our services, but compensation may change unfavorably. Reimbursements are lower, despite our best efforts. Radiologists should be very open-minded about how to add value, over the coming years, and should look for opportunities to contribute as much as possible. We could have a role in stewardship of the use of expensive and critical technologies. We need to push the envelope, in terms of being a modern medical IT service. ZUCKERMAN: I believe that if you do the right thing for the patient and make your decisions with the patient in mind, it all will work out fine. I would not try to dissuade someone from private practice; it’s as viable as any of the other options. We’re a member of Strategic Radiology, a consortium of other large radiology practices across the country, and there are advantages to having a national presence. We’re aiming at sharing best practices and at taking advantage of economies of scale. One function is to act as a buying group for equipment and supplies. We’re by no means fully integrated as one corporate entity; members retain their individuality, at this point. This model hasn’t existed in medicine until recently, since the drive to consolidate had not previously been so great. Practices like ours will need to accommodate the demands of the Patient Protection and Affordable Care Act, and to do that, we will have to be more patient centered and more data driven. That translates, for radiologists, to advising our colleagues (nonradiologists) on what studies to order in a certain situation. We use the word appropriateness: We have to educate our colleagues on appropriateness of studies. NORBASH: We’re going to incorporate technology more. Research methodology and sciences will be taught in a more organized way. I’m also optimistic about traditional clinical-radiology education. My sense is that many academic departments will evolve to a two-tier model: one tier of more specialized and highly focused researchers and another tier of practitioners who teach and are responsible for a greater percentage of clinical work. It will be dynamic and exciting, and radiologists have always been good at adapting to changing environments. Radiology will continue to get stronger by the day, and its utility will dramatically increase. To succeed, however, it will be crucial to sit at the table and communicate—to other physicians and to third-party payors—the value that we provide. KAYE: We are going to have many masters and more accountability. One hospital might have a PHO model; another might be going toward a system-based multispecialty group. Hospitals and groups of physicians are exploring accountable-care organizations, which would assume risk and share in gains from savings. There also will always be independent physicians who will require my services. I intend to participate in all of the above. My task is to provide services in multiple venues, and it will require a lot of administrative effort, on our part, to be all things to all people. Academic practices have already evolved so that clinical productivity will carry more weight in evaluation and compensation. Previously, you might not have been expected to interpret a certain number of exams a year; now, that productivity will be monitored, in addition to your teaching and research obligations. There will be people who are more research focused and some who are more clinic focused. All radiologists will face more benchmarks and the measurements that go with them. Institutions will look at turnaround time for a report, hours of service, and quality—especially if you practice in a hospital. Outpatient imaging will change in that compensation has gone down, both for professional and the technical components of reimbursement. Two very important influences on compensation are the commoditization engendered by corporatization of our profession and expansion of teleradiology, as well as the prospect that care will be bundled. With regard to bundling, what will be the compensation model for physicians? Nothing will change overnight, but looming out there is the prospect that instead of using a fee-for-service model, compensation might be determined as a percentage of the overall dollars available for physicians—or as a percentage of the amount allocated to a certain DRG per patient. How do you determine the value of each physician’s contribution, and who does it? The guidelines could be set by primary-care physicians only, by a larger group, or by various organizations. Teleradiology could commoditize what we do and force us to compete across a wider geographic region. As compensation goes down, groups also will avoid hiring new radiologists, and one way to do that is to outsource work to teleradiologists. Quality of care could suffer significantly because you’re focused on volume. Teleradiologists fulfill only one—albeit the most obvious—component of a radiologist’s role. Patients and referring physicians are best served when someone is there for consultation who knows the patients and the staff. To the extent that radiology is outsourced, it diminishes the attractiveness of radiology as a profession. ZINN: Teleradiology’s role will constantly shift, depending on who’s doing the imaging and interpretations, but in general, it will continue to grow. Nowadays, the computer screens in the offices of hospitals are the same as those in my home, so given the speed of computers, teleradiology will only get better, and it will be used more. I see a tremendous opportunity for radiologists to be general physicians and make money doing things they never thought they would do—things other than just reading films, such as working on medical reviews, giving expert testimony, performing evaluations for environmental studies, or being blinded readers for research projects. There also are programs out there related to wellness, longevity, and preventive medicine; lots of advisory/evaluation-related opportunities revolve around the health of the patient. RBJ: What are the lifestyle implications of today’s practice choices? ZUCKERMAN: The big picture is that no matter what options one chooses, compensation will decrease in the future. Any perceived differences among these pathways will tend to diminish, over time. NORBASH: In academic centers, the most successful researchers can be very driven; they can spend long hours on research, writing, and grant submission. There’s a gross misconception that academic radiologists have a relaxed lifestyle. You had better understand the sacrifices you will be making in lifestyle in exchange for fulfillment and contribution to society if the academic pathway is chosen. For some people, there’s nothing like academic medicine—but I would examine your motives and interests, to be sure. BRESLAU: People need to understand what they’re getting into: Keep an open mind; keep your options open; don’t burn any bridges; keep your skills up (so you can move around); look for opportunities, all along the way, to enhance your relationships with clinical colleagues; and look for opportunities to be more involved in direct patient interactions. Get out of the shadows. Joseph Dobrian is a contributing writer for Radiology Business Journal.