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Editorials |
1 From the Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received October 25, 2001; accepted October 29. Address correspondence to M.D.C. (e-mail: mecohen@iupui.edu).
Index terms: Editorials • Radiology and radiologists, socioeconomic issues
The Greek historian Herodotus told an instructive tale about Xerxes, the King who led the great Persian expedition against Greece in 480 BC. Having suffered a major defeat, Xerxes boarded a ship to return to Persia. On the way, a great storm threatened to sink the ship, which was overloaded with the King’s attendants. The pilot told the King that there was no hope of survival unless the ship’s load was lightened. Xerxes then turned to his fellow Persians and said, "It is on you that my safety depends. Now let some of you show your regard for the King." A number threw themselves overboard, and the ship later came safely to harbor. After the ship landed, Xerxes ordered that the pilot should be presented with a golden crown for saving the King’s life. However, he also commanded that the man’s head should be cut off, for having caused the loss of so many Persian lives.
The results of a 2001 survey conducted by C. Douglas Maynard, MD, and E. Stephen Amis, MD, for the American College of Radiology identified a serious and growing shortage of academic radiologists (1). Only one of the 124 academic radiology programs contacted was not seeking to hire at least one academic radiologist. On average, each academic radiology department faces a deficit of 5.5 faculty members (1). Dr Maynard estimates that there are approximately 600 faculty vacancies in academic radiology departments across the United States. This is almost twice the number of vacancies reported in a recent special communication on educational programs in U.S. medical schools: 311 academic radiology vacancies out of 5,063 positions (2).
One clear implication of these results is this: Academic radiology programs need to find ways to improve recruitment and retention of faculty. This article explores the historical roots of the shortage of academic radiologists and the current factors that tend to draw radiologists away from academic careers and outlines a number of steps that all radiologists should support to improve this shortage.
Historical Perspective
Medical historian Kenneth Ludmerer (3) has divided the history of 20th century academic medicine in the United States into three phases. Following the 1910 Flexner report (4) on medical education, medical schools became university based and developed full-time teaching faculties. Until the onset of World War II, medical schools focused most of their resources on educating the next generation of physicians. After World War II, medical schools shifted their focus to research to the extent that by 1965 research grants accounted for more than 60% of the budgets of the nation’s premier research institutions. In 1965, with the enactment of Medicare and Medicaid programs, medical schools realized that there was a huge financial incentive to shifting their focus to the delivery of clinical care. In the following decades, the size of clinical operations began to dwarf the magnitude of teaching and research programs combined. During this period, clinical service changed from accounting for 5% of the medical budget to accounting for well over 50%.
In the 1990s, this shift to a clinical focus was further augmented by managed care. As clinical reimbursement levels fell, medical school deans and hospital administrators sought ways to maintain their revenue streams. They developed policies that encouraged faculty members to devote much more of their time to providing clinical care and improving their clinical productivity. In radiology, for example, Arenson et al (5) observed an increase in clinical work output in academic departments from 3,790 to 4,458 relative value units (RVUs) per full-time employee between 1996 and 1998. As this transformation took place, medical school faculty members increasingly resembled their colleagues in private practice, devoting progressively less time and attention to the distinctively academic missions of teaching, research, and service to their department, medical school, or national medical organizations. The faculties of most U.S. medical schools today comprise large numbers of nonteaching, nonresearch faculty members whose professional lives are focused almost entirely on the delivery of clinical care.
For many years, academic departments were able to finance their research and teaching activities through subsidies from their clinical operations. Health care payers were willing to pay a premium for care delivered in academic centers, and that premium was used to fund medical student and resident education, as well as unfunded or underfunded faculty research. With the fall of clinical reimbursement levels in the 1990s, the clinical subsidies for teaching and research dwindled markedly (6,7). The productivity of medical school faculty members was increasingly measured in terms of clinical units such as RVUs, on which departments tended to base compensation. Faculty radiologists not only devoted more of their time to clinical work, but they also worked harder during that time and thus had less time and energy for the distinctive academic missions of education, research, and service. Academic physicians are now pushed to devote more time to clinical care, and some physicians believe that they will be penalized if they devote substantial time to academic pursuits (8).
The Problem Today
The challenges facing academic radiology are not specific to radiology, but rather they exist through all of graduate medical education (9). A series of recent commentaries in JAMA drew attention to the generally perilous state of academic medicine (5–7,10). Health care is increasingly being treated as a for-profit commodity, creating an environment in which it is difficult for not-for-profit academic centers to thrive (6). In the 1990s, the numbers of private practices run by full-time faculty members increased rapidly (10). Academic medicine may not survive and certainly will not flourish if medicine becomes a purely for-profit field in which all physicians are competing in a "survival-of-the-fittest" atmosphere (6,11). Many medical schools are in serious danger of losing their academic vision (9). Faculty members are no longer asking why they are there or what they may contribute, and many have begun to regard scholarly activities such as teaching as optional rather than core responsibilities. Mentoring of students and residents is declining.
It is unrealistic to expect radiology faculty members to continue increasing their clinical output while simultaneously maintaining—let alone augmenting—their productivity in education and research. A recent study (12) identified a marked inverse relationship between the clinical output of radiology faculty members and their number of peer-reviewed articles, published abstracts, and presentations. In many academic departments, incentive and reward systems are heavily weighted toward clinical work; faculty development programs in education, research, and service are lacking; and scholarly traditions and infrastructure are either inadequate or nonexistent. In effect, such departments discourage their junior faculty members from devoting more than a minimum amount of time to the scholarly work necessary to maintain their academic appointments. When these policies result in faculty members who have little in the way of educational or investigative achievement to show for 5–7 years as assistant professors, many departments simply switch them to clinical-track appointments.
Another difficulty facing academic radiology is the growing attractiveness of private practice. Radiology residents and fellows who choose private practice careers can expect to reach full partnership in 3–5 years and earn incomes 50%–100% higher than their colleagues who choose university-based employment. Such income differentials are difficult to justify when the boundaries between academic radiologists and nonacademic radiologists are increasingly becoming blurred, with both working as hard as they can in the clinical sphere. Moreover, the subspecialization that once distinguished academic radiologists is no longer confined to the academic domain, as larger private practice groups are increasingly becoming subspecialized (8). Finally, the case mix of academic practice differs from that of private practice in ways that render academic practice less attractive to many radiologists. Academic centers tend to provide care to a higher proportion of indigent patients and patients with complex and/or severe illness that necessitates more time for image interpretation (11,13). These factors tend to make academic practice appear more difficult, less efficient, and less financially rewarding.
Many of the intrinsic rewards of academic radiology are diminishing. Faculty members who were attracted to academic practice because of a sincere interest in education or research find that they have insufficient time for such pursuits. Most academic departments have been looking for ways to reduce the amount of time their members spend on nonclinical activities. Faculty members find it increasingly difficult to find time for—let alone excel at—didactic instruction, mentoring students and residents, or designing and conducting research. People want to do their jobs well, and when they see that departments and schools are not adequately supporting the academic mission, they become frustrated and discouraged. Having aspirations, skills, and experience that are underused leads to discouragement, anger, and low self-esteem (14). Not only are radiologists leaving academic departments to join private practices, but radiology residents and fellows, who are sensitive to the attitudes of the faculty members who train them, also are being dissuaded from pursuing academic careers.
In our opinion, the deficit of academic radiologists is even more serious than it might initially appear. This observation stems from the fact that academic radiologists have an especially important role in shaping the future of radiology. The future of radiology as a distinct medical specialty hinges on the opportunity for this specialty to grow and adapt, and academic radiologists are responsible for a large proportion of the research conducted in the field. Moreover, academic radiologists have an especially important role in educating the next generation of physicians, both medical students and residents. If medical students and residents are taught well, some of the best of them will choose careers in radiology, and those who do not will represent a better-educated radiologic referral base in other medical specialties. Finally, academic radiologists, through their policy-making and advocacy efforts, tend to play an especially important role in the leadership of national organizations that shape the future of the field. If outstanding individuals are not recruited and retained in academic careers, the quality of radiologic research, education, and leadership will suffer. This will harm all radiologists, whether they are academicians or private practitioners.
What sort of future do we envision for radiology? Do we want to produce a generation of radiologists who think of themselves as mercenaries or hired guns, with no sense of loyalty or commitment to the academic enterprise, who are ready and willing to sell their services to the highest bidder? If we allow our departments and institutions to be governed by a utilitarian attitude such that they are focused solely on providing tangible rewards to those who generate the most revenue, then the academic mission and vision will be lost. If academic radiology is to survive in the years to come, departments must remain true to their academic mission, providing faculty members with the encouragement and resources, including time, that they need for academic work (15).
Remedies
If academic radiology is to recruit and retain a sufficient number of the best and brightest physicians in training in the coming years, it must do so not by pretending to be something it is not, but rather by more fully becoming what it ought to be. Academic radiology will not be salvaged by transformation into the lowest-cost most efficient field for providing clinical radiology services. Such "success" would mean the forsaking of the very academic identity of academic radiology. Leaders in academic radiology must devote themselves to defining what it means to be an academic department of radiology and to determining how academic success should be defined. Until academic leaders clearly understand where they are trying to go and why, they should not be surprised when many of their faculty members seem to lack a sense of academic purpose and direction. These leaders need to clearly define the role of education, research, and service in their faculty members’ professional lives and structure their departments in ways that promote success in each of these areas.
Academic leaders must find ways to ignite and fan the flames of passion for academic excellence (15). Medical students and residents should be deliberately exposed to academic role models who are excelling in the distinctive missions of academic radiology, and opportunities for collaboration and mentorship should be readily available. Faculty members should be conspicuously acknowledged and rewarded for their successes in the academic sphere, and incentive and reward systems should reflect the importance of all the academic missions, as opposed to predominantly clinical productivity. This passion must permeate all levels of the radiology department, right up to the top: If the department chair is not enthusiastic about education, research, and service, then it is unrealistic to suppose that faculty and residents will be. The academic department should not only make it possible for its members to excel at its distinctively academic missions but also foster a higher level of practice in the clinical sphere as well by means of a critical and inquisitive attitude toward clinical practice, a focus on evidence-based medicine, and opportunities to collaborate with and learn from leading academic practitioners in other medical specialties.
Academic departments need to foster serious discussion among their members concerning their collective mission and objectives (16). Members of academic departments must know what they are about and soberly examine their strengths and weaknesses with respect to that identity. One of the most harmful things that a department can do is to encourage its members to lie to themselves and to one another, pretending that their department is a genuinely academic organization pursuing the scholarly objectives of the university when it is in fact behaving as a revenue-motivated clinical practice. Is the academic radiology department a legitimate contributor to the intellectual and scientific missions of the university, or is it merely a service department that happens to have the same street address? Medical school deans are increasingly treating academic radiology departments in the latter manner, filling vacant chair positions by quickly choosing an acceptable candidate rather than performing a national search for a leader with strong academic commitments.
The members of an academic department must believe that they can rely on one another to pursue the overall academic objectives of the organization (17). It is not only unnecessary but also unwise to expect every member to be a triple or quadruple threat—that is, one who excels in each mission of education, research, service, and clinical work. Each faculty member need not have the same profile of commitments in each of these areas. Some may be more productive in education, while others are more productive in research or service and still others are more productive in clinical work.
No member of an academic radiology department should feel like a second-class citizen or be compensated or rewarded in a dramatically different way merely because his or her contributions to the academic mission do not generate as much revenue or academic prestige. Allowing large disparities to develop in these areas, and thus disrupting the balance between the division of labor and the overall unity of purpose that characterizes a successful academic organization, is a sure way to undermine the overall integrity of the academic mission. If members begin to believe that their colleagues are pursuing very different goals, such as to maximize their own incomes at the expense of the department’s academic mission, then dissensions, jealousies, and backstabbing are likely to result. It is the role of departmental leaders to ensure that the organization maintains its academic integrity, even in the face of internal or environmental forces that, if not appropriately dealt with, might encourage individual sections or faculty members to attempt to gain the upper hand.
Curiosity is perhaps the single trait that best characterizes the ideal academic physician. Although all physicians must continue to learn throughout their careers, the successful academic physician has a special passion to understand. Great academic radiologists examine everything—including their own clinical practice, the research literature, their individual approach to teaching, and their organization’s objectives—critically. They ask, "Why are things done this way?" and "Could we find a better way?" The best academic radiologists are risk takers, experimenters, and trailblazers. They are not afraid to make mistakes, because they realize that the best academicians learn more from their errors than from their successes. Faced with declining clinical subsidies for education and research, they seek new and innovative ways to generate revenue through outstanding teaching and investigation programs. They seek ways to not only cut costs but also improve effectiveness, and they counterbalance the drive for increased volumes with a focus on higher quality. Successful academic leaders recognize the importance of challenges, because they know that it is only through challenge that we grow and develop. They are always seeking opportunities to learn.
If academic radiology is to thrive in the coming years, its leaders must stop broadcasting a Xerxian message to their current and future faculty members. They must cease paying mere lip service to their missions in education, research, and service when they are stretching every fiber of the organization to increase clinical profitability. It is not fair to recruit new faculty members by promising substantial support for their developments as academicians while piling on more and more clinical responsibilities. Such behavior compromises the integrity of both the leader and the department and leads to a serious erosion of trust. When trust is lost, it can only be replaced by a general sense of discouragement and cynicism concerning the entire academic enterprise.
In summary, the way to make academic radiology thrive is to accent and invest in its distinctively academic missions. We must enable medical students, residents, fellows, and faculty members to (a) as clinicians, discover how rewarding it can be to understand their clinical practice both critically and thoroughly; (b) as researchers, play an important part in advancing the knowledge base of the field and see their discoveries put into practice around the world; (c) as educators, shape the future of radiology and medicine by training the next generation of physicians; and (d) through service, define and promote the missions of academic health centers and institutions of higher learning, which will embody the meaning of "academic" for generations to come.
In conclusion, our department has successfully implemented many of these suggested remedies. We have collectively defined and accepted a vision and mission for our department that clearly enhances and defines our commitment to academic success. We value and reward academic activities and clinical work equally. We provide the opportunities—including time, infrastructure, and resources—that our faculty members need to succeed in academic endeavors and reap the personal intrinsic rewards of these successes.
REFERENCES
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  C. D. Maynard Eugene W. Caldwell Lecture 2007: Radiology Research Good to Great? Am. J. Roentgenol., October 1, 2007; 189(4): 757 - 764. [Full Text] [PDF]
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 D. P. Friedman and A. J. Maitino How Often Do Neuroradiologists Perform Sonography of the Carotid Arteries? A Survey of Academic and Nonacademic Radiology Practices, with Implications for Fellowship Training AJNR Am. J. Neuroradiol., August 1, 2003; 24(7): 1300 - 1302. [Abstract] [Full Text] [PDF]
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 A. E. Berkow and M. D. Cohen Academic Radiology: Sustaining the Mission [letter] * Dr Cohen responds: Radiology, March 1, 2003; 226(3): 927 - 927. [Full Text] [PDF]
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