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Pediatric Radiology

Department of Radiology, St John's Mercy Medical Center, 615 S New Ballas Rd, Creve Coeur, MO 63141
e-mail: jgrunz{at}ix.netcom.com

Editor:

As a community-based pediatric radiologist, I read with interest the article by Drs Bramson and Taylor (1), in the June 2005 issue of Radiology, regarding the challenges to the subspecialty and the authors' suggested solutions. To summarize, they are concerned with the lack of pediatric radiologists relative to workforce needs and would like to make changes to training and practice patterns in order to ensure the relevance of pediatric radiology as a subspecialty.

I respectfully disagree both with Drs Bramson and Taylor's characterization of the problems facing pediatric radiology and with their proposed solutions. Regarding workforce needs, a bit of historical perspective is essential, and I would offer my own experience. When I applied to pediatric radiology fellowship programs in 1992, I recall that approximately 70 postfellowship pediatric radiology faculty positions were available. After graduating from a well-regarded pediatric radiology fellowship in 1994, there were virtually no postfellowship faculty positions available. Fortunately, after a second fellowship in cross-sectional imaging, I secured a position at a community hospital near St Louis, Missouri. At the Society for Pediatric Radiology meeting in 1998, held in St Louis, discussions were held to limit the number of pediatric radiology fellowship positions because of the absence of suitable positions for graduates. At the time, the perceived wisdom was the need for "professional birth control" to limit the number of pediatric radiology fellowship graduates.

I believed at the time that this was an extremely short-sighted viewpoint. A short 7 years later, the "crisis" that has developed is the opposite of that which was predicted in 1998. Now, the "crisis" is the absence of candidates for pediatric radiology positions. In contrast with the model posited by Drs Bramson and Taylor, I would suggest that the economic model is not the analogy of Microsoft versus Apple Computer but the more basic model of supply and demand. In a small medical subspecialty such as pediatric radiology, there will constantly be a cyclical over- and underproduction of supply (fellowship graduates) to match demand (staff positions). The current environment is a "seller's market." Graduates have a number of opportunities from which to choose, but, inevitably, forces of the marketplace will adjust the supply to meet the demand.

I must also respectfully disagree with several of the authors' policy proposals, which would weaken, rather than strengthen, pediatric radiology. They suggest a shortened period of fellowship training, a dedicated pediatric radiology track in residency, and/or the use of nonphysician technologists to act as "physician extenders."

These proposals would weaken the subspecialty by calling into question the competence and knowledge of pediatric radiologists as a whole. As a specialty, our knowledge of childhood diseases, their diagnostic imaging appearances, and treatment options is paramount to providing quality patient care. The certificate of added qualification (CAQ) program for pediatric radiology was instituted in part to assure quality to practitioners in the subspecialty. Does weakening these standards in the name of efficiency promote respect for the specialty? Does it improve respect in the eyes of our colleagues? I think not.

As for the dedicated pediatric radiology residency track, such a residency program would surely limit the options of its graduates. What if a physician would like to make a career change and practice breast radiology or cross-sectional imaging, even on a part-time basis? Or practice in a community hospital, in which pediatric radiology was only 50%–75% of the workload? I suspect that such a radiologist would have a much harder time obtaining and retaining a staff position. Not all of pediatric radiology is practiced in an academic setting. To cite an example, my hospital has five radiologists with CAQ certification in pediatric radiology, and this is in a city with two large, and justifiably well-regarded, university-affiliated children's hospitals.

One solution Drs Bramson and Taylor do not suggest is increasing the salary and opportunities of fellowship candidates. Most pediatric radiology fellows are not poor but could certainly use a bit of extra income. For the cash-strapped department, maybe staff physicians could make a small donation to the fellowship program. After all, fellows tend to perform many functions that staff physicians prefer to avoid, such as call responsibilities. Such services would surely come at a much higher price if performed by locum tenens or teleradiology services. I suspect that moderate salary increases and/or offers of "tryout" staff positions following training would increase both the quality and the quantity of potential pediatric radiology trainees.

Last, Drs Bramson and Taylor do not consider a very important adjunct to the pediatric radiology subspecialist—that is, the general radiologist. All board-certified radiologists are required to pass the pediatric radiology section of the boards and have additional expertise in all areas of diagnostic imaging, including computed tomography, ultrasonography, and magnetic resonance studies. This is certainly more training than emergency room physicians or orthopedic surgeons have received, especially those practicing at smaller or rural hospitals. If there is a void to be filled, I would suggest that the general radiologist is the most logical choice to fill it.

In the meantime, I would suggest that market forces and high quality of care will rescue pediatric radiology from the crisis that it now faces, if, in fact, such a crisis really does indeed exist.

	Reference

TOP Reference References

 

1. Bramson RT, Taylor GA. SOS: can we save pediatric radiology? Radiology 2005;235(3):719–722.[Free Full Text]

Response

Department of Radiology, The Children's Hospital, 300 Longwood Ave, Boston, MA 02115
e-mail: robert.bramson@childrens.harvard.edu

Although we may disagree with many of his comments, we thank Dr Grunz for his letter. Indeed, the primary purpose of our article (1) was to spark discussion about the situation in pediatric radiology, and we believe that such discussions inevitably lead to disagreements. We regard both as healthy and good. For reasons of brevity we will touch on only a few points we would like to emphasize in response to his letter.

Dr Grunz is correct in pointing out the shortsightedness of limiting the number of pediatric radiology fellowships proposed in the mid-1990s. The early 1990s was a period in which the government and other third-party payers pushed the concept of managed care. One of the precepts of managed care was that specialists cost too much money. The government tried various methods to encourage medical students and young physicians to enter primary care rather than to specialize. It was during this time that many top-quality programs were asked to decrease the number of available residency slots in radiology. The rationale for this did not make sense at the time and certainly did not make sense as subsequent events unfolded. Indeed, many leaders in pediatric radiology, as well as in other specialties, opposed these efforts by the government. We refer Dr Grunz to a 1993 editorial in Radiology (2) that describes how leaders in pediatric radiology approached the problem and discusses what the situation was really like during that time frame and the number of positions available for pediatric radiologists.

We agree that supply and demand is a strong driver in medical markets. Although it is unlikely that pediatric radiology will grow disproportionately in the foreseeable future, we believe that the demand for pediatric radiologists will remain steady. We believe it is unlikely that there will be an increase in the number or size of pediatric radiology training programs. As a result, there needs to be a better match between the work that only pediatric radiologists can do and the work that can be performed by others under their supervision. The American College of Radiology is considering many of the options we outlined as possible solutions for the general radiologist. In addition, we believe that the practice of using physician extenders in many other clinical subspecialties has not served to weaken them but rather has allowed the appropriate matching of clinician skill sets and clinical problems. We do not think anything we are proposing will weaken the quality of pediatric radiology. What we said is that we want to look at how we educate people and really see what type of training is needed and how things could be improved. We do not think that making training longer equates to making it better. We continue to believe that a constant reevaluation of both the content and the delivery of our educational system will improve it.

With regard to Dr Grunz's proposal to increase salaries of pediatric radiology fellows and try out positions, these indeed are options to consider. Our group has increased the salary level for 2nd-year fellows in our department in order to reflect the higher level of work and responsibility they shoulder. Other groups have established "early identification" programs to find and encourage promising individuals to choose pediatric radiology as a career, with the added incentive of securing a staff position as early as the 2nd year of radiology residency.

Finally, Dr Grunz points out that the general radiologist may take up the slack of pediatric work as shortages continue. Given the increasing workload general radiologists are experiencing, the relatively low volume of pediatric studies performed in any given adult hospital, and the subsequent lack of comfort in dealing with uncooperative children, it is much more likely that pediatric studies will become increasingly concentrated in larger pediatric centers where the support systems and expertise are readily available.

We thank Dr Grunz for his comments and encourage others to reflect and propose ideas on how we can save our specialty from the slow but relentless attrition of pediatric radiologists.

	References

TOP Reference References

 

1. Bramson RT, Taylor GA. SOS: can we save pediatric radiology? Radiology 2005;235(3):719–722.[Free Full Text]
2. Kirks DR. Pediatric radiology: flexibility, viability, credibility, and opportunity [editorial]. Radiology 1993;187(2):311–312.[Free Full Text]

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