There is no disagreement among radiologists and radiology administrators that there is a shortage of radiologists. And the situationfueled by a lack of radiology slots in medical schools, an increase in the number and complexity of new procedures, the demand for more services, and the retirement of many experienced radiologistsis likely not to get better any time soon.

But radiologists, administrators, and the American College of Radiology (ACR) are not sitting idly by. They are actively working to alleviate the problem both short termwith more pay, better working conditions, and careful recruiting and retention strategiesand long term, with the development of more radiology programs and slots for both medical students and allied health students. The latter processwhich everyone agrees is the key to the solutioncould take up to a decade to meet the demand. The ACR also is working with the American Society of Radiologic Technologists (ASRT) to develop programs and strategies to increase the number of people who want to be radiology technologists (see related story, page 14).

The short-term strategies, though far from solving the problemcurrently the ratio of job openings to available radiologists is about 3.8 to 1, a deficit of about 600 radiologists, according to the ACRare netting positive results and are allowing practices and hospitals to provide services to meet the growing demands of patients.

Although the Dallas radiology market is very competitive, Paul H. Ellenbogen, MD, chairman of the Department of Radiology at the 700-bed Presbyterian Hospital of Dallas, says his group, Dallas Radiologists, currently has no shortages. This does not mean, however, that the 16-member practice is not feeling the effects of the radiologist shortfall. "Right now, we have essentially the exact number of people we need to run our four facilities," he says. "We could continue to function at our current capacity for the next several years, but it would mean we would all work more than we want to and we wouldn't have any reserve if someone became disabled or ill."

For Ellenbogen, recruitment and retention are long-term prospects. The group recently hired a radiologist still in training to join the practice in July 2003. "This is a person we have known for several years and have cultivated and mentored&so we've signed him on the dotted line essentially 18 months before he finishes his training," he says. "We are considering doing that with other individuals."

Though the practice is lean at the moment, the group continues to be careful in the way it recruits. "We have a recruitment committee made up of five people and they screen the candidates and decide who we want to invite for an interview," says Ellenbogen. " I'm hoping to find somebody who wants to be in my group and that once we reach an agreement, we're going to see this as a forever type of deal&we want them to come into this with the expectation that this is going to be their only job for their entire professional career." Ellenbogen, who has been with the group for more than 25 years, adds that during his tenure, 21 radiologists have made the group their only professional stop.

Fundamental to the recruitment strategy is finding radiologists with the same work ethic. "It has never been our philosophy to make as much money as possible, because, if it was, we wouldn't be hiring more people," says Ellenbogen. "We want people who really enjoy radiology, who want to work hard when they're here, who want to be productive, who want to provide excellence in care, but don't see radiology as the only thing in their life and don't see money as their only goal,"

Moneythough not a primary focus of the groupdoes play a role in retention, but not in inflated salaries (which in some practices can be as high as $500,000). "When you become a partner, you make exactly the same amount of money as the guy who's been here for 20 years," says Ellenbogen. "You get the same vacation, choice of office, days off, and [share in] ownership of the practice and equity. We are completely equal."

Carefully recruiting new radiologists is not the only solution the group is implementing. A retired partner comes back a few days a month to work during the day. The group also uses high school and college studentsmany of whom are interested in radiology careersto assist with hanging films, making appointments, and helping with dictation, making the physicians more efficient.

In addition to shifting some routine, non-medical tasks to aides, the group is also taking full advantage of technology to make them more efficient, offsetting any current or potential shortages. The group is currently transitioning to PACS from multiviewers.

For John Torres III, vice president professional services for Team Health West, the shortages are compounded by the character of the radiology practices his company manages. The 3-man practices based at Whittier Memorial Hospital, Whittier, Calif, and John F. Kennedy Memorial Hospital, Indio, Calif, provide comprehensive services to their communities. About 60% to 70% of both practices' work is general radiology, and the balance is in specialized procedures. This means that any radiologist who joins either group must have a good all-around knowledge of every procedure. "The shortages, in my experience, fall into two areas," says Torres. "I'm finding people who are coming out of programs and want to specialize, and that in itself creates a shortage for the type of practices I have. The other aspect is that a number of the experienced radiologists out there who have practiced on both sides&now know they can go out on the market and essentially practice in the kind of setting they want and basically almost dictate the kind of income they could and want to earn."

However, not every radiology fellow wants to specialize. "I've talked to a number of interventional fellows, and sometimes you find radiologists that have the long view," says Torres. "They're interventional fellows, they may want to do primarily their specialty, but they also discover that the ship can sail only so long before there's a turn in the market somewhere. They don't want to lose their other skills, so those guys are willing to utilize their general radiology skills and hopefully develop the interventional side of the business we have and become the specialist [in that modality]."

But schools are not the only places where new hires come from. "A lot of [our radiologists are found] through networking and referrals," says Torres. "Even competitors who know about my practices will talk with my physicians."

One thing that Torres has found is that successful recruiting has little to do with offering large salaries. "I soon discovered that it wasn't so much compensation but the practice itself that [the radiologists] were really trying to focus on," he says. "They wanted a practice that would lend itself to their particular interests or skills. That was one factor and of course compensation was the second, but the compensation was not the overriding one."

But successful recruiting is only half the battle. Retaining these radiologists is Torres' other challenge. "A lot of the up-front work is done in trying to get that physician as familiar with the practice as possible," he says. "That means talking with the full-time people who work there, talking with the technologists, talking with the attendings, with anybody they may interact with. Obviously, when they come out to the practice, they'll see the location of the department, the equipment that is being used, how it's being used. Then they can come in as a locum tenens whether an internal locum through us or an external locum that is presented to us. They can work a couple of trial shifts, to get an idea of what the practice is like."

In addition to allowing potential hires to work as locum tenens, partners are also willing to train their new associates in the procedures that are unfamiliar to them. Torres says that this is a selling point for many radiologists.

In addition, for some potential partners, state-of-the-art systems and equipment are a deciding factor as to whether they will accept or decline an offer. "The [lack of] PACS is definitely an issue," says Torres. "We had one physician who declined a position because he had worked in a practice that had a PACS and saw the advantages of it. It's very crucial and important that the hospitals start to implement their plans to develop their departments and our hospitals have. They're moving to upgrade almost all equipment in their departments to current standards, basically to all digital&because when the physicians go through, that's what they look for."

While individual practices are tackling specific challenges, the ACR has set up a task force to solve the problem at the national level. Fundamental to this solution is increasing the number of residents in radiology programs. "Radiology is a very exciting field, an interesting field, and if the slots [in medical schools] could be available, I think the physicians will be there," says Charles D. Williams, MD, FACR, a member of the Board of Chancellors of the ACR and chairman of the organization's Human Resources Committee, as well as chairman of the Department of Radiology at Tallahassee Memorial Hospital, Tallahassee, Fla. "So, one way we're trying to [make that happen] is to lobby for additional radiology training slots above the cap, which was set by the Centers for Medicare & Medicaid Services (CMS). Initially, we had the Snowe-Harkin Bill and we got a number of sponsors for that; it was going extremely well until September 11 and then security became primary. That was a setback, but now I think we're going to move forward on that." The Snowe-Harkin Bill includes a provision for CMS to pay for three additional radiology slots at each of the 200 radiology programs in the United States. Williams cautions that it will take about 5 years from the time the bill is passed to see an increase in the number of radiologists entering the field. The task force has also added a similar amendment to the Assured Access to Mammography Act.

The ACR is also working to develop a radiology assistant description that will be universally accepted and form the framework for advanced training programs. "Radiologist assistants do not interpret images," says Williams. "They are generally [radiologic technologists] who go on for advanced training that will help with some patient assessment, patient management, and patient education; they can make initial image observations and communicate those observations to the radiologist and perform selected radiologic procedures. They are there to make us more productive and more efficient, not to be independent like the nurse practitioner. Hopefully, that will attract more people into the field, and because of the shortage it will help make the radiologist more productive and efficient."

Echoing Torres and Ellenbogen, Williams says money is not the answer to the problem. "All [money] does is make it more competitive; it doesn't increase the numbers," he says. "If there are 3.8 job openings for every radiologist, all you're doing is shifting radiologists."

As chairman of the Department of Radiology at Tallahassee Memorial Hospital, Williams has been fortunate. Currently his group has no vacancies. He credits this to two factors. "We're in a locale that's attractive to live in, and it's a practice that's challenging but interesting in a good work setting," he says. "If we were in a different locale, we would have a lot more difficulty. And because there's a shortage, the people finishing training go to places where they'd like to raise a family, live, and practice."

Chris Wolski is associate editor of Decisions in Imaging Economics.