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Ensuring the Radiologist Workforce:Opportunities During Education

Frank Anthony Morello, Jr., MD, William A. Murphy, Jr., MD

The authors conducted a literature review to better understand the current trends in the medical workforce and,specifically, the effect these have had in radiology. The cyclic nature of the radiology workforce supply hasparalleled similar experiences in the general medical profession and other specialties. A review of proveneducation and training initiatives demonstrates positive workforce effects in particular circumstances. Theadaptation of proven education initiatives should enhance the future radiology workforce in both private andacademic settings.

Key Words: Radiology workforce, radiology training, radiology education

J Am Coll Radiol 2004;1:848-853. Copyright © 2004 American College of Radiology

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ver the past several years, a radiology workforce short-ge has been a major concern for the profession. Despiteeports predicting a continuing shortage [1], some feelhat the shortage may be less severe and of shorter dura-ion than previously suspected [2]. Such workforce con-usion is not unique to radiology. Workforce size is dif-cult to estimate and predict. An apparent easing of thehortage should not cause the profession to relax its ef-orts to ensure an adequate supply of radiologists for theuture.

History demonstrates many attempts to understandnd equalize the physician-to-workload ratio in variouspecialties. Often, a strong correlation exists between thevident physician shortage and a preceding diminishedercentage match of medical students within the dis-ressed specialty’s training programs. In each circum-tance, the recognition of trouble led to a focused re-ponse. For example, Dr. Daniel McCarty [3] referred tohe soaring number of unmatched internal medicine res-dency spots in 1987 as “Black Tuesday.” Subsequent

arketing efforts directed at medical students were em-loyed to portray internal medicine as an attractive androfessionally satisfying field. This resulted in higheratch percentages to internal medicine residencies,hich was noticeable to other medical specialties, as

ommented on by Anzilotti et al. [4] in a 2001 issue ofadiology: “It [internal medicine] is the single largestatching specialty.”

niversity of Texas, M. D. Anderson Cancer Center, Houston, Texas.

Corresponding author and reprints: Frank Anthony Morello, Jr., MD,niversity of Texas, M. D. Anderson Cancer Center, Department of Inter-

entional Radiology, 1515 Holcombe Blvd., Unit 325, Houston, TX 77030;

p-mail: fmorello@tmh.tmc.edu.

48

A few years later, general surgery experienced a drop inhe number of medical students entering that specialty,eaching a critical low point after the 2000 Nationalesidency Matching Program match. At that time, it was

hought that minor contributing factors included an in-rease in the number of female medical students (whoere not choosing surgery) and an increase in medical

itigation [5,6]. However, several reports pointed to aerceived lack of a “controllable lifestyle” as the singleost important reason why medical students either did

ot choose general surgery or changed their minds at aater date. According to Dr. James Craven [7], of the

epartment of Surgery at the Louisiana State Universityealth Science Center, “Some [medical students] areilling to sacrifice their professional aspirations, includ-

ng financial reward, for better personal and family lives.”edical careers perceived to offer better lifestyles, in-

luding anesthesiology, dermatology, radiology, emer-ency medicine, pathology, ophthalmology, and neurol-gy, seemed more attractive than general surgery [8]. Alan was initiated to address lifestyle issues in the surgeryraining curriculum, increase early exposure to medicaltudents, and make recommendations on how to increasehe marketability of general surgery as an exciting field onhe cutting edge of technology and patient care [9]. Im-lementation is expected to improve the desirability ofeneral surgery as a career path, but the results have yet toe realized.Past analyses of radiology workforce adequacy demon-

trated similar features. In 1970, Dr. Herbert Abramsbserved that the radiology manpower shortage of thatra was attributable to a lack of interest in the field [10].ubsequent advancements in ultrasonography, com-

uted tomography, magnetic resonance imaging, and

© 2004 American College of Radiology0091-2182/04/$30.00 ● DOI 10.1016/j.jacr.2004.04.018

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Morello, Murphy/Ensuring the Radiologist Workforce 849

nterventional procedures helped radiology become onef the most popular medical specialties during the 1980snd 1990s. In the mid-1990s, the combination of a peakn the number of U.S. residency positions and a lowoint in the radiology job market decreased the attrac-iveness of radiology as a career [4]. A nadir in medicaltudent matriculation into U.S. diagnostic radiology res-dencies resulted in only 50% of positions filled in the996 National Residency Matching Program match [8].he radiology match rebounded, and 99% of positionsave been filled since 2001 [8]. However, a shortage ofracticing radiologists continues [1], with a proportion-tely greater shortage of radiologists in academic pro-rams [11].

Medical students are the pool from which all special-ies draw their practitioners. Hence, specialties competeor talent and must be attractive to prospective trainees.ommon to the recurring specialty workforce crises and

heir resolutions is the importance of medical students’nd residents’ education. To maintain an adequate radi-logist workforce, there must be a sufficient number ofesidents entering training programs through the match.ven in times of excellent match performance, the goal is

o remain attractive to medical students and to retainesidents already in training. Although academic radiol-gists have the greatest influence in this regard, the entirerofession has a stake in the successful attraction of med-cal students into radiology. The ultimate quality andurability of the profession depend on medical students’hoice and residents’ satisfaction. We review and reem-hasize the fundamental education factors under theontrol of radiologists that influence choice and content-ent.

EDICAL STUDENTS

edical students are the source of radiology trainees.xposure to radiology in medical school is the major

actor in attracting quality students into residency posi-ions [12]. First-year and second-year medical studentsay be the best candidates because they have less formed

pinions about specialties than their third-year andourth-year colleagues. To maximize their attraction toadiology, we must understand what motivates medicaltudents to choose specialties.

Medical students currently choose specialties with theost controllable lifestyles and the greatest professional

atisfaction. In addition to expecting a better quality ofife during training and practice, medical students alsoant specialties that offer the satisfaction of “hands-on”edical care [7]. Graduating seniors now trend away

rom primary care and surgical specialties and towardareer choices that provide more defined work hours and

ore control over their own lives. In the September 2003 o

ssue of the Journal of the American Medical Association,orsey et al. [13] quantitated this by reporting that “The

pecialty preferences of U.S. senior medicaltudents�changed significantly from 1996 to 2002 (P �001), and controllable lifestyle explained 55% of theariability in specialty preference.” Anesthesiology, radi-logy and emergency medicine became specialties ofhoice [14].

The good news is that radiology offers lifestyle featuresought by medical students. The bad news is that medicaltudents do not know much about the richness and vi-ality of the specialty or its subspecialties. Radiology isairly ineffective in defining its professional qualities foredical students. In large part, this is due to a lack ofedical students’ exposure to radiology. Medical stu-

ents are shown “x-rays” in gross anatomy, but they oftenre instructed by basic scientists on anatomic-radio-raphic correlation. Medical students also receive formaladiology exposure in the clinical years through someorm of clerkship, either a 1-week course or a 1-monthlective. It is not fair to expect them to make careerecisions on the basis of such a limited exposure. This haseen verified with studies such as the one performed byhe Department of Radiology at the University of Mich-gan Hospitals, in which questionnaires regarding per-eptions about radiology were given to a class of enteringedical students [15] and then resubmitted to this same

lass at their graduation [16]. Over the 4 years, theirerceptions of radiology did not significantly change.he surveyed students viewed radiology as a well-paid

pecialty with a pleasant lifestyle but with low levels ofatient contact and intellectual excitement.The goals of many medical school radiology clerkships

re vague and perceived differently by radiologists andonradiologists. Freundlich and Murphy [17] found thatheir radiology clerkship had almost no influence onpecialty decision (2.1%). This was in large part due tohe perception of the clerkship by the students. By com-leting the clerkship, over 90% of students expected tonterpret images themselves and correlate their findingsith the radiologist’s report. On the other hand, if a

oncentrated effort is made to define realistic goals andnhance a clerkship, the perception may be entirely dif-erent. Gunderman et al. [18] surveyed fourth-year med-cal students from 1995 to 2000 and compared the re-ults with local and national radiology application dataor the same years. Between 1995 and 2000, the numberf fourth-year U.S. medical students applying to radiol-gy increased 1.6 times. At the study institution, thatumber increased 4.5 times (P � .020). The authorsttributed this difference to the improved quality of ra-iology teaching at the study institution and specifichanges in a required second-year medical school radiol-

gy course.

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850 Journal of the American College of Radiology/Vol. 1 No. 11 November 2004

A national change in medical school curricula to en-ance radiology exposure and training is unlikely. Theffort needs to be local, coming from within radiologyepartments and subspecialty sections and driven by in-ividual radiologists. We reemphasize initiatives to in-rease the quality and quantity of radiology education inedical schools. These efforts require one radiologist at a

ime. The aggregate impact of many individual interven-ions on a nationwide basis can make a difference andreserve the attractiveness of radiology training pro-rams.

edical School Admissions

olunteering to interview potential medical students anditting on the admissions committee provide the earliestossible exposure to radiology that a medical student canncounter. The presence of a radiologist also serves no-ice to the fellow admissions committee members thatadiologists want to be involved in medical student edu-ation. Interaction with admissions committee col-eagues is influential. It is a foundation for participationn basic science medical education.

asic Science Lectures

tudents have positive opinions about clinical specialtiesith early integration into the medical school curriculum

5]. First-year and second-year medical school lecturesan be quite monotonous. A radiologist can, and should,ive anatomy lectures and be involved in the anatomicissections. The clinical correlation helps students learnhe material, and the students remember the interestinglinical vignettes and the radiologists who taught them.

any medical schools incorporate problem-based learn-ng groups, and complex radiologic cases are ideal foruch purposes. For example, a case of renal obstructionnd percutaneous drainage can be approached from sev-ral aspects: anatomy, physiology, pharmacology, pa-hology, and so on. As consultants, radiologists arenowledgeable in these areas and can be effective teach-rs. With radiologists as faculty moderators for theseroups, medical students gain valuable and lasting expo-ure to the profession.

edical Student Mentors

any medical schools use faculty mentor programs forheir students as means of continuous assessment. Men-ors can intervene to help students in academic difficultynd also serve as sources of reassurance that “this too shallass.” Regardless of the specialty, a mentor demonstrateshe benefits of the specialty, provides a role model formulation, helps students become familiar with the field,nd, most important, demonstrates the enjoyment andnergy that the discipline affords [6]. Students automat-

cally make favored mentors the designated contact per- g

ons if anyone has an interest in the specialty. Such earlynd continued contacts with medical students can influ-nce eventual choices. Before pursuing this opportunity,hough, an interested radiologist must willingly prioritizeufficient time to provide the necessary mentorship andealize that the altruistic nature of this commitment su-ercedes any potential specialty marketing that this po-ition would offer.

edical Student Radiology Clerkships

t is important to personally represent our specialty tounior and senior medical students so they can see radi-logy through our eyes instead of through the eyes ofonradiologist physicians. These mini-apprenticeshipsan capitalize on good impressions established in earlierears.

ubspecialty Elective Clerkships

hese offer enhanced radiology exposure to medical stu-ents who are seriously looking at radiology as a career.he electives are most effective when adequately publi-

ized. A participating student should get as muchands-on work as possible by viewing images, roundingn patients, performing imaging studies such as ultra-ound, and scrubbing in on interventional cases. First-and experience demonstrates the reasons radiology is anxciting career.

nformative Career Sessions

adiology and its subspecialties should be represented athe medical school “career fair” equivalent. If no suchechanism exists, one can be created. Reserve a medical

tudent classroom for an evening, post invitation flyersear students’ mailboxes, order pizzas, and hold a semi-ar to talk about radiology and its subspecialties. Annualareer sessions with information, food, and fun have aumulative impact.

esearch Opportunities

he magnitude and impact of radiology in the medicalesearch arena grows every year. Increased collaborationith medical and surgical specialties provides exposure

nd opportunity to stay at the forefront of clinically rel-vant research. The recent creation of the National Insti-ute for Biomedical Imaging and Bioengineering and thenprecedented number of research dollars available foradiology research support these efforts. Medical stu-ents are more competitive for residency positions if theyave had some research experience. We should take ad-antage of the opportunities provided by our professionalocieties, such as the Radiological Society of Northmerica (http://www.rsna.org), that encourage medical

tudents’ research by offering medical student–specific

rants to radiology programs. An enjoyable and educa-

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Morello, Murphy/Ensuring the Radiologist Workforce 851

ional research experience has a positive impact on aedical student’s career choice. Encouraging trainee re-

earch at any level will have a positive impact on choice ofubspecialty fellowship training and continuation intocademic practice.

ESIDENTS

adiology residents supply the radiologist workforce.he residency goal should be to train highly competent

nd efficient radiologists who can enter either private orcademic practice. First-year and second-year residentsypically have not yet solidified their career paths and wille influenced during their residency education.

ole Models

preceptor’s early involvement shows an interest in theesident’s education. An effective role model educationn the early years of residency can solidify an eagerness tooin the private workforce or to pursue subspecialty fel-owship training and a potential academic career path.adiologists are busy physicians, and in a daily routine, a

esident lecture may not have high priority, but a timelynd quality lecture will have a positive influence on theesidents’ opinion of radiology and its subspecialties. Toaximize the resident’s experience and self-confidence, a

ecturer should involve individual residents by puttinghem in the “hot seat” and helping them gain a sense ofducational accomplishment without excessive intimida-ion. The quality educator role model has a positive in-uence within the training program, but unfortunately,he converse has a greater impact. Residents quickly de-elop a negative opinion of a particular subspecialty if aecturer is a “no-show” or displays a negative and intim-dating attitude. If a resident is considering fellowshipraining, a negative educator may cause the resident tovoid a fellowship in his or her home training program oro skip fellowship altogether.

If, however, residents see medical education in a pos-tive light, this impression may spark an interest in aca-emic medicine. The love of education can also be culti-ated at an early stage by allowing residents to assist inedical student education. Offering resident teaching

wards and providing training in teaching methods canevelop further motivation.

ubspecialty Selection

positive impact through didactic lectures and “view-ox” (or at the monitor) apprenticeships should translatento interest and enthusiasm during various subspecialtyotations. One-on-one staff interaction with residentsoth during the interpretation of radiologic studies andn the patient care areas emphasizes the diversity of the

ubspecialty fields. Tiered and tailored academic focus t

ppropriate to a particular resident’s education level en-ures that the resident is not overwhelmed and demon-trates the expanding nature of knowledge in each sub-pecialty, giving the resident something to anticipate byursuing a fellowship. Conversely, if residents do noth-ng more than hang x-rays, listen to staff members dictatenterpretations, check on laboratory values, and obtainatient consents, it is unlikely that they will leave theirotations with the excitement necessary to inquire aboutellowships. Negative experiences on any rotation canave detrimental effects when career decisions are made.imilarly, if residents hear general complaints aboutther specialties—losing turf, poor reimbursements,echnologists, nurses, or equipment—they will not havestrong desire to pursue certain subspecialty paths [5]. Aositive attitude is one of the most important attractionso our field. Because most of us genuinely enjoy the worke do, our daily behavior should exhibit those attitudes.ubtle messages such as these strongly influence the de-ision to enter a fellowship program and the choice of aubspecialty.

ools of the Education Trade

ocused lectures, study groups, interesting case reviews,orbidity and mortality conferences, and board reviews

re some of the tools that can be used to enhance resi-ency education. Regardless of the particular subspe-ialty area, radiology preceptors can take a visible interestn qualifying residents for the American Board of Radi-logy written and oral examinations. The successful ac-omplishment of quality education initiatives should cre-te an exceptional reputation for the radiology staff andhe individual subspecialty rotations among all residents.eeping education interesting, relevant, and fun helpsake the choice of an academic career more viable at the

ime the career path decision is made.

he Postgraduate Year 1 Requirement andSecond Career Residents”

ecause of the postgraduate year 1 clinical prerequisiteor radiology, some medical and surgical interns in hos-itals may have already matched to radiology residencies.he faculty radiologists may not know who these people

re. It pays to treat all clinical colleagues with respect so asot to adversely affect the good will of future residents.otating medical students also observe interactions withlinical residents. Those pursuing specialties other thanadiology may be so positively influenced by their inter-ctions with radiologists that they redirect their careeraths to radiology. Positive interactions with such col-

eagues can be influential in marketing radiology and itsraining potential. Overly critical dealings with radiologyesidents or with interns and residents from other special-

ies may have an unrealized negative impact. Second

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852 Journal of the American College of Radiology/Vol. 1 No. 11 November 2004

areer radiology residency applicants are an excellentool from which to recruit quality trainees. Volunteeringo give a medical or surgical grand rounds radiologyecture is another tool to gain positive exposure to thisandidate group.

ELLOWS

uccessful residency training programs produce candi-ates for private practice, subspecialty fellowship train-

ng, or academic careers. At this stage, the individualaking the decision chooses the path. The residency

rogram already had its chance to influence the decisionhrough the quality of its training. Today’s job market isavorable for radiology residents to go directly into pri-ate practice. According to a 2003 report by the physi-ian recruitment agency Merritt, Hawkins, and Associ-tes [19], since 1999, radiology has consistently had onef the highest income potentials, and the number ofadiology job searches has been the most of any specialtyince 1999. According to Dr. Lee F. Rogers [20], “Fel-owship positions have gone begging because more and

ore resident graduates have found it possible to goirectly into desirable private practice situations withouthe prerequisite of fellowship training.” This was nation-lly quantified by the results of the 2002 interventionaladiology fellowship match and the 2003 general radiol-gy subspecialty match, both administered by the Na-ional Residency Matching Program. In the 2002 inter-entional radiology fellowship match, the majority of.S. fellowship positions were submitted to the matchrocess—99% of programs accredited by the Accredita-ion Council for Graduate Medical Education partici-ated—and 50% of the available positions in the matchere left unfilled. In the 2003 fellowship match, inter-entional radiology saw a second-year decrease to 37%.nly 53% of the overall radiology fellowship positionsere filled. The number of residents who pursue fellow-

hip positions is influenced by many complicated factors.owever, the unmistakable fact is that the magnitude of

ellowship training is diminished. That can only meaness sophistication in the installed base of radiologistsationwide over time.Many factors affect the radiology workforce. Most of

hese are difficult, if not impossible to control as they aremaller pieces of a much larger medical workforce puzzle.nfluence over the radiology workforce starts with edu-ation, and education is one thing the profession doesontrol. Increasing the quality and quantity of medicaltudent radiology exposure should yield more studentsnterested in radiology residency. Excellence in residentducation coupled with quality academic role modelinghould increase the number of residents who enter sub-

pecialty fellowship training programs. Radiologists with

dditional sophistication enrich all radiology practices.ededication to sound education principles shouldaintain and even increase the quality and quantity of

he radiologist workforce, ultimately strengthening onef the most valuable medical specialties in medicine to-ay.

SSUES FOR CONSIDERATION

. Fewer radiology residents entering fellowships mayin time lead to fewer candidates for academic radiol-ogy faculty positions, because fellows constitute thelargest pool from which new academic radiologistsare recruited.

. Fewer academic radiologists may mean that fewerresidents are trained, and the available radiologistworkforce will shrink.

. Fewer fellows in training may also mean the subspe-cialty sophistication of the installed base of radiolo-gists will diminish. Clinicians may find less sophisti-cated radiologists of less value.

. Academic radiology practices could be more effectiveat attracting medical students to residency trainingprograms and at retaining radiology residents in fel-lowship programs.

. Private and academic radiologists could find manyways through volunteerism to enhance educationwithin radiology to ensure the attractiveness of thefield to medical students, the quality of the educa-tional experience for residents, and the relevance offellowship training.

. The preservation of academic practices is critical topreservation of the radiologist workforce. Both pri-vate-practice and academic radiologists have thesame stake in the success of academic practices as faras radiologist workforce preservation and quality areconcerned. All radiologists could rededicate them-selves to quality radiology education.

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