I have been around a long time. I’ve got gray hair. We have been here, and we have done most of this, before. In fact, there have always been disruptors in radiology practice.

When I was coming through, we had diagnosis-related groups, or DRGs. DRGs were going to kill our business because, all of a sudden, we were not going to get paid fee for service. Computer-assisted diagnosis (CAD) was supposed to put me, a chest radiologist, out of business, too. Medicine was not going to need radiology anymore because a CAD system could do all the detection. Then, it was the PAC system that was going to distribute our work all over the world, and modern medicine wasn’t going to need any radiologist.   

Can you even imagine an oversupply of radiologists today? I was in Houston in the mid- to late-1990s, when radiology had a double-match. And when I finished fellowship, there were two academic chest radiology jobs in the entire country. Two! Thus, I ended up in Houston not because that was where I wanted to go, but because that was where the work was.

I ask any of you now: do you feel like you don’t have enough work? Currently, there are 1,800 job postings on the American College of Radiology’s Career Center. Meanwhile, radiology produces about 1,230 trainees per year. By sheer numbers, we’re 600 radiologists behind before we even start. This number doesn’t consider part-time workers or “quiet retirement” retirees. Right now, the best estimate is about 50,000 working radiologists in the United States. Of those, I would guess 10%, maybe 20%, work part time. The real number could be even higher.

Volumes are off the wall. There’s no questioning the increase. During the COVID-19 pandemic, we did see a significant volume drop. Almost every mammography screening program was shut down for at least four weeks, so the rebound has been astronomical. We perform roughly 80 million CTs in the U.S. annually—probably more—and those are just what can we track through billing data. Globally, radiologists perform 5 billion imaging studies around the world. These are massive numbers. Burnout and wellness are issues we’re really struggling with. 

Sure, one day, there could be an oversupply of radiologists, but it might be in ways we’re not yet thinking about it. Imagine if nurse practitioners start practicing radiology. Imagine if ED doctors, armed with AI, begin taking away our business. I advise you to not get too comfortable.

It’s not just radiologists; any health care job with “-ologist” at the end is in short supply. Pathology technicians, technologists doing specimens, our nursing force—all are short. We don’t have technologists to do basic imaging in the ED.

There is no shortage of administrators, however. We’ve got plenty, and they are disrupting. We have personnel telling us how to practice medicine—how to practice radiology—who don’t really know our field. Given the 20-year emphasis on corporatized medicine, we’re hearing more and more about turnaround times and productivity, including software with a speedometer on your PACS. If you are not reading fast enough, you’ll receive an alert, blinking red and green and yellow to better set your pace.

We all think of PACS as being radiology’s domain. As pathology becomes more digitized, and as dermatology slides and other images go DICOM format and input to PACS, radiologists don’t own PACS anymore. Your PACS replacement might be determined by the pathology department, not your fellow radiologists. You could end up working with a system that you do not like, or don’t want at all. Period.

While we may no longer own PACS outright, we can control these systems, although that may lead to a different problem: ghosting. Patients don’t know who radiologists, one of medicine’s highest-paid specialties, are. And they don’t like paying an imaging bill when they’ve never met their radiologist. We try where we can, but often, we’re not the best at patient communication. We’ve done very well not talking to them, until the last few years. Exceptions, like breast, IR, or pediatrics, will have more interaction, but if patients still don’t know who we are (and administrators don’t like overpaying us), we remain at risk. Radiology must get back in front of people.

Amazon, Google, Walmart…UnitedHealthcare—there are new major players in the market. Patient populations put consumer demands on “Alexa” and “Doctor Google” to tell them what the doctor should be doing, questioning why we did not recommend x, y, and z. Honestly, none of this was around when I trained. And that’s not too long ago. In a short period of time, we’ve had all these kinds of things creep into our business. Let’s also talk about scope of practice creep. If we don’t have enough radiologists to do the work, there will be a void, and someone or something is going to fill that void.

Job consolidation is something new to radiology in the last 10-plus years. When most of us got out of training, we went to academic centers and to private practices. We did not have large, multi-institutional practices. My present system, the Medical University of South Carolina (MUSC), is acquiring hospitals all over the state. And then, in a sense, the private practice groups in these hospitals face decisions to join us, stay independent, etc. Mergers and acquisitions are affecting every group, obviously. I’ve been in a situation where a hospital was at threat of losing their CMS accreditation and not being paid. The hospital was under what’s called immediate jeopardy, meaning if you don’t fix this issue, you will no longer be allowed to treat Medicare and Medicaid patients. That changes the practice overnight. 

I think every one of us has seen or at least heard about what can happen when aspects of private equity creep into our employment.

What happens when private equity pulls out? Suddenly, they’re saying you have to buy your group back, or you’re out of a job. There are pros and cons, but trust me, as soon as private equity cannot make money, they will be out. Their job is to make money, not to care about patients. Recently, Walmart announced they’re pulling out of health care in 51 clinics, shutting down radiology groups that contracted to do all that work. Walmart couldn’t make it work. Do you think they care about the patients that were in their system? No. They’re going to do what they can to get the patients taken care of. Do you think they care about the physicians and radiologists they hired to run that system?

In the U.S., 80% of physicians are employed by hospitals or corporations. When I was in private practice as a general dentist, I was my own professional corporation (PC). PCs are going away and dying, leading to this question: if work continues to get worse for us, will physicians unionize? I wondered about that. As independent practitioners, we are not allowed to unionize. As employees of corporate structures, that rule doesn’t necessarily apply. We’re seeing radiology residents and fellows unionizing because of work-life stress issues. If we continue to have corporate entities employing thousands of radiologists, will radiologists unionize? Because we can’t keep up the volume that’s being thrown at us for the money that they’re paying us.

Non-compete laws are getting repealed, though not in every state. The FTC has ruled that they’re not allowable. While I suspect several legal challenges, ultimately, you’ll be able to go from one hospital to the next in the same town overnight. No more non-competes will change your business, affecting where you go to work. Some of my current residents going out to practice now have reservations and hesitations about joining a particular group because this commitment would practically block them out of that entire city. We also struggle with what I call “radiology rabbits,” those who jump from job to job to job. It costs me a lot of money to recruit someone just to have them leave within a year. I’ve seen estimates of $30,000–40,000 per person that you recruit and hire. But if you’re done non-competing, you can go from job to job. It does take away the cohesiveness we used to have in private groups, where you are going to work with the sample people for the next 10, 15 years. Your ability to be part of a system or group—to have a home—is going to change. You may be one of those people who continually seeks that home, but it may not ever exist.

There’s also a changing of the guard with younger generations, and I don’t say they’re wrong about lifestyle balance. Actually, I wish I’d been smart enough to think about that when I was coming up! We just got out and went to work. I finished fellowship on June 30th in Boston. I had to start in Houston July 1, so I drove all day on June 30th, then went to work the next day. As a department chair, remote reading is incredible, but I was totally against remote reading, until I did it. I then bought PACS stations for all my faculty because I thought it was the greatest thing in the world. I don’t have to come into the hospital on Saturday and Sunday—definitely a disruptor to the practice as we think about flexible scheduling going forward.

Subspecialty is something we all do. When we were residents, I would say 30–40% of folks did subspecialty fellowships. Most people went straight out into private practice. Now, 90% of people do fellowships. And guess what? When they get out, they want to do their specialty fellowship work. They want to be breast, or they want to do neuro. They don’t want work as a jack-of-all-trade general radiologist. (Some do, but then, they don’t necessarily want to do everything they want.) Many don’t want to do IR, breast, etc. This is changing the workforce, having to figure out how to staff it.

I am concerned about the classic academic radiology department, as well. I think that as we morph closer to what private practice is, my radiologists do not receive academic time similar to what I got. In theory, they get 20% academic time. In reality, it’s probably 10%. At some point, your curiosity, your interest, and your desire to teach, work, and research gets overwhelmed by the workloads coming at you. Hospital administrators, frequently buying four or five regional hospitals, just want the work done. Academic radiologists get overcome by both work volume and by the non-academic radiologists who have since become part of their group. It takes a lot of time to teach the next generation of residents who are going to be the people of the future, working in the workforce in the next few years.

We have to do whatever we can to protect as much as possible, especially in education. When radiologists don’t have as much time to teach, radiology ends up with a lot less time to move forward.