Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
1273
Perspective
Radiology Summit 1990: Specialization in RadiologyTrends, Implications, and Recommendations James
H. ThralI1
and
Jack
Wittenberg
Increasing specialization among radiologists is a well-established trend and-most broadly-is a consequence of the increasing sophistication and complexity of medical practice finding expression in the practice of radiology. The strength of the trend toward more specialization is great enough that the debate and controversy of the past decade about whether specialization and the accreditation of specialties is good for radiology has given way, without “official” resolution or even consensus, to a discussion of how best to go forward: to define
areas
of
specialization;
to
protect
and
enhance
with additional experience or training in an area but who might not work exclusively in that area. On the basis of this viewpoint, there was consensus that specialization had become a pervasive part of the practice of radiology. In large private groups and most academic practices, specialization is already highly
the
practice of radiology in an era of specialization; and to protect and enhance the legitimate career aspirations of individual radiologists, whether their primary interests are oriented toward general or specialty practice. The following observations are based on a panel discussion with approximately 25 participants from a wide variety of private and academic practice backgrounds that took place as part of the 1 990 Radiology Summit in Asheville, NC.
Background
and
developed.
However,
even
in small
private
practice
groups, there is a strong trend toward individuals taking on responsibilities in specialties, especially in nuclear medicine, neuroradiology, mammography, and angiography/interventional procedures. Perhaps ironically, representatives of large groups and especially large academic practices expressed a problem in finding radiologists to do general work, whereas small groups felt increasing pressure to find radiologists to meet emerging needs for more specialized practice. The two most important factors driving the degree of specialization in current practice appeared to be department or group size and practice venue. A recurrent theme was that specialtytrained radiologists in private practice frequently do a significant amount of general radiology (at least until the group or practice size is large enough to sustain a full-time specialist); this was far less common in many academic practices.
Assessment
The panel chose not to attempt a rigid definition of either specialist or generalist. Rather, it held the view that a generalist was someone whose work concerned multiple organ systems and/or multiple technologies, but not necessarily in all organ system areas, and that a specialist was someone
Drivers
of Change
The panel considered the trends inside and outside of radiology that had been most important in driving the change
Received November 26, 1990; accepted after revision December 27, 1990. Participants in the 1990 Radiology Summit panel were James H. Thrall (moderator), R. Nick Bryan. William J. Casarella, Donald W. Chakeres, Carl J. D’Orsi, Raymond A. Gagliardi, Milton Gallant, Jeffrey T. Goodwin, Thomas S. Harle, Anton N. Hasso, Ray Kilcoyne. Donald A. Kirks, Kenneth L. Krabbenhoft, Theresa C. McLoud, Thomas F. Meaney. Michael T. Modic, Henry P. Pendergrass. Lee F. Rogers. Alfred A. Smith, Robert J. Stanley. Lynne Steinbach, Michael S. Tenner,
Ina L. Tonkin, Ama van Breda, Jack Westcott,
, Both
authors:
AJR 156:1273-1276,
Department June
of Radiology,
Jack Wittenberg, Massachusetts
1991 0361 -803X/91/1
566-1
and James E. Youker.
General
Hospital
273 © American
Boston,
Roentgen
MA 021 1 4. Address Ray Society
reprint
requests
to J. H. Thrall.
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
1274
THRALL
AND
toward more specialization. Three factors stand out. First, and probably by far the most important, has been the unprecedented creation of new radiologic knowledge in the past two decades. This explosive growth has profoundly increased the level of sophistication in diagnosis and treatment that our specialty can now offer to patients. The increases in knowledge and breadth of practice have made it impossible for any one person to practice at the “state of the art” in all areas of radiology. Second, turf battles over who provides services have created a need for radiologists to achieve the highest possible levels of expertise to defend the boundaries of their practices. Such levels of expertise require specialized focus, which includes both clinical and research dedication. Third, and parallel in time with the foregoing factors, have been changes in privileging criteria fostered by the Joint Commission on Accreditation of Hospitals Organization (JCAHO) to require more specificity and a stronger link between performance assessment and the granting of privileges. Specialization provides a natural mechanism for addressing both issues. Several other factors were considered significant, although less important, than the three just enumerated. Increasing subspecialization in other fields has raised the expectations of referring physicians about the level of expertise held by radiologists. Likewise, there has been an increasing level of sophistication and expectation among patients. Third-party payers are also beginning to look at levels of expertise and are linking specialization to their willingness to rimr5 for complex procedures. Lastly, the growth and development of strong specialty organizations within radiology has fostered the development of specialization. As professional and scientific organizations have gained strength, stature, and membership, they have become focal points for their respective specialties. In fact, it is from the specialty organizations that requests have been generated for official accreditation of training programs in their respective specialties.
WITTENBERG
ing, albeit slowly. Another important area of activity not completely defined by the organ system approach is interventional radiology. However, the majority of academic departments and private practices include vascular/interventional procedures as a separate area of specialization. The view expressed by a number of people on the panel was that vascular/interventional radiology may actually evolve as a separate area of practice akin to the separation between diagnostic and therapeutic radiology.
Accreditation
“Specialties”?
Radiology embraces multiple imaging technologies, which are in turn applied to all of the organ systems in the body. This has raised the question of whether it is more logical to segment practice on the basis of an organ system orientation or a technological orientation. The clear consensus was that the organ system approach is ultimately the most logical and strongest one because it allows the specialist in radiology to learn the clinical and surgical aspects of the respective organ systems, thereby having parity in knowledge with the clinicians with whom he or she interacts. New technologies are often introduced by people who are dedicated to the technology; but as the technology matures, it becomes progressively incorporated into the organ system matrix. The consensus was to accept and encourage this evolutionary paradigm. This approach has been successfully applied in both CT and MR imaging. There has been less integration of nuclear medicine and sonography into organ system specialty practices, but this too appears to be evolv-
and
Certification
In discussing specialization, it is important to define and understand the difference between accreditation and certification. Accreditation applies to training programs, not individuals. It is the province of the Residency Review Committee (RRC) working under the aegis of the Accreditation Council on Graduate Medical Education (ACGME). The ACGME in turn is jointly sanctioned by the American Board of Medical Specialties (ABMS), American Medical Association (AMA), American Hospital Association (AHA), American Association of Medical Colleges, and Council of Medical Specialty Societies. The specific charge to the RRCs is the accreditation of hospital-based graduate medical education programs. The process of achieving accreditation for a new specialty is complex, but begins with a specialty group or society or other organization forwarding a request to the radiology RRC. The RRC develops special training requirements and works with the RRCs of the other specialties, as well as the other interested organizations including the ABMS, AMA, and AHA, to obtain final approval. Certification is the province of the various specialty boards. For radiology, it is the American Board of Radiology (ABR), and the term applies to persons who seek certification after residency (or fellowship) training. One of the concerns in the process of accreditation and certification is that accreditation might be granted to training programs without the opportunity for
What Are the Radiology
AJR:156, June 1991
individuals
for
certification.
The
ABR
has
agreed
sider certification credited programs
paths for people completing in neuroradiology and pediatric
Potential
of Specialization
Benefits
to con-
newly acradiology.
The consensus of the panel was that specialization in important benefits to radiology and to patients radiologic
procedures.
Most
importantly,
patients
benefit
results having from
higher-quality clinical care as a result of the higher levels of expertise brought to bear by specialty-trained radiologists. Specialty programs, particularly in academic centers, are focal points for research and innovation in the development of new procedures and technology. The presence of specialty-trained radiologists has a positive impact on residency training programs, although caution was expressed that the experience of the resident must be protected when fellowship training is offered in a particular specialty area. The special requirements for RAG accreditation of specialty fellowship training programs take such considerations into account.
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
AJR:156,
SPECIALIZATION
June 1991
Greater expertise has unquestionably helped the competitive position of radiology in turf wars with other branches of medicine. The greater the level of expertise, the more likely that a given area of practice is retained within radiology. The panel also believed that opportunities for specialization within radiology were a positive factor in recruiting high-quality medical students into radiology. A corollary point is the high level of career satisfaction expressed by specialists.
radiologists to perform requested procedures, particularly highly specialized and/or interventional procedures. There was some belief within the panel that increasing specialization has also created problems of access for patients and delay in service to both patients and referring physicians in some practice settings. This occurs when only a few specialists can perform or review a particular study. It was noted that clinicians are under pressures of their own that
Potential
Problems
Associated
with
Specialization
Specialization results in longer training and therefore higher costs to both the trainee and the institution providing the training. It is not clear how the higher cost to institutions will be subsidized in an era of shrinking reimbursement. It is also a concern that the total training time encompassing medical school, residency, and specialty training has become very long. The ABR and RRC must take this into account by developing options that minimize the requirements for specialty qualification. One of the most important problems associated with specialization is its impact on staffing requirements. The consensus of the panel was that specialization requires more people and that it results in more complex departmental and practice organization. A recurrent theme was that the force driving increased staffing needs is that new, highly specialized procedures are very physician-time intensive, particularly because many of them require direct hands-on involvement by physicians. New procedures such as intraoperative sonography have actually been given up by some radiology departments owing to the extreme demands on physicians’ time. Another theme permeating the discussions was the issue of flexibility. This was regarded as more of a problem in the academic than in the private practice environment but an issue for both. In private practice there is frequently not enough work for a full-time specialist, and many groups, as a matter of policy, require specialists to provide general radiology cross coverage to retain flexibility and parity of effort within the group. In academic practices, such cross coverage is more difficult to achieve because of the career interests and orientation of the specialists. The loss of the flexibility of cross coverage directly increases staffing requirements. The higher staffing costs in this setting are not offset in any way by reimbursement, which remains the same regardless of the level of expertise brought to bear. It was noted that the American College of Radiology Committee on Manpower has determined that there is a current shortage of radiologists, with the possibility of a much greater shortage of radiologists by the year 2000. The net increase from recent initiatives to increase the number of positions in some training programs is expected to fall far short of fulfilling projected needs. The manpower shortage was thought to be greater in nonmetropolitan areas and is particularly acute in some specialties. For example, the Society for Pediatric Radiology maintains a directory of positions that currently lists approximately 70 unfilled positions. The panel believed that one of the major risks to the field of radiology from a manpower shortage could be loss of turf if there are not enough
1275
IN RADIOLOGY
are different
from
those
in the
past
and
have
developed
heightened expectations for timeliness of service. Discussions on the merits of specialization and specialty certification must take into account the potential threat of diminishing the value of the basic certification in radiology. Despite the degree of specialization that is occurring, “general radiology” continues to constitute the bulk of the work in both private and academic practice. Caution must be taken to ensure that in the rush for specialization, the importance of maintaining high-quality general radiology credentials is not lost to trainees, referring physicians, and reimbursers. On a positive note, it was thought that the creation of specialists within radiology and the granting of specialty accreditation and certification would not create undue medicolegal exposure to generalists or lead to the obsolescence of generalists. Historically, specialization has not resulted in medicolegal problems, as exemplified in the internal medicine experience. Also, on the basis of the experience in internal medicine, as long as the demand for general services is sufficient, obsolescence should not be a problem. The panel spent considerable time discussing the issue of credentialing and privileging in light of new JCAHO guidelines and standards. A consensus was not attained on how best to approach the problem. In one view, specialists who restricted their practices were considered at risk for losing privileges in areas not actively pursued. A countervailing viewpoint was that credentialing and privileging documents can be structured to accommodate a broad definition of “core” or “general” radiology and protect specialists from broad loss of privileges. A recurrent theme in the discussion was the desirability of maintaining a hybrid or blended practice so that specialists could maintain skills outside of the specific areas of interest. Another issue not leading to consensus was the potential for competition within the field of radiology, between groups with and without a particular specialist. One point of view held that groups with expertise in a specialty might invade the turf or even the institutions of other groups not having that expertise. At the other end of the spectrum was the view that cross coverage between groups and the development of innovative affiliation arrangements could actually represent a solution to the need by small groups to provide increased specialization and expertise.
Implications:
What
Will
Increased
Specialization
Require? From the foregoing discussion, it is clear that the sanctioning of specialties through the RRC accreditation process and the subsequent development of certification testing by the
THRALL
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
1276
AND
ABR are fundamental to the orderly evolution of specialization in radiology. This process is underway, and is guided by a superstructure of oversight organizations outside of radiology. A major issue within the purview of radiology and its constituent organizations is the definition of residency and fellowship curricula. The panel entered into a spirited discussion of the 4-year radiology residency curriculum and its relationship to specialty training. Any future specialty certification will require 4 years of basic residency training in radiology, followed by 1 or more years of additional training in that specialty, before eligibility for specialty certification. With the exception of the 6-month requirement in nuclear medicine, the board does not currently have specific time requirements linked to individual specialties. On the other hand, the ABR is clearly concerned that some training programs are offering de facto 1 -year fellowships or periods of focused training within the 4-year time frame. The consensus of the panel was that individual programs should be allowed to retain the greatest flexibility possible to fit the needs of individual departments, trainees, and regions of the country. Moreover, because radiology is in a dynamic era of change, it is not realistic to overlegislate the time required for training in each component. The panel believed that there is a significant need and even an obligation for the radiology RRC and the ABR to make clear statements regarding the degree of flexibility of training programs in establishing their curricula.
Conclusions
and Recommendations
Specialization has become an important and pervasive part of radiology practice. Specialization has strengthened radiol-
The reader’s
attention
is directed
to the commentary
WITTENBERG
AJR:156,
June 1991
ogy and should be regarded as a positive force and direction in the natural evolution of the field. Specialization has aggravated the manpower shortage in radiology through the development of time-intensive highly specialized procedures and techniques. The American College of Radiology should continue to review manpower projections and consider what steps can be taken to increase radiology manpower. The alternative is the potential loss of areas of practice and shrinkage of the boundaries of radiology. Retaining
flexibility
is a key
factor
in sustaining
specializa-
tion in both academic and private practices. Radiology groups and individual radiologists should strongly consider how to retain general cross-coverage capability to guarantee timeliness of service and access and to address staffing shortages. Credentialing and privileging strategies need to be refined to accommodate both specialists and generalists. Some areas, such as interventional radiology, may require new standards linked to experience, whether or not those standards include specification of actual numbers of cases for privileging and reprivileging. Specialization promotes better care of patients. Innovative practice models should be developed and encouraged to provide access to the highest level of specialization possible. This may require collaboration between heretofore competing groups. Training curricula must be developed for specialties and the relationship between residency training and fellowship training better defined. The ABR and the radiology RRC are encouraged to make policy statements to guide residency program directors in the structuring of the 4-year radiology residency curriculum. The most flexibility possible is highly desirable to allow programs to tailor their curricula to their own special circumstances and opportunities.
on this article,
which
appears
on the following
pages.
1273
Perspective
Radiology Summit 1990: Specialization in RadiologyTrends, Implications, and Recommendations James
H. ThralI1
and
Jack
Wittenberg
Increasing specialization among radiologists is a well-established trend and-most broadly-is a consequence of the increasing sophistication and complexity of medical practice finding expression in the practice of radiology. The strength of the trend toward more specialization is great enough that the debate and controversy of the past decade about whether specialization and the accreditation of specialties is good for radiology has given way, without “official” resolution or even consensus, to a discussion of how best to go forward: to define
areas
of
specialization;
to
protect
and
enhance
with additional experience or training in an area but who might not work exclusively in that area. On the basis of this viewpoint, there was consensus that specialization had become a pervasive part of the practice of radiology. In large private groups and most academic practices, specialization is already highly
the
practice of radiology in an era of specialization; and to protect and enhance the legitimate career aspirations of individual radiologists, whether their primary interests are oriented toward general or specialty practice. The following observations are based on a panel discussion with approximately 25 participants from a wide variety of private and academic practice backgrounds that took place as part of the 1 990 Radiology Summit in Asheville, NC.
Background
and
developed.
However,
even
in small
private
practice
groups, there is a strong trend toward individuals taking on responsibilities in specialties, especially in nuclear medicine, neuroradiology, mammography, and angiography/interventional procedures. Perhaps ironically, representatives of large groups and especially large academic practices expressed a problem in finding radiologists to do general work, whereas small groups felt increasing pressure to find radiologists to meet emerging needs for more specialized practice. The two most important factors driving the degree of specialization in current practice appeared to be department or group size and practice venue. A recurrent theme was that specialtytrained radiologists in private practice frequently do a significant amount of general radiology (at least until the group or practice size is large enough to sustain a full-time specialist); this was far less common in many academic practices.
Assessment
The panel chose not to attempt a rigid definition of either specialist or generalist. Rather, it held the view that a generalist was someone whose work concerned multiple organ systems and/or multiple technologies, but not necessarily in all organ system areas, and that a specialist was someone
Drivers
of Change
The panel considered the trends inside and outside of radiology that had been most important in driving the change
Received November 26, 1990; accepted after revision December 27, 1990. Participants in the 1990 Radiology Summit panel were James H. Thrall (moderator), R. Nick Bryan. William J. Casarella, Donald W. Chakeres, Carl J. D’Orsi, Raymond A. Gagliardi, Milton Gallant, Jeffrey T. Goodwin, Thomas S. Harle, Anton N. Hasso, Ray Kilcoyne. Donald A. Kirks, Kenneth L. Krabbenhoft, Theresa C. McLoud, Thomas F. Meaney. Michael T. Modic, Henry P. Pendergrass. Lee F. Rogers. Alfred A. Smith, Robert J. Stanley. Lynne Steinbach, Michael S. Tenner,
Ina L. Tonkin, Ama van Breda, Jack Westcott,
, Both
authors:
AJR 156:1273-1276,
Department June
of Radiology,
Jack Wittenberg, Massachusetts
1991 0361 -803X/91/1
566-1
and James E. Youker.
General
Hospital
273 © American
Boston,
Roentgen
MA 021 1 4. Address Ray Society
reprint
requests
to J. H. Thrall.
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
1274
THRALL
AND
toward more specialization. Three factors stand out. First, and probably by far the most important, has been the unprecedented creation of new radiologic knowledge in the past two decades. This explosive growth has profoundly increased the level of sophistication in diagnosis and treatment that our specialty can now offer to patients. The increases in knowledge and breadth of practice have made it impossible for any one person to practice at the “state of the art” in all areas of radiology. Second, turf battles over who provides services have created a need for radiologists to achieve the highest possible levels of expertise to defend the boundaries of their practices. Such levels of expertise require specialized focus, which includes both clinical and research dedication. Third, and parallel in time with the foregoing factors, have been changes in privileging criteria fostered by the Joint Commission on Accreditation of Hospitals Organization (JCAHO) to require more specificity and a stronger link between performance assessment and the granting of privileges. Specialization provides a natural mechanism for addressing both issues. Several other factors were considered significant, although less important, than the three just enumerated. Increasing subspecialization in other fields has raised the expectations of referring physicians about the level of expertise held by radiologists. Likewise, there has been an increasing level of sophistication and expectation among patients. Third-party payers are also beginning to look at levels of expertise and are linking specialization to their willingness to rimr5 for complex procedures. Lastly, the growth and development of strong specialty organizations within radiology has fostered the development of specialization. As professional and scientific organizations have gained strength, stature, and membership, they have become focal points for their respective specialties. In fact, it is from the specialty organizations that requests have been generated for official accreditation of training programs in their respective specialties.
WITTENBERG
ing, albeit slowly. Another important area of activity not completely defined by the organ system approach is interventional radiology. However, the majority of academic departments and private practices include vascular/interventional procedures as a separate area of specialization. The view expressed by a number of people on the panel was that vascular/interventional radiology may actually evolve as a separate area of practice akin to the separation between diagnostic and therapeutic radiology.
Accreditation
“Specialties”?
Radiology embraces multiple imaging technologies, which are in turn applied to all of the organ systems in the body. This has raised the question of whether it is more logical to segment practice on the basis of an organ system orientation or a technological orientation. The clear consensus was that the organ system approach is ultimately the most logical and strongest one because it allows the specialist in radiology to learn the clinical and surgical aspects of the respective organ systems, thereby having parity in knowledge with the clinicians with whom he or she interacts. New technologies are often introduced by people who are dedicated to the technology; but as the technology matures, it becomes progressively incorporated into the organ system matrix. The consensus was to accept and encourage this evolutionary paradigm. This approach has been successfully applied in both CT and MR imaging. There has been less integration of nuclear medicine and sonography into organ system specialty practices, but this too appears to be evolv-
and
Certification
In discussing specialization, it is important to define and understand the difference between accreditation and certification. Accreditation applies to training programs, not individuals. It is the province of the Residency Review Committee (RRC) working under the aegis of the Accreditation Council on Graduate Medical Education (ACGME). The ACGME in turn is jointly sanctioned by the American Board of Medical Specialties (ABMS), American Medical Association (AMA), American Hospital Association (AHA), American Association of Medical Colleges, and Council of Medical Specialty Societies. The specific charge to the RRCs is the accreditation of hospital-based graduate medical education programs. The process of achieving accreditation for a new specialty is complex, but begins with a specialty group or society or other organization forwarding a request to the radiology RRC. The RRC develops special training requirements and works with the RRCs of the other specialties, as well as the other interested organizations including the ABMS, AMA, and AHA, to obtain final approval. Certification is the province of the various specialty boards. For radiology, it is the American Board of Radiology (ABR), and the term applies to persons who seek certification after residency (or fellowship) training. One of the concerns in the process of accreditation and certification is that accreditation might be granted to training programs without the opportunity for
What Are the Radiology
AJR:156, June 1991
individuals
for
certification.
The
ABR
has
agreed
sider certification credited programs
paths for people completing in neuroradiology and pediatric
Potential
of Specialization
Benefits
to con-
newly acradiology.
The consensus of the panel was that specialization in important benefits to radiology and to patients radiologic
procedures.
Most
importantly,
patients
benefit
results having from
higher-quality clinical care as a result of the higher levels of expertise brought to bear by specialty-trained radiologists. Specialty programs, particularly in academic centers, are focal points for research and innovation in the development of new procedures and technology. The presence of specialty-trained radiologists has a positive impact on residency training programs, although caution was expressed that the experience of the resident must be protected when fellowship training is offered in a particular specialty area. The special requirements for RAG accreditation of specialty fellowship training programs take such considerations into account.
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
AJR:156,
SPECIALIZATION
June 1991
Greater expertise has unquestionably helped the competitive position of radiology in turf wars with other branches of medicine. The greater the level of expertise, the more likely that a given area of practice is retained within radiology. The panel also believed that opportunities for specialization within radiology were a positive factor in recruiting high-quality medical students into radiology. A corollary point is the high level of career satisfaction expressed by specialists.
radiologists to perform requested procedures, particularly highly specialized and/or interventional procedures. There was some belief within the panel that increasing specialization has also created problems of access for patients and delay in service to both patients and referring physicians in some practice settings. This occurs when only a few specialists can perform or review a particular study. It was noted that clinicians are under pressures of their own that
Potential
Problems
Associated
with
Specialization
Specialization results in longer training and therefore higher costs to both the trainee and the institution providing the training. It is not clear how the higher cost to institutions will be subsidized in an era of shrinking reimbursement. It is also a concern that the total training time encompassing medical school, residency, and specialty training has become very long. The ABR and RRC must take this into account by developing options that minimize the requirements for specialty qualification. One of the most important problems associated with specialization is its impact on staffing requirements. The consensus of the panel was that specialization requires more people and that it results in more complex departmental and practice organization. A recurrent theme was that the force driving increased staffing needs is that new, highly specialized procedures are very physician-time intensive, particularly because many of them require direct hands-on involvement by physicians. New procedures such as intraoperative sonography have actually been given up by some radiology departments owing to the extreme demands on physicians’ time. Another theme permeating the discussions was the issue of flexibility. This was regarded as more of a problem in the academic than in the private practice environment but an issue for both. In private practice there is frequently not enough work for a full-time specialist, and many groups, as a matter of policy, require specialists to provide general radiology cross coverage to retain flexibility and parity of effort within the group. In academic practices, such cross coverage is more difficult to achieve because of the career interests and orientation of the specialists. The loss of the flexibility of cross coverage directly increases staffing requirements. The higher staffing costs in this setting are not offset in any way by reimbursement, which remains the same regardless of the level of expertise brought to bear. It was noted that the American College of Radiology Committee on Manpower has determined that there is a current shortage of radiologists, with the possibility of a much greater shortage of radiologists by the year 2000. The net increase from recent initiatives to increase the number of positions in some training programs is expected to fall far short of fulfilling projected needs. The manpower shortage was thought to be greater in nonmetropolitan areas and is particularly acute in some specialties. For example, the Society for Pediatric Radiology maintains a directory of positions that currently lists approximately 70 unfilled positions. The panel believed that one of the major risks to the field of radiology from a manpower shortage could be loss of turf if there are not enough
1275
IN RADIOLOGY
are different
from
those
in the
past
and
have
developed
heightened expectations for timeliness of service. Discussions on the merits of specialization and specialty certification must take into account the potential threat of diminishing the value of the basic certification in radiology. Despite the degree of specialization that is occurring, “general radiology” continues to constitute the bulk of the work in both private and academic practice. Caution must be taken to ensure that in the rush for specialization, the importance of maintaining high-quality general radiology credentials is not lost to trainees, referring physicians, and reimbursers. On a positive note, it was thought that the creation of specialists within radiology and the granting of specialty accreditation and certification would not create undue medicolegal exposure to generalists or lead to the obsolescence of generalists. Historically, specialization has not resulted in medicolegal problems, as exemplified in the internal medicine experience. Also, on the basis of the experience in internal medicine, as long as the demand for general services is sufficient, obsolescence should not be a problem. The panel spent considerable time discussing the issue of credentialing and privileging in light of new JCAHO guidelines and standards. A consensus was not attained on how best to approach the problem. In one view, specialists who restricted their practices were considered at risk for losing privileges in areas not actively pursued. A countervailing viewpoint was that credentialing and privileging documents can be structured to accommodate a broad definition of “core” or “general” radiology and protect specialists from broad loss of privileges. A recurrent theme in the discussion was the desirability of maintaining a hybrid or blended practice so that specialists could maintain skills outside of the specific areas of interest. Another issue not leading to consensus was the potential for competition within the field of radiology, between groups with and without a particular specialist. One point of view held that groups with expertise in a specialty might invade the turf or even the institutions of other groups not having that expertise. At the other end of the spectrum was the view that cross coverage between groups and the development of innovative affiliation arrangements could actually represent a solution to the need by small groups to provide increased specialization and expertise.
Implications:
What
Will
Increased
Specialization
Require? From the foregoing discussion, it is clear that the sanctioning of specialties through the RRC accreditation process and the subsequent development of certification testing by the
THRALL
Downloaded from www.ajronline.org by 193.0.65.67 on 10/19/15 from IP address 193.0.65.67. Copyright ARRS. For personal use only; all rights reserved
1276
AND
ABR are fundamental to the orderly evolution of specialization in radiology. This process is underway, and is guided by a superstructure of oversight organizations outside of radiology. A major issue within the purview of radiology and its constituent organizations is the definition of residency and fellowship curricula. The panel entered into a spirited discussion of the 4-year radiology residency curriculum and its relationship to specialty training. Any future specialty certification will require 4 years of basic residency training in radiology, followed by 1 or more years of additional training in that specialty, before eligibility for specialty certification. With the exception of the 6-month requirement in nuclear medicine, the board does not currently have specific time requirements linked to individual specialties. On the other hand, the ABR is clearly concerned that some training programs are offering de facto 1 -year fellowships or periods of focused training within the 4-year time frame. The consensus of the panel was that individual programs should be allowed to retain the greatest flexibility possible to fit the needs of individual departments, trainees, and regions of the country. Moreover, because radiology is in a dynamic era of change, it is not realistic to overlegislate the time required for training in each component. The panel believed that there is a significant need and even an obligation for the radiology RRC and the ABR to make clear statements regarding the degree of flexibility of training programs in establishing their curricula.
Conclusions
and Recommendations
Specialization has become an important and pervasive part of radiology practice. Specialization has strengthened radiol-
The reader’s
attention
is directed
to the commentary
WITTENBERG
AJR:156,
June 1991
ogy and should be regarded as a positive force and direction in the natural evolution of the field. Specialization has aggravated the manpower shortage in radiology through the development of time-intensive highly specialized procedures and techniques. The American College of Radiology should continue to review manpower projections and consider what steps can be taken to increase radiology manpower. The alternative is the potential loss of areas of practice and shrinkage of the boundaries of radiology. Retaining
flexibility
is a key
factor
in sustaining
specializa-
tion in both academic and private practices. Radiology groups and individual radiologists should strongly consider how to retain general cross-coverage capability to guarantee timeliness of service and access and to address staffing shortages. Credentialing and privileging strategies need to be refined to accommodate both specialists and generalists. Some areas, such as interventional radiology, may require new standards linked to experience, whether or not those standards include specification of actual numbers of cases for privileging and reprivileging. Specialization promotes better care of patients. Innovative practice models should be developed and encouraged to provide access to the highest level of specialization possible. This may require collaboration between heretofore competing groups. Training curricula must be developed for specialties and the relationship between residency training and fellowship training better defined. The ABR and the radiology RRC are encouraged to make policy statements to guide residency program directors in the structuring of the 4-year radiology residency curriculum. The most flexibility possible is highly desirable to allow programs to tailor their curricula to their own special circumstances and opportunities.
on this article,
which
appears
on the following
pages.
