The world is running low on radiologists. This much all
concerned parties agree on. But when it comes to putting
hard numbers on just what the shortage means-or figuring
out what to do about it-that agreement falls apart.
"If anybody gives you a straight, clear answer," said
Otha Linton, executive director of the International Society
of Radiology, "you shouldn't believe them."
The first problem is that radiology is practiced differently
throughout the world. In Germany, about 70% of imaging
studies are done by nonradiologists. In Italy, only ultrasound
studies are performed by general physicians, while 90%
to 95% of all other imaging studies are performed by or
under the authorization of a radiologist.
Similarly, radiographers play a greater or lesser role
depending on the country. In medically underserved countries,
radiographers are the main imaging workforce. But industrialized
countries with a limited supply radiologists, such as
the U.K., also depend heavily on radiographers to do the
basic work.
THE BIG PICTURE
If 10 experts are asked what is behind the global shortage
of radiologists, they'll give at least 12 answers. The
shortage is most acute in the developed world. No, it's
the developing world that suffers the greatest deficiency.
Technology can help relieve the scarcity. No, technology
is a big part of the problem. Market forces will ease
the strain. No, market forces can't be trusted to handle
such a complex problem. Governmental policies need to
be put in place. No, government interference got us into
this mess in the first place.
"The appetite for imaging is bottomless," said Dr. Pablo
Ros, a professor of radiology at Harvard Medical School
and former chair of the Committee on International Relations
and Education of the RSNA.
Workloads are heavier across the board. Imaging volumes
increase faster than new radiologists enter the field.
In the U.S., for example, the rate of imaging utilization
is increasing by 6% each year, while the number of new
radiologists is increasing by only 2% per year, according
to Dr. Charles Williams, chair of the American College
of Radiology's Commission on Human Resources.
"It's becoming impossible to meet coverage demands,"
he said. "We're seeing an increasingly overworked and
unhappy workforce."
That situation prevails across the developed world. In
Sweden, imaging volumes are increasing by 2% to 5% per
year. The U.K. and Canada are both seeing demand for imaging
gowing by 5%. The demand isn't likely to fall.
"Most of these countries are facing the problem of an
aging population," said Dr. F. L. Chan, head of the department
of radiology at Queen Mary Hospital in Hong Kong. "The
shift to more chronic illness and cancers in the older
population results in not only a special demand on clinical
management in general, but also a higher demand on radiological
services."
INCREASED COMPLEXITY
But the story doesn't end there. The complexity of the
imaging being done also continues to intensify dramatically.
"Years ago, the American College of Radiology was willing
to say that a full workload for a radiologist was 10,000
cases a year, reading stacks of film and doing flouros
on the GI system," Linton said. "If we produce 100 images
from a CT or MRI study, there's no way that doesn't take
longer to look at than the five or six x-ray films of
25 years ago."
Even though it's clear the developing world is facing
a fundamental lack of even the most basic radiological
services, nailing down firm numbers is no easy task. Missionary
hospitals and other health facilities that operate outside
of the government's purview, for example, tend not to
be counted in official statistics.
"Statistics are difficult to obtain, and they should
be regarded with some cautiousness," said Dr. Harald Ostensen,
coordinator of Diagnostic Imaging and Laboratory Technology
for the World Health Organization in Geneva. "If you ask
a health minister in a certain country how the condition
in his or her country is, you get one story. If you travel
around in the country, you will see a totally different
story."
Whatever the numbers, radiologists agree the situation
is dire. About two thirds of the world's population has
little or no access to radiological services. In South
Africa-one of the better staffed countries in Africa-most
hospitals in the public sector have never seen a radiologist,
according to Dr. Peter Corr, a professor of radiology
at the University of Natal. The 20 francophone countries
of Africa have about 117 radiologists among them, Linton
said. Some countries in Asia have as few as one radiologist
per million population, said Dr. Lenny Tan, a professor
of diagnostic radiology at the National University of
Singapore and president of the Asian Oceanian Society
of Radiology.
Government mismanagement of all stripes has contributed
to the problem. Many capitalist countries, including the
U.S. and U.K., predicted that their populations would
suffer from a shortage of general physicians and cut training
positions for specialists. Unfortunately, governments
have been wrong in their predictions over the last four
decades, said Dr. E. Stephen Amis Jr., cochair of the
ACR Task Force on Human Resources. Meanwhile, countries
with socialized medical systems don't offer enough incentives
to increase productivity, according to doctors in those
countries.
"There is no gold standard of productivity. Consequently,
the average productivity of a radiologist in Italy is,
to my knowledge, lower than in other countries," said
Dr. Roberto Passariello, chair of radiology at the University
of Rome. "In our services, we need many radiologists to
take care of issues that are usually taken care of by
a lower number of radiologists but probably a higher number
of radiographers in other countries."
But governments are almost exclusively responsible for
funding training positions. Uniformly, radiologists say
the number of these positions just isn't enough.
"We had over 600 applications for seven positions," said
Dr. Barry Goldberg, associate chair of research and director
of ultrasound at Thomas Jefferson University Hospital.
"Out of those 600, at least 100 were the top of the top.
We could easily have accepted 100 people, but we can't.
There certainly is a desire to go into radiology, but
you need training. The bottleneck is the radiology training
programs."
ECONOMIC FACTORS
Another factor contributing to that training bottleneck
in many countries is the decrease in numbers of academic
radiologists. In the U.S., doctors in private practice
can make more than twice as much money as their academic
counterparts, Ros said. In Germany, academic radiologists
don't face the same hurdles.
"Since other radiologists don't earn so much more money,
academics are quite happy to stay at the university,"
said Prof. Bernd Hamm of the University of Berlin.
Market forces in the U.S. play out in other ways as well.
"Our shortage keeps contributing to the shortage everywhere
else," Linton said. "There is a desire for bright young
physicians who come to this country for training to stick
around when they finish."
This trend can hit the home countries of those young
doctors especially hard. South Africa, for instance, has
fewer than 400 radiologists for a population of more than
42 million, Corr said. But because salaries are low and
crime is problematic, many radiologists and radiographers
trained in South Africa choose to look for work elsewhere.
Countries with stronger economies facing their own shortages
take advantage of this factor: About 30% of Australia's
overseas radiologists come from South Africa. Canada recruited
South African radiologists so aggressively that the country
complained to the United Nations that Canada was poaching
its educational resources.
Practices designed to help the developing world, such
as training programs that ship radiologists to major Western
academic centers, can actually do more harm than good,
Ostensen said.
"If these people are taken out of their own countries,
they will not go back home," he said. "If they do go home,
they haven't learned anything that they can use in their
small district hospital with one x-ray machine and no
CT and no MRI. The only way to help these people is to
train them onsite."
Surprisingly, the movement of radiologists to more lucrative
countries tends not to be a problem in Europe. Although
doctors can move freely throughout the European Union,
borders of language still exist, said Dr. Holger Pettersson,
president of the European Association of Radiology (EAR).
English is a common language, but a doctor must be able
to speak the national language in order to practice effectively
in another country.
IS TECHNOLOGY A SOLUTION?
Some experts look to technology to help ease the shortage
of radiologists. Canada, facing a projected shortfall
of at least 500 radiologists by 2006, began replacing
much of its outdated imaging equipment in 1999, said Normand
Laberge, CEO of the Canadian Association of Radiologists.
"A short-term way of increasing capacity is having better
equipment," he said. "Instead of taking 20 minutes to
complete a scan with an old CT, you have a multislice
scanner that takes two minutes to scan."
Other doctors are pinning their hopes for the future
on teleradiology, PACS, and other innovations that they
hope will increase the efficiency of imaging facilities-eventually.
"PACS will be fine once it's 100% rolled out, but it's
far from 100%," Amis said.
When ask if a solution is on the horizon or what can
be done to ease the shortage, the experts, predictably,
disagree. Some in the U.S. advocate the creation of a
"supertech" to perform more of the basic work. At the
moment, however, radiographers are in shorter supply than
radiologists.
Another idea, which Ros acknowledges is somewhat heretical,
is simply to cede the studies that don't produce much
income to other specialists or even general practioners.
Canada's Laberge protests, however, that this idea could
put the quality of the reading in peril.
A controversial proposal in the U.S. is to reduce the
time spent in training from five years to four years.
At the same time, however, many European countries are
discussing adopting the U.K.'s five-year training protocol.
In the developing world, the practice of "training the
trainers" onsite or in regional centers may help increase
the number of radiographers, but the equipment shortage
is still critical.
"There is no magic bullet," Amis said.
Sarah Jersild is a freelance writer in Chicago.