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  • Radiologists Face Challenges in Era of Subspecialization

    September 01, 2013

    Experts tout the growing trend of radiology subspecialization as a way to remain viable as a specialty.

    Multispecialty fellowships offer a promising avenue for general radiologists looking to remain relevant as the profession continues its march toward subspecialization, experts say. On the plus side, the development of multispecialty radiologists could also help radiology survive as a distinct entity.

    Radiology subspecialization began and accelerated amid the development of new imaging modalities and a focus on efficiency and reduced error rates. Today, most progressive radiology groups practice as an integrated group of subspecialty radiologists, according to Richard Strax, M.D., an interventional radiologist and associate professor at Baylor College of Medicine in Houston.

    “Subspecialization has been a general trend in all of medicine and the desire to become subspecialized is compounded in a healthcare system where subspecialists are more generously rewarded for their work,” Dr. Strax said.

    Results from a group of surveys published in the March 2009 issue of the Journal of the American College of Radiology (JACR) showed that more than 90 percent of radiologists go on to earn a fellowship in areas like neuroradiology or pediatric imaging. In the same survey, 62 percent of radiologists reported recent expansion of subspecialization within their practices. While fellowship participation is not an exact measure of subspecialization, experts consider it the most direct indicator.

    Competition and academic interests were among the motivating factors behind radiologist subspecialization, while economics was a key external driver of the trend. “Subspecialization is cost-effective,” said Benjamin Strong, M.D., chief medical officer at Virtual Radiologic (vRad), a teleradiology company in Eden Prairie, Minn. “A subspecialist radiologist is able to read a specialty exam more accurately and efficiently, giving the patient a more accurate interpretation and the practice a faster throughput.”

    The rapid growth of teleradiology companies like vRad over the past decade has increased the need for subspecialists. When Dr. Strong started at vRad in 2004, the company had only 32 radiologists and about 200 clients. Today, vRad employs more than 400 radiologists and has more than 2,000 client sites, making it well suited to exploit the ability of larger companies to reduce costs and improve efficiency.

    “As you develop economies of scale, you can put together a number of subspecialties that can cover the work,” Dr. Strax said. “For complicated or obscure problems, you are able to find someone with training in that area.”

    For instance, Dr. Strong, who earned a fellowship in musculoskeletal MR imaging, has 50 state licenses and more than 750 hospital credentials. “That adds up to quite a few MRIs that I can read, including some very challenging cases,” he said.

    “Distinction will Prevent Extinction”

    The growth of teleradiology is one reason that some radiology experts see a fully subspecialized radiology model as the way of the future. In his 2008 American College of Radiology (ACR) Presidential Address, Barry D. Pressman, M.D., touted subspecialization as a way to help radiology remain viable as a specialty. “Distinction will prevent extinction,” he said. A year later, British radiologist Nicola Strickland, M.D., stood before the Management in Radiology Congress in Budapest and asserted that “the generalist is dead. Long live the specialist.”

    More recently, Jonathan Breslau, M.D., a member of an ACR task force on subspecialization, concluded that the phenomenon would “allow for the full benefit of economies of scale to get the work done faster and more accurately, with the highest quality supervision of the imaging and consultation with ordering physicians.”

    But Dr. Strax, who served on the same task force, noted that the general radiologist has not vanished despite the advantages offered by the subspecialist model. Drs. Breslau and Strax provide a point/counterpoint discussion on the issue in the August 2012 issue of JACR. (See sidebar.)

    “It’s easy to be a specialist if you’re focused on one system, but we are imaging the whole body,” Dr. Strax said. “When imaging the abdomen and pelvis, you’re looking at the vascular system, the gastrointestinal tract, the spine, the reproductive organs—what is the subspecialty there? Each system can have its own subspecialists.”

    Indeed, an ACR study found that only half of interventionalists spend 70 percent or more of their time doing interventional radiology, and breast imaging specialists interpret only 30 percent of all mammograms.

    “In most radiology practices, people do work outside of their subspecialty,” Dr. Strax said. “There are many times in my department when I’m working outside of the vascular/interventional area, such as reading chest X-rays and CT scans of the abdomen.”

    “When you carve out all the specialty work, it still makes up just a minority of radiologic studies,” added Dr. Strong. “There is still a role for the general radiologist.”

    The Multispecialty Radiologist: The Wave of the Future?

    Future parameters of that role remain to be seen. The ACR task force suggested that general radiologists may need additional training beyond residency to bring added value to a facility or company. One popular proposal is the development of a multispecialty radiologist with training in various subspecialties.

    “Almost every radiologist does a residency of four to five years and a fellowship of one to two years in a subspecialty,” Dr. Strax said. “A multispecialty radiologist could do a two-year fellowship after residency, spending six months in each of four areas or eight months in each of three areas.”

    “I could see a setting in which a multispecialty radiologist would apply,” Dr. Strong said. “They would come to a practice with a greater breadth of knowledge than a single subspecialist who may have lost skills in other areas.”

    The best-case scenario for radiology is one in which subspecialists work closely with multispecialists, Dr. Strax said.

    “You can’t cover medicine only with subspecialists because you’re going to get imaging studies that breach multiple specialties,” he said. “You’ll need multispecialty radiologists to do much of the work that falls between the cracks of specialties.”

    A multispecialty radiologist would also be useful in filling scheduling voids, according to Dr. Strax. Small and rural practices in particular would need individuals with the flexibility to cover multiple modalities and consult on patients with many diseases, he added.

    “Putting subspecialists and multispecialty radiologists together is the way to keep the specialty coherent,” he said. “As radiology organizations and groups become larger, they’ll be more self-sufficient and better able to handle the diverse demands in a way that will hold the profession together.”

    Web Extras

    Access the point/counterpoint articles on Generalization vs. Subpecialization by Jonathan Breslau, M.D., and Richard Strax, M.D., in the Journal of the American College of Radiology (JACR) at JACR.org/content/point_counterpoint.

    Access an abstract of the study, “Factors Influencing Subspecialty Choice Among Radiology Residents: A Case Study of Pediatric Radiology,” in the September 2009 issue of JACR.org/article/S1546-1440%2809%2900232-4/abstract.

    Richard Strax, M.D.
    Benjamin Strong, M.D.
    Experts tout the growing trend of subspecialization as a way to help radiology remain viable as a specialty. Above: teleradiology is one reason that some radiology experts see a fully subspecialized radiology model as the way of the future.
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