Re: “The Declining Radiology Job Market: How Should Radiologists Respond?”

LETTERS TO THE EDITOR Re: “Recent Measures to Improve Radiology Reporting: Perspectives From Primary Care Physicians” In their recent article, Gunn et al [1] noted the paradoxical finding that referring primary care physicians want radiologists to recommend appropriate additional imaging procedures but at the same time dislike unqualified recommendations because they feel medicolegally obligated to perform any further examinations that have been suggested, especially if located in a separate section of the radiology report. They also correctly observed that the failure of a radiologist to make appropriate recommendations could both compromise patient care and risk litigation. I have addressed this issue in my practice and developed two simple approaches. If I believe that an additional imaging study should be obtained, I generally use the phrase “If there is need tofurthercharacterizethisabnormality, X would be the next imaging procedure.” In this way, I have fulfilled my medicolegal obligation as a radiologist by “suggesting,” rather than “recommending,” further imaging. Moreover, such phraseology protects referring clinicians from family members if they believe that further imaging would be futile, as in the case of a patient for whom only palliative therapy is appropriate. A similar situation occurs in the frequent case of chest radiographic findings that are equivocal for pneumonia. By using the phrase “superimposed pneumonia should be considered in the appropriate clinical setting,” I effectively raise the possibility of pneumonia but also protect the referring clinician by offering a choice. If the clinical decision is not to treat with antibiotics, the radiology report provides protection from a patient or family members demanding antibiotic therapy that the clinician deems inappropriate. Conversely, if the clinician

believes that antibiotics are needed, the radiology report provides protection against zealous hospital accountants trying to limit their use. My referring clinicians have greatly appreciated this approach of raising consciousness without issuing firm recommendations. Yours will too. Ronald L. Eisenberg, MD, JD Department of Radiology Harvard Medical School Beth Israel Deaconess Medical Center 330 Brookline Avenue Boston, MA 02215 e-mail: [email protected] REFERENCE 1. Gunn AJ, Sahani DV, Bennett S, Choy G. Recent measures to improve radiology reporting: perspectives from primary care physicians. J Am Coll Radiol 2013;10:122-7. http://dx.doi.org/10.1016/j.jacr.2013.04.004 ● S1546-1440(13)00223-8

Re: “The Declining Radiology Job Market: How Should Radiologists Respond?” The remonstration by Levin and Rao [1] to practice groups to employ more junior radiologists, even at the cost of a lower salary, is timely and noble. However, to purposefully not pursue one’s economic interest in favor of fostering the common good is not easy; hence the tragedy of the “commons” [2]. Had the radiologists who inaugurated the remote reading services of teleradiologists to escape overnight call heeded such advice, we might not have been in the position of being as easily “Walmarted” as we are today. They, of course, might have reasonably countered that had they not used teleradiology, someone else would have. In these times of supply-demand mismatch, academic radiology could take the lead and be the exemplar of civic sense in radiology. I have some suggestions.

© 2013 American College of Radiology 0091-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.04.004

First, reduce the number of residency spots offered in the match. Not, I hasten to add, the number of current residents. This may create additional work for faculty members, particularly in programs in which residents are a large part of the work efficiency, but it is worth it in the long run for our profession. It is surely better to have fewer trainees with full employment than more trainees with partial employment. Every large program should pledge to reduce the class by 2. Second, train residents to be excellent general radiologists first, foremost, and forever. This is what makes them most marketable in the radiology labor market. The private practice market needs generalists or, if you prefer, jacks of all trades and masters of at least one. Third, and this applies to both academic centers and private practice, put an indefinite moratorium on the use of radiology extenders for work that has normally been in the dominion of radiologists. This, again, would result in the unsavory combination of a decrement in salary and an increment in work. However, the common good will gain. Fourth, lead by example in gatekeeping imaging utilization. Gatekeeping goes beyond being an imaging consultant. The consultant discusses the relative merits and demerits of a ventilation/perfusion scan versus CT for pulmonary embolism. The gatekeeper questions the need for either and often denies the imaging. This will reduce incomes and perhaps even the Press Ganey (or some derivative) score. However, it will slow us down the road to commoditization and might even win some respect from payers. Fifth, and here the ACR will have a key role, reduce the bureaucratic burden for radiologists and trainees in radiology. There is little doubting the general futility of the red tape, the form filling and adherence to 479

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lowest common denominator mandates that the various phenotypes of the undoubtedly noble and unintentionally onerous quality initiatives demand. However, an hour spent satisfying bureaucrats is an hour away from being visible to patients. There are few eventualities more demoralizing for a profession than trainees without jobs. For the radiol-

ogy “common” not to be a tragedy, every institution must play its part. Saurabh Jha, MD University of Pennsylvania Department of Radiology MRI Learning Center Hospital 3400 Spruce Street Philadelphia, PA 19104 e-mail: [email protected]

REFERENCES 1. Levin DC, Rao V. The declining radiology job market: how should radiologists respond? J Am Coll Radiol 2013;10:231-3. 2. Hardin G. The tragedy of the commons. Science 1968;162:1243-8. http://dx.doi.org/10.1016/j.jacr.2013.04.006 ● S1546-1440(13)00225-1