- Email: [email protected]
Ruminations From a European Chairperson
A VIEW FROM ABROAD
Ruminations From a European Chairperson Johan G. (Hans) Blickman, MD, PhD Some time ago in this journal [1], I tried to put on paper my experiences in choosing to become a chairman in Europe, after many years as an academic radiologist in the United States. In the intervening 5 years, I have had an interesting experience with a number of twists and turns that might bear relating. The whole experience certainly did not quite go the way I had envisioned, yet there may be things to learn from this contribution to “A View From Abroad.” I will try to share the lessons I learned, while not forgetting the background as to why and how. Even though it is thus a “personal” narrative, in this increasingly international world, perhaps future “crossovers” can take heed, think long and hard before deciding, and then hopefully prosper. I will structure the review by again analyzing the mission of an academic department of radiology, namely, clinical services (patient care), education (people), and research. A critical analysis of what I had thought or hoped for vs what reality turned out to be follows. First, something obvious: there is no doubt that the warning “you will not know and cannot be prepared for what hits you once you really are chairman” was spot on! Not that I was not prepared, no, but the sheer variety of problems that would arrive at my desk could not have been anticipated. Often I remarked that, in addition to emulating role models and having experience in running parts of a large department, in the same breath, I should have studied to become a kindergarten teacher or a psychiatrist before taking this job. In other 224
words, be careful what you wish for—you might get it. To summarize my entire experience (and you might think this redundant), there are obvious major cultural and structural differences between academic medicine and radiology in Europe and the United States, and these can be discussed and enumerated quite easily. The real differences go deeper, and I will try to give my view of what they are and how they affect the profession and the people in it in unexpected ways. PATIENT CARE In the Netherlands, the delivery of medical care has evolved as a highly capitated system, a form of socialized medicine. Medical care is part of the entire social care package, integrated in the “cradle-to-grave” state assistance that Western Europe offers its citizens, largely instituted after World War II. By definition, it is the government that steers this process, and as a result, medical care has become a right, not a privilege. As a result of this, Europeans have built health systems so inclusive that even illegal immigrants are entitled to free treatment beyond just emergency care. This is in contradistinction to the United States, where the Hill-Burton Act guarantees free emergency care, but for most of the remainder, health care is guaranteed by employers. This system too has many flaws, as the current heated discussion surrounding health care reform shows. However, that is beyond the scope of this treatise. By embracing this highly evolved socialist system, a lot of good has de-
veloped. No one is denied health care, and standards are high. Concomitantly, though, other social changes occurred in many Western European countries. The past 30 years saw a great leveling of the social strata in Europe; all are equal, from postal worker to professor. Holland is famous for its manner of conducting meetings and discussions, the “polder model,” wherein all have a voice, and all may dissent or agree until the end of the discussions. Unfortunately, the result is often a sort of “wet blanket”—no one is a winner (or loser), and most do not (openly) disagree with one another, but all can say and feel that they were part of the decision-making process. This inevitably leads to a leveling of peaks and valleys, resulting in a great mediocrity. Not for all, but for a majority for sure. Attempts to get noticed, get ahead, or excel are discouraged (when you ask why, the response is “be normal, that makes you crazy enough”). To me, a sad result of this is that the competitive element in all layers of academic achievement has virtually disappeared, evolving into a system in which a few will try and excel, and then either give up, get ostracized for excelling, or more and more get frustrated and leave, leading to an oft ignored “brain drain.” Many more academic hopefuls and accomplished emigrate from, rather than immigrate to, Europe. Except for a brief period at the beginning of the 21st century, when there was a blip of Irish medical specialists returning to the Emerald Isle, east-to-west migration has dominated. In contradistinction the hallmark of academia in the United
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.10.005
A View From Abroad 225
States is the search for excellence and, more important, the pride to show that. In the Netherlands, and also in most of Western Europe, academic specialists are salaried. In itself this is not bad: a guaranteed salary and pension are nice, and in principle, it should eliminate jealousy for what others make. Unfortunately, I found that in the Netherlands, each individual medical center makes its own deals with its specialists surreptitiously. After I carefully gathered facts from my colleagues in the country, my staff turned out to be the lowest paid group in the country, and to adjust this took years of trying to substantiate and remedy the situation at the board level. In the end, however, it was a Pyrrhic victory; the rest of the medical center soon heard about it and bitterly resented radiologists earning approximately 1,000 euros per month more. As I was president of the medical staff at the time, it was soon whispered that it was a conflict of interest as well. Talk about enjoyable work! Nonacademic hospitals have practice groups that set their own salaries, and there is also a factor of 2.5 in salary difference with their academic medical colleagues. Because they can also have residents, you might think this is the best of both worlds. To a degree, it is. The past few years, however, have seen the reluctant introduction of diagnosis-related groups in the Netherlands, coupled with a state-mandated maximum hourly wage for specialists of 120 euros ($200). Our private practice colleagues most likely will see their substantially higher salaries come down significantly, but I doubt far enough to stem the drain of specialists going into private practice from academia. The result is a lot of job dissatisfaction, disastrous for the academic
component of radiology, which also does not encourage change. This change, however, is necessary, as radiology in the Netherlands in general still suffers from the perception that the field is populated by doctors who “failed” in other specialties and were put in dark rooms and leave early to play golf. In other words, there is a long way to go toward 24/7 service. Only recently has it become standard at university medical centers (but really at most hospitals) for staff members to come in when on call, every day of the week. Because all imaging departments are digital, it should in theory be simple to be online 24/7 as an imaging department, and thus present at least remotely, if not physically, in the diagnostic pathway. As we are physicians too, that should be a resonating incentive. The financing of medical care is, not surprisingly, from the delivery through the education of practitioners, also under fire, as the funding is drying up in the face of increasing need. Major reductions in health care funds are unfortunately to be expected also in Europe. For patient care funds, the state delegates the doling out of these funds to the almost 180 hospitals in the Netherlands to insurance companies. These companies make their own deals with the hospitals, but there is no complete and transparent accountability of what happens to those funds once received by the individual hospitals. This, to use radiology as an example, frequently leads to a most frustrating scenario in which funds are appropriated by the hospital for a department, but the imaging part is either ignored or given short shrift. At the end of the year, a sort of accounting is produced, and the shortfall (there is never a surplus), particularly for the imaging, laboratory and pathology, and anesthesia departments, is
only partly covered, while the remaining shortfall is added (read: subtracted) to the next year’s budget. It is very difficult to control one’s destiny if funding cannot be influenced. Protests fall on deaf ears; very recently, it was discovered that 4 of university medical centers got more money than they had a right to, and 4 got less. The Dutch solution is that the 4 that got more could keep the money, and the other 4 were made whole. PEOPLE As outlined above, this system takes away the “money talks” incentive, and it is exactly that fact that has as its immediate result that one cannot motivate people. If it is okay to work part-time, and there are no penalties for abusing the system, especially those who are on fixed and, in their mind, small benefit packages are demotivated. It actually makes no difference, then, to work harder, produce more, or try to impress others such as students and peers, let alone patients. Indeed, motivating and getting rid of those who do not care to be motivated is an impossible and thankless task for a chair. For example, in several instances over the past 9 years, the union told me not to execute my decision that a staff radiologist should look for another position because that radiologist was not performing in any of the 3 missions, or a court case would ensue. All evaluations and remedial attempts were done by the rules, yet the medical center’s legal office concurred, and the staff members remained. Talk about being in charge! Recruiting, retaining, and stimulating academic staff members is thus quite difficult when money is not a reward, and this explains why currently, the staff of an academic department is made up of 3 broad
226 A View From Abroad
categories—the “ancient traditional” ones with a calling, for whom money is not key; those from elsewhere in the European Union who are making a significant leap in academic potential and income compared to where they came from; and those not interested in working more than 32 to 44 hours or not wanted anymore at high-volume private practices. This does not mean no one enters academia. It is rare, though, for a newly minted junior faculty member to want to go to another academic medical center, so those who do stay tend to have stayed put. It is accepted that a large majority of staff members did their secondary, university, and specialty training, followed by staff positions, in the same city if not the same institution. Allowing junior faculty members to “hang around” for the right private practice job to open is an option but encourages the above. Another way to encourage choosing an academic career is to stimulate junior faculty members to write their theses. Giving them time to do this is a major ingredient of binding them and stimulating them to stay in academic careers. This has been considered in the United States as well; incorporating research time into residency time can thus have an advantage. Otherwise, there are few incentives in Holland to enter or stay in academia. This is quite different from the system in the United States, where standards are present and adhered to throughout the entire process, and a slew of incentives, maybe not all successful, exist to entice young radiology residents to stay in academia. So what causes these differences? It is an attitudinal problem, in my experience. It begins when training residents is not reserved only for ac-
ademic hospitals; any radiology group can apply for accreditation to have a training program, which allows for 2 or 3 resident programs. In addition, most medical specialists are not governed by board examinations at the end of their specialization, and if a form of “intraining” examination exists, such as in radiology, one does not have to pass it! The latter is in itself no different from the ABR’s examination, except that no system of hospital privileges exists in the Netherlands, so there is no down side to not passing either. Only twice during a 5-year residency can a program director remove a resident from the program: after the first and third years. The result is a wide variety of “graduating” skills, with no final examination testifying that essential knowledge has been acquired and that the specialty can be satisfactorily practiced by the individual—A matter of establishing and adhering to standards. This attitude can be changed only if in Europe we motivate the best and brightest to enter the specialty, and those need to see that those in it are fulfilled. Unfortunately, virtually no attention is given to imaging in medical schools; it is a stepchild in most curricula. Is it any wonder, then, that in contradistinction to the United States on the whole, the best and brightest medical students do not choose imaging as their specialty? The specialty itself, through its own residency review committee, made up of radiologists both from academic and private practices, evaluates residencies in principle every 5 years, unless there are compelling reasons, such as up to 3 major deficiencies, that mandate 2-year evaluations. Unfortunately, the standards that are agreed on are not rigorously implemented, and the result is a wide variety of abilities and skills because teachers are
not regulated, and regulating pupils becomes equally varied. Finally, after “graduating,” there is now a legal rule to meet CME criteria, 200 points in 5 years, but again with no sanctions if the limit is not met, and how the National Licensing Board is to check whether an individual practitioner has actually garnered the required CME points has yet to be agreed on. This all makes for poorly reproducible quality standards, something that is finally starting to get the attention of the government. Mandatory examinations are in the offing, as are more stringent quality controls with regard to resident competencies, such as the CanMEDS example. This new residency curriculum that has been developed by the European Association of Radiology/European Congress of Radiology Residency Committee is certainly a big step forward. Radiology is a recognized specialty in all 30 European Association of Radiology member countries, and neuroradiology, interventional radiology, and pediatric radiology are recognized subspecialties. Finally, although not yet mandatory, Joint Commission–like evaluations of hospitals are starting to occur, performed by a national organization made up of a wide variety of experts but, unlike the Joint Commission, with no power for real sanctions. The issues mentioned here all pertain to the traditional body of diagnostic imaging knowledge. These days, we also must deal with part-time trainees and (part-time) supervisory radiologists, yet they need to know more and more, and the product that we are delivering to our referring physicians is rapidly changing, increasing in both complexity and number. What thus worries me more is that no provision is being made to build in time or opportunity to
A View From Abroad 227
train residents in image manipulation, robotic therapeutic implications, minimally invasive technology, and virtual techniques. This is particularly important because imaging has moved and is moving on the back of the tumultuous information technology (IT) developments, from simple imaging to nanotechnology, to personalized medicine, to robotics, and to artificial intelligence brain interfacing, among others, such as molecular imaging. To put it more succinctly, we should think about who will do the protocolling, the 3-D reconstructions, and the computer-aided diagnostics and detection. Should this be done offline? By whom? Should they be MDs, or can or should they be non-MDs? And in both cases, what should they be familiar with and obtain experience in? How did and do we handle this? In the most simple form, there existed the so-called supertechnologists, who had an interest and therefore did all the postprocessing and other image manipulations during their daily work hours. On the other hand, we’ve had for many years radiologists and radiology residents who are extremely facile with computers and did this more or less in their free time. The third level of competence would be medical physicists or IT personnel, who usually were hampered by not enough medical knowledge. This is all too expensive and time-consuming. Take a likely brain tumor. These days, we need—actually, the neurosurgeon demands—somebody with neurologic imaging knowledge, neurosurgical knowledge, and robotic 3-D spatial knowledge, and we need somebody who understands that malignant brain tumors are infiltrative, that when removed the operator always leaves tumor tissue behind and thus, tumor recurrence is virtually
100%, and that mean survival is measured in months. To be able to garner all this very important information for referring clinicians is our task as imagers, and the conclusion must be that we either expand the training of current radiology residents or we need new players with new skills sets. Or maybe both. It is thus clear that we need to rethink who should be part of the modern imaging team. In the Netherlands, we have started a technical medicine degree course at the University of Twente with the idea that a new skill set is needed in the modern imaging world that is exploding around us. Such a person needs to have enough medical knowledge to understand the implications of imaging on the diagnostic and therapeutic process but at the same time have sufficient technical and engineering knowledge to support the same. This person would certainly qualify for the title physician extender, but in no way is it comparable to a nurse practitioner or physician assistant. A specific imaging or maybe technical imaging or, more appropriately, technical medical imaging skill set needs to be developed and integrated into the residency curriculum. A place for international collaboration? RESEARCH The US Food and Drug Administration is often regarded as cumbersome and difficult, and I had high hopes that without this impediment, it would be easier to do cutting-edge research more quickly. But because the government decides all, it turned out to be not as easy as that. In Britain, Holland, and Germany, even after new drugs (including contrast agents, new imaging tools, etc) are approved, access to them is complicated by the fact that independent government
agencies must decide if they are worth buying. Phase II and III trials were just as rigorous, but the results were slower in filtering through the bureaucratic layers. So how did our research output in the Radboud University Medical Center imaging department rise each year? Aside from having a number of dedicated PhDs who had more time to publish, the PhD writing custom, with a premise that one’s study is not quite complete if a thesis has not been done, generates a number of young investigators who invigorate the research effort on a number of fronts. A neat option is to offer an 8-year position to an incoming resident, whereby the 3 years needed to complete the thesis are spread over an aggregate 8-year residency. This is the more interesting option, as writing a thesis after graduating residency is well nigh impossible. It does carry the risk for less peer contact because the noncandidate imaging residents graduate (much) earlier. The few academic staff members who have time and energy to mentor these PhD candidates in this way manage substantial publication output. Indeed, a thesis now almost always consists of bundling a minimum of 6 to 8 articles with a common theme, at least half of which need to have the PhD candidate as first author. This also explains why many have larger bibliographies, as they are mentioned as last authors on all papers generated from their departments. For other staff members, the combination of a part-time position and little incentive for working outside their union-mandated 42 hours, including call, leaves them often out of academia. Unfortunately, research experience on their curricula vitae has very little impact on residents’ subsequent choices for academic or private prac-
228 A View From Abroad
tice or their ability to land positions in either. It is thus only for those who buck the trend of mediocrity that an academic career is a treat. This is unsustainable in the long run. CONCLUSION So, how does one keep one’s enthusiasm as a chair? When one looks at the people, motivation is the hardest task, and recruiting and retaining are a big part of that. Money helps, but lifestyle plays a big part as well. With regard to teaching, there is still more to be done to have a qual-
ity-driven specialty in Western Europe, not in the least because it seems hard to convince people that a lot of wheels do not need to be reinvented. Examples are a form of board examination and a rigorous, reproducible CME responsibility. Both the United Kingdom and the United States already have this, and some form of those would work equally well. A greater effort to educate our medical students and our clinical colleagues in the real and perceived value of imaging is key. As for the research paradigm, it is hard to ignore the brain drain from east to west and the diminishing
number of young researchers in Western Europe. Outcomes research and international collaboration is one answer, but even in the digital world, that is seemingly difficult to develop. A partial answer is an organization such as the Association of University Radiologists and its subsidiaries. Too bad it has proved nearly impossible to create a similar structure in Europe over the past 5 years. REFERENCE 1. Blickman H. Being a chair of a radiology department: observations from the Netherlands. J Am Coll Radiol 2004;1:146-50.
Johan G. (Hans) Blickman, MD, PhD, Department of Imaging Sciences URMC, Golisano Childrens Hospital 601 Elmwood Avenue P.O. Box 648 Rochester, New York 14642-8648; e-mail: [email protected].
Ruminations From a European Chairperson Johan G. (Hans) Blickman, MD, PhD Some time ago in this journal [1], I tried to put on paper my experiences in choosing to become a chairman in Europe, after many years as an academic radiologist in the United States. In the intervening 5 years, I have had an interesting experience with a number of twists and turns that might bear relating. The whole experience certainly did not quite go the way I had envisioned, yet there may be things to learn from this contribution to “A View From Abroad.” I will try to share the lessons I learned, while not forgetting the background as to why and how. Even though it is thus a “personal” narrative, in this increasingly international world, perhaps future “crossovers” can take heed, think long and hard before deciding, and then hopefully prosper. I will structure the review by again analyzing the mission of an academic department of radiology, namely, clinical services (patient care), education (people), and research. A critical analysis of what I had thought or hoped for vs what reality turned out to be follows. First, something obvious: there is no doubt that the warning “you will not know and cannot be prepared for what hits you once you really are chairman” was spot on! Not that I was not prepared, no, but the sheer variety of problems that would arrive at my desk could not have been anticipated. Often I remarked that, in addition to emulating role models and having experience in running parts of a large department, in the same breath, I should have studied to become a kindergarten teacher or a psychiatrist before taking this job. In other 224
words, be careful what you wish for—you might get it. To summarize my entire experience (and you might think this redundant), there are obvious major cultural and structural differences between academic medicine and radiology in Europe and the United States, and these can be discussed and enumerated quite easily. The real differences go deeper, and I will try to give my view of what they are and how they affect the profession and the people in it in unexpected ways. PATIENT CARE In the Netherlands, the delivery of medical care has evolved as a highly capitated system, a form of socialized medicine. Medical care is part of the entire social care package, integrated in the “cradle-to-grave” state assistance that Western Europe offers its citizens, largely instituted after World War II. By definition, it is the government that steers this process, and as a result, medical care has become a right, not a privilege. As a result of this, Europeans have built health systems so inclusive that even illegal immigrants are entitled to free treatment beyond just emergency care. This is in contradistinction to the United States, where the Hill-Burton Act guarantees free emergency care, but for most of the remainder, health care is guaranteed by employers. This system too has many flaws, as the current heated discussion surrounding health care reform shows. However, that is beyond the scope of this treatise. By embracing this highly evolved socialist system, a lot of good has de-
veloped. No one is denied health care, and standards are high. Concomitantly, though, other social changes occurred in many Western European countries. The past 30 years saw a great leveling of the social strata in Europe; all are equal, from postal worker to professor. Holland is famous for its manner of conducting meetings and discussions, the “polder model,” wherein all have a voice, and all may dissent or agree until the end of the discussions. Unfortunately, the result is often a sort of “wet blanket”—no one is a winner (or loser), and most do not (openly) disagree with one another, but all can say and feel that they were part of the decision-making process. This inevitably leads to a leveling of peaks and valleys, resulting in a great mediocrity. Not for all, but for a majority for sure. Attempts to get noticed, get ahead, or excel are discouraged (when you ask why, the response is “be normal, that makes you crazy enough”). To me, a sad result of this is that the competitive element in all layers of academic achievement has virtually disappeared, evolving into a system in which a few will try and excel, and then either give up, get ostracized for excelling, or more and more get frustrated and leave, leading to an oft ignored “brain drain.” Many more academic hopefuls and accomplished emigrate from, rather than immigrate to, Europe. Except for a brief period at the beginning of the 21st century, when there was a blip of Irish medical specialists returning to the Emerald Isle, east-to-west migration has dominated. In contradistinction the hallmark of academia in the United
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.10.005
A View From Abroad 225
States is the search for excellence and, more important, the pride to show that. In the Netherlands, and also in most of Western Europe, academic specialists are salaried. In itself this is not bad: a guaranteed salary and pension are nice, and in principle, it should eliminate jealousy for what others make. Unfortunately, I found that in the Netherlands, each individual medical center makes its own deals with its specialists surreptitiously. After I carefully gathered facts from my colleagues in the country, my staff turned out to be the lowest paid group in the country, and to adjust this took years of trying to substantiate and remedy the situation at the board level. In the end, however, it was a Pyrrhic victory; the rest of the medical center soon heard about it and bitterly resented radiologists earning approximately 1,000 euros per month more. As I was president of the medical staff at the time, it was soon whispered that it was a conflict of interest as well. Talk about enjoyable work! Nonacademic hospitals have practice groups that set their own salaries, and there is also a factor of 2.5 in salary difference with their academic medical colleagues. Because they can also have residents, you might think this is the best of both worlds. To a degree, it is. The past few years, however, have seen the reluctant introduction of diagnosis-related groups in the Netherlands, coupled with a state-mandated maximum hourly wage for specialists of 120 euros ($200). Our private practice colleagues most likely will see their substantially higher salaries come down significantly, but I doubt far enough to stem the drain of specialists going into private practice from academia. The result is a lot of job dissatisfaction, disastrous for the academic
component of radiology, which also does not encourage change. This change, however, is necessary, as radiology in the Netherlands in general still suffers from the perception that the field is populated by doctors who “failed” in other specialties and were put in dark rooms and leave early to play golf. In other words, there is a long way to go toward 24/7 service. Only recently has it become standard at university medical centers (but really at most hospitals) for staff members to come in when on call, every day of the week. Because all imaging departments are digital, it should in theory be simple to be online 24/7 as an imaging department, and thus present at least remotely, if not physically, in the diagnostic pathway. As we are physicians too, that should be a resonating incentive. The financing of medical care is, not surprisingly, from the delivery through the education of practitioners, also under fire, as the funding is drying up in the face of increasing need. Major reductions in health care funds are unfortunately to be expected also in Europe. For patient care funds, the state delegates the doling out of these funds to the almost 180 hospitals in the Netherlands to insurance companies. These companies make their own deals with the hospitals, but there is no complete and transparent accountability of what happens to those funds once received by the individual hospitals. This, to use radiology as an example, frequently leads to a most frustrating scenario in which funds are appropriated by the hospital for a department, but the imaging part is either ignored or given short shrift. At the end of the year, a sort of accounting is produced, and the shortfall (there is never a surplus), particularly for the imaging, laboratory and pathology, and anesthesia departments, is
only partly covered, while the remaining shortfall is added (read: subtracted) to the next year’s budget. It is very difficult to control one’s destiny if funding cannot be influenced. Protests fall on deaf ears; very recently, it was discovered that 4 of university medical centers got more money than they had a right to, and 4 got less. The Dutch solution is that the 4 that got more could keep the money, and the other 4 were made whole. PEOPLE As outlined above, this system takes away the “money talks” incentive, and it is exactly that fact that has as its immediate result that one cannot motivate people. If it is okay to work part-time, and there are no penalties for abusing the system, especially those who are on fixed and, in their mind, small benefit packages are demotivated. It actually makes no difference, then, to work harder, produce more, or try to impress others such as students and peers, let alone patients. Indeed, motivating and getting rid of those who do not care to be motivated is an impossible and thankless task for a chair. For example, in several instances over the past 9 years, the union told me not to execute my decision that a staff radiologist should look for another position because that radiologist was not performing in any of the 3 missions, or a court case would ensue. All evaluations and remedial attempts were done by the rules, yet the medical center’s legal office concurred, and the staff members remained. Talk about being in charge! Recruiting, retaining, and stimulating academic staff members is thus quite difficult when money is not a reward, and this explains why currently, the staff of an academic department is made up of 3 broad
226 A View From Abroad
categories—the “ancient traditional” ones with a calling, for whom money is not key; those from elsewhere in the European Union who are making a significant leap in academic potential and income compared to where they came from; and those not interested in working more than 32 to 44 hours or not wanted anymore at high-volume private practices. This does not mean no one enters academia. It is rare, though, for a newly minted junior faculty member to want to go to another academic medical center, so those who do stay tend to have stayed put. It is accepted that a large majority of staff members did their secondary, university, and specialty training, followed by staff positions, in the same city if not the same institution. Allowing junior faculty members to “hang around” for the right private practice job to open is an option but encourages the above. Another way to encourage choosing an academic career is to stimulate junior faculty members to write their theses. Giving them time to do this is a major ingredient of binding them and stimulating them to stay in academic careers. This has been considered in the United States as well; incorporating research time into residency time can thus have an advantage. Otherwise, there are few incentives in Holland to enter or stay in academia. This is quite different from the system in the United States, where standards are present and adhered to throughout the entire process, and a slew of incentives, maybe not all successful, exist to entice young radiology residents to stay in academia. So what causes these differences? It is an attitudinal problem, in my experience. It begins when training residents is not reserved only for ac-
ademic hospitals; any radiology group can apply for accreditation to have a training program, which allows for 2 or 3 resident programs. In addition, most medical specialists are not governed by board examinations at the end of their specialization, and if a form of “intraining” examination exists, such as in radiology, one does not have to pass it! The latter is in itself no different from the ABR’s examination, except that no system of hospital privileges exists in the Netherlands, so there is no down side to not passing either. Only twice during a 5-year residency can a program director remove a resident from the program: after the first and third years. The result is a wide variety of “graduating” skills, with no final examination testifying that essential knowledge has been acquired and that the specialty can be satisfactorily practiced by the individual—A matter of establishing and adhering to standards. This attitude can be changed only if in Europe we motivate the best and brightest to enter the specialty, and those need to see that those in it are fulfilled. Unfortunately, virtually no attention is given to imaging in medical schools; it is a stepchild in most curricula. Is it any wonder, then, that in contradistinction to the United States on the whole, the best and brightest medical students do not choose imaging as their specialty? The specialty itself, through its own residency review committee, made up of radiologists both from academic and private practices, evaluates residencies in principle every 5 years, unless there are compelling reasons, such as up to 3 major deficiencies, that mandate 2-year evaluations. Unfortunately, the standards that are agreed on are not rigorously implemented, and the result is a wide variety of abilities and skills because teachers are
not regulated, and regulating pupils becomes equally varied. Finally, after “graduating,” there is now a legal rule to meet CME criteria, 200 points in 5 years, but again with no sanctions if the limit is not met, and how the National Licensing Board is to check whether an individual practitioner has actually garnered the required CME points has yet to be agreed on. This all makes for poorly reproducible quality standards, something that is finally starting to get the attention of the government. Mandatory examinations are in the offing, as are more stringent quality controls with regard to resident competencies, such as the CanMEDS example. This new residency curriculum that has been developed by the European Association of Radiology/European Congress of Radiology Residency Committee is certainly a big step forward. Radiology is a recognized specialty in all 30 European Association of Radiology member countries, and neuroradiology, interventional radiology, and pediatric radiology are recognized subspecialties. Finally, although not yet mandatory, Joint Commission–like evaluations of hospitals are starting to occur, performed by a national organization made up of a wide variety of experts but, unlike the Joint Commission, with no power for real sanctions. The issues mentioned here all pertain to the traditional body of diagnostic imaging knowledge. These days, we also must deal with part-time trainees and (part-time) supervisory radiologists, yet they need to know more and more, and the product that we are delivering to our referring physicians is rapidly changing, increasing in both complexity and number. What thus worries me more is that no provision is being made to build in time or opportunity to
A View From Abroad 227
train residents in image manipulation, robotic therapeutic implications, minimally invasive technology, and virtual techniques. This is particularly important because imaging has moved and is moving on the back of the tumultuous information technology (IT) developments, from simple imaging to nanotechnology, to personalized medicine, to robotics, and to artificial intelligence brain interfacing, among others, such as molecular imaging. To put it more succinctly, we should think about who will do the protocolling, the 3-D reconstructions, and the computer-aided diagnostics and detection. Should this be done offline? By whom? Should they be MDs, or can or should they be non-MDs? And in both cases, what should they be familiar with and obtain experience in? How did and do we handle this? In the most simple form, there existed the so-called supertechnologists, who had an interest and therefore did all the postprocessing and other image manipulations during their daily work hours. On the other hand, we’ve had for many years radiologists and radiology residents who are extremely facile with computers and did this more or less in their free time. The third level of competence would be medical physicists or IT personnel, who usually were hampered by not enough medical knowledge. This is all too expensive and time-consuming. Take a likely brain tumor. These days, we need—actually, the neurosurgeon demands—somebody with neurologic imaging knowledge, neurosurgical knowledge, and robotic 3-D spatial knowledge, and we need somebody who understands that malignant brain tumors are infiltrative, that when removed the operator always leaves tumor tissue behind and thus, tumor recurrence is virtually
100%, and that mean survival is measured in months. To be able to garner all this very important information for referring clinicians is our task as imagers, and the conclusion must be that we either expand the training of current radiology residents or we need new players with new skills sets. Or maybe both. It is thus clear that we need to rethink who should be part of the modern imaging team. In the Netherlands, we have started a technical medicine degree course at the University of Twente with the idea that a new skill set is needed in the modern imaging world that is exploding around us. Such a person needs to have enough medical knowledge to understand the implications of imaging on the diagnostic and therapeutic process but at the same time have sufficient technical and engineering knowledge to support the same. This person would certainly qualify for the title physician extender, but in no way is it comparable to a nurse practitioner or physician assistant. A specific imaging or maybe technical imaging or, more appropriately, technical medical imaging skill set needs to be developed and integrated into the residency curriculum. A place for international collaboration? RESEARCH The US Food and Drug Administration is often regarded as cumbersome and difficult, and I had high hopes that without this impediment, it would be easier to do cutting-edge research more quickly. But because the government decides all, it turned out to be not as easy as that. In Britain, Holland, and Germany, even after new drugs (including contrast agents, new imaging tools, etc) are approved, access to them is complicated by the fact that independent government
agencies must decide if they are worth buying. Phase II and III trials were just as rigorous, but the results were slower in filtering through the bureaucratic layers. So how did our research output in the Radboud University Medical Center imaging department rise each year? Aside from having a number of dedicated PhDs who had more time to publish, the PhD writing custom, with a premise that one’s study is not quite complete if a thesis has not been done, generates a number of young investigators who invigorate the research effort on a number of fronts. A neat option is to offer an 8-year position to an incoming resident, whereby the 3 years needed to complete the thesis are spread over an aggregate 8-year residency. This is the more interesting option, as writing a thesis after graduating residency is well nigh impossible. It does carry the risk for less peer contact because the noncandidate imaging residents graduate (much) earlier. The few academic staff members who have time and energy to mentor these PhD candidates in this way manage substantial publication output. Indeed, a thesis now almost always consists of bundling a minimum of 6 to 8 articles with a common theme, at least half of which need to have the PhD candidate as first author. This also explains why many have larger bibliographies, as they are mentioned as last authors on all papers generated from their departments. For other staff members, the combination of a part-time position and little incentive for working outside their union-mandated 42 hours, including call, leaves them often out of academia. Unfortunately, research experience on their curricula vitae has very little impact on residents’ subsequent choices for academic or private prac-
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tice or their ability to land positions in either. It is thus only for those who buck the trend of mediocrity that an academic career is a treat. This is unsustainable in the long run. CONCLUSION So, how does one keep one’s enthusiasm as a chair? When one looks at the people, motivation is the hardest task, and recruiting and retaining are a big part of that. Money helps, but lifestyle plays a big part as well. With regard to teaching, there is still more to be done to have a qual-
ity-driven specialty in Western Europe, not in the least because it seems hard to convince people that a lot of wheels do not need to be reinvented. Examples are a form of board examination and a rigorous, reproducible CME responsibility. Both the United Kingdom and the United States already have this, and some form of those would work equally well. A greater effort to educate our medical students and our clinical colleagues in the real and perceived value of imaging is key. As for the research paradigm, it is hard to ignore the brain drain from east to west and the diminishing
number of young researchers in Western Europe. Outcomes research and international collaboration is one answer, but even in the digital world, that is seemingly difficult to develop. A partial answer is an organization such as the Association of University Radiologists and its subsidiaries. Too bad it has proved nearly impossible to create a similar structure in Europe over the past 5 years. REFERENCE 1. Blickman H. Being a chair of a radiology department: observations from the Netherlands. J Am Coll Radiol 2004;1:146-50.
Johan G. (Hans) Blickman, MD, PhD, Department of Imaging Sciences URMC, Golisano Childrens Hospital 601 Elmwood Avenue P.O. Box 648 Rochester, New York 14642-8648; e-mail: [email protected].