As with any industry, healthcare continually faces supply-and-demand challenges. In radiology, the once seemingly distant crisis of a strained workforce coupled with a growing demand for imaging services is now reaching critical mass. Finding solutions will require a shift in practice and thinking around innovative approaches to efficiency — positive disruptors that will shape radiologists’ role in providing uncompromised patient care. The first in a series on the radiology workforce and rising volumes looks at current and near-term challenges to existing delivery models and feasible strategies to mitigate negative outcomes.

If numbers never lie, radiology is facing a harsh truth. There is no sugar-coating the severity of the situation — it is time for the specialty to put its collective heads together to stave off the direst future scenarios. Finding new efficiencies within radiology groups and embracing new and existing technologies may hold the key to solidifying the cornerstone of healthcare services in the coming decades.

An aging Baby Boomer population, imaging overutilization, an increase in insured patients and the changing makeup of many radiology groups are the main drivers of workplace overload that threaten high-quality, accessible care. Other significant factors exacerbating the volume-versus-capacity conundrum include an overreliance on imaging by non-radiologist providers, expanded capabilities of diagnostic imaging that make it ubiquitous in healthcare visits, evolving ideals around job satisfaction, changes involving hiring practices and employee retention, fewer training opportunities, largely stagnant residency slots, and unbending attitudes around workplace culture. 

“We’re not going to solve our immediate problem by just training more radiologists. This is important to understand,” says Eric M. Rubin, MD, FACR, chair of the ACR Commission on Human Resources. The commission is responsible for building relationships between ACR and allied health professional associations, using data-driven approaches to understand our workforce, and serving as a resource for healthcare professionals in radiology. The commission also assesses environmental factors affecting the specialty and makes recommendations as needed.

“To be honest, the ACR cannot solve the workforce shortage alone. The College can’t decrease the volume of imaging we are seeing and cannot directly change the mismatch between volume and capacity,” Rubin says. “But we do have resources at our disposal that can impact the future direction of current challenges — including research, advocacy, economic policy guidance, educational opportunities, and programs designed to mitigate workforce challenges.”

Looking at supply in comparison to demand within multiple physician categories, demand is projected to continue to grow faster than supply under the most likely scenarios, according to a new report from the Association of American Medical Colleges (AAMC). This is expected to lead to a total shortage of between 13,500 and 86,000 physicians by 2036. Radiology falls within the AAMC’s “other specialties” category, which estimates a combined specialty shortage of 19,500 physicians.

From 2021 to 2036, the U.S. population is projected to grow by 8.4% while the population of Americans over the age of 65 is projected to grow by about 34%, the AAMC report shows. This increase translates into high demand for physician specialties that predominantly care for older Americans. In addition, a large portion of the physician workforce is nearing the traditional retirement age of 65. This means it is possible, if not likely, that more than a third of currently active physicians will retire within the next decade. There is a glimmer of good news for radiology, according to an ACR/RBMA employment trends study published in the JACR: The average age of retirement for radiologists is 75, and most radiologists work full-time until retirement.

How We Got Here

Demand for imaging services, workforce demographics, job satisfaction and burnout, hiring burdens and staff retention, educational challenges and the residual effects from the COVID-19 pandemic are feeding the volume-versus-capacity crisis. These drivers are not new or surprising, but looking through the lens of how they culminated into an increasingly challenging workforce environment may guide recovery efforts and reshape thinking around potential solutions to ensure future success.

“When there are always so many things to do and you have so many balls in the air, it is difficult to pause and shift your focus to a problem you’ll have in 10 years,” Rubin says. That has contributed to the current workforce crisis, which is not only born of caring for aging Baby Boomers but also an influx of newly insured patients. “We have a significantly larger pool of insured patients that were brought in under the Affordable Care Act,” Rubin says. “While it is always the goal to provide people with insurance coverage, there were some missteps in establishing ways to increase the capacity to care for them within our healthcare system.”

We wouldn't be talking about the physician shortage if AI was having a great impact because it is in use in half of practices.

In looking at new efficiencies through technology, radiology has seen some overnight changes in the past. “We have faced significant increases in imaging in the last 25 years,” Rubin says. “Around 1998, CT technology evolved from single-slice to multi-slice CT scanning. Suddenly we had this great evolved technology that could provide insight into what was going on with patients and do it rapidly — increasing throughput within emergency rooms and other care settings.” But at the same time we saw large increases in the number of studies performed and the number of images per study.  

Around the same time, digital PACS systems evolved to allow us to handle the new volume in ways that were more efficient than the old film model. “So at that time, we did have this match for dealing with volume relative to capacity. The question is, do we have those types of things to help us through now?”

The use of AI could mitigate the lack of capacity within radiology, Rubin says, but the direction AI tools will ultimately take remains uncertain. “I don’t think AI for clinical interpretation is mature enough now to make jobs easier for radiologists on a day-to-day basis,” he says. “Where it can help is with clinical, non-interpretive tasks — similar to the efficiencies afforded by PACS and other technologies.”

AI can potentially ease the burden of some non-cognitive responsibilities so that radiologists can do more during their workdays. “In the same respect, some people may not be happy to hear that this could also increase the number of studies they can read in a day,” Rubin says.

Using What You Have

The wave of Baby Boomers driving radiology’s volume-versus-capacity crisis is expected to recede around 2030, Rubin says. Many practices have turned to alternative staffing models, using more non-physician radiology providers (NPRPs), many of whom provide invaluable services around certain tasks operating in a radiologist-led team. “For now, we must work with the people who are available,” he says. “While it is a hot-button issue, integrating NPRPs — with proper oversight and within their scope of practice — could help radiologists concentrate on what they are there to do.”

Physician extenders are not the only underutilized professionals that could help with workloads. “We can reevaluate how international radiologists or radiologists living abroad with U.S. training and U.S.-based licenses could help us,” Rubin suggests. “We could try to persuade radiologists on the cusp of retirement to work a bit longer using flexible and less stressful scheduling. We could even consider increasing the ability of fellows who are Board-eligible to read cases.”

There are newer modalities, such as prostate and rectal MRI, available now that some practicing radiologists were never trained in. “It is possible to educate these people, not only to benefit the individual radiologist, but to improve upon shortfalls within existing groups so they can fill those skill gaps without hiring another radiologist,” Rubin says. “While that won’t necessarily decrease volume, it broadens the skillset of radiologists.” Using AI may also provide educational and training tools that could give generalists significant subspecialty skills.

If innovative technology is implemented properly, dictations could be much faster and organizing the information radiologists need could be more efficient, Rubin says. “Ideally, you would save time. I will be asking our members at the upcoming annual meeting if creating more efficiencies is something the ACR should be concentrating on,” Rubin says. “I also want to know if they think we should approach this on our own or through a collaborative, multi-society process involving industry that will move us toward that end.”

Overutilization and Burnout

As the specialty looks at how to handle an influx of patients, it also needs to examine how to streamline the radiology work that is being done to keep people healthy. “We need to educate referring clinicians about the appropriate use of imaging,” says Rebecca L. Seidel, MD, associate professor in the division of breast imaging of the department of radiology and imaging sciences at Emory University School of Medicine and chair of the ACR Bulletin editorial advisory group. “It is something that could take some of the volume pressure off. The ACR has done a lot of work on using appropriateness criteria and clinical decision support because unnecessary imaging contributes to high volume with little or no benefit to patients.”

The ACR Appropriateness Criteria^® (AC) are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. The College has worked on these for decades to head off reimbursement cuts by managing imaging utilization. Rapid imaging growth in the late 1990s and early 2000s hindered efforts, and inappropriate or low-value imaging added to the increase.

Unmanageable workloads not only impact patient care but limit the ability of healthcare professionals to work at the top of their game. This overwork leads to burnout.

The adverse impact of burnout on the quality of patient care and physician satisfaction has been recognized for years and is hitting radiology harder now than in the past. Some literature on workforce issues asserts the problem has become pervasive and has reached crisis levels. Increasing after-hour workloads, chaotic workplaces and bureaucratic tasks contribute to the workforce shortage in the forms of staff frustration and resignation.

Half of radiologists surveyed reported feeling burned out, with women reporting higher rates of burnout than their male colleagues, at 65% compared to 44%. A lack of respect from administrators and colleagues coupled with too many hours on the job were top drivers. 

Pressure around recruiting more and new radiologists and burdensome administrative tasks also play a significant role in physician satisfaction and burnout. Pay is not the issue — with 62% of radiologists saying they would take a pay cut if it meant having a better work-life balance.

Leadership and Shortages

Jocelyn D. Chertoff, MD, MS, FACR

“Providers should be able to go home and stop working and have time that is theirs — time for life and things that matter to them outside of work,” says Jocelyn D. Chertoff, MD, MS, FACR, recently retired chair of radiology at Dartmouth Geisel School of Medicine and Dartmouth-Hitchcock Health, and professor of radiology and obstetrics at Geisel.

“We need innovative approaches to how doctors work, who they work with and where they work,” Chertoff says. “Investments in people and in rebuilding trust in leadership is key. A lack of trust in your practice leaders leads to decreased physician performance, burnout and staffing shortages.”

Obtaining potential staff assets is sometimes bogged down by politics and policies, Chertoff says. “We have this sort of turf-based problem with bringing in people who have trained in other countries.

There are medical professionals who get excellent training in other countries, but it is difficult for them to navigate the process to practice here. That’s something we could address — to make it easier to get qualified people working,” she says. To this end, ACR is supporting legislation in Congress to create smoother pathways for international medical graduates and immigrant physicians to practice in the U.S.

There needs to be a different way to build, retain and manage staff, Chertoff says. “Leaders must think about how to optimize flexibility and accommodate staff needs,” she says. There are generational differences that translate into working styles, but also other factors to consider when looking at workforce makeup, she says. Nurse practitioners, for example, shouldn’t just be given the jobs residents don’t want to do. “Why would an NP stay in that kind of job?,” she says. “Everybody wants a path to advance their careers, or they won’t stick with it and they will leave.”

Also, Chertoff says, “There is a big problem with getting enough boots-on-the ground radiologists. Of course, there is a predicted physician shortage across the board, and caps on residency training slots are not helping the situation. We get around 800 applications for three diagnostic radiology spots — another 100 or so for IR spots — because there is a lot of interest in radiology. But hospitals simply can’t or won’t fund additional radiology spots, and I’m guessing it’s the same for other specialties.”

Chertoff says it’s a bit of a catch-22. “Administrators say, ‘You can’t have more residents just because you have so much work because they aren’t there just to do work.’ If you say, ‘Well, we have great learning opportunities for residents to make them better,’ the answer is increasingly, ‘Well, the hospital won’t pay for it, so how do you intend to pay for it?’ There has been a lot of discussion around how to pay for it, but nothing is really changing.”

While the availability of residency slots offered in U.S. radiology programs has steadily grown for the past three decades, there still aren’t enough, Chertoff says. The current graduate medical education (GME) financing system offers little, if any, program-level incentives to improve the quality or efficiency of physician training. In 1965, the Social Security Act created Medicare, Medicaid and GME funding. Although federal funding of GME wasn’t intended to be permanent, Medicare still accounts for the largest source of GME funding, with Medicaid the second largest source.

Technologists in Demand

While securing and training more residents is pressing, managing the numbers and capacity of technologists cannot be overlooked. “There is a significant vacancy rate amongst radiology technologists in healthcare systems and sites across the country,” Rubin says. “There is a tremendous shortfall in the number of jobs that have been calculated and projected that need to be filled.”

Even when you think you are fully staffed, at any moment someone may quit or get sick, Seidel says. “It could be anything from getting a new machine that needs an operator to an entire imaging center getting acquired,” she says. “It can be a constant battle between staffing and keeping up with volume.”

In terms of improving efficiency among technologists, there is only so much you can do, Seidel says. “They do physically demanding work. You can make sure they are working at the top of their license, but they are human beings, and they can only do so much and continue do a good job of it.” Trying to offload any busy work or clerical work they may be responsible for could help, she adds.

Hiring and keeping skilled mammography and ultrasound technologists can be incredibly challenging, Seidel says. “And it’s not just the numbers, but the experience and expertise too,” she points out. “There are not enough experienced technologists or radiology staff. When you do hire someone, they are more likely to be junior or less skillful or knowledgeable than in the past.” 

Shifting Perceptions and Values

There is some generational disruption happening in radiology that will continue to impact workforce challenges. “Some of the younger generation of radiologists are extremely independent thinking and have different priorities — and this happens to be coinciding with a time when it is increasingly more difficult to see the potential long-term growth and success of practices, especially around reimbursement,” Rubin says. “You have independent-thinking radiologists who may or may not be interested in practice-building. We have even seen from our surveys over the past three years a small, but growing, contingent of independent contractors.”

The pandemic also spawned a shift in thinking around how people place value on their jobs, Seidel says. “I think those changes have persisted. There was a shift in mindsets on the staffing side of things. I think some radiologists and technologists now just go where the money is — those with a traveler’s mindset. There doesn’t seem to be as much interest in joining a place where you have opportunities to learn and potentially land a leadership position,” she says.

Teleradiology and Telework

Working remotely was often a necessity during COVID, on a scale radiology wasn’t used to. “There has been a societal and cultural shift from ‘live to work’ to ‘work to live’ that is changing the radiology workforce landscape,” says Rubin. “Many people are willing to give up the water cooler in exchange for the external social networks they have built for themselves or their families. It can be too disruptive to work-life balance, so a lot of people are not going to change jobs if they have to work on-site.” On the plus side, Rubin says, teleworkers find they are much more productive due to decreased travel time to and from work.

Teleradiology and working from home have become an integral component of radiology departments and are unlikely to go away in the future. Advantages include decreased stress, increased work-life balance and increased feelings of autonomy. Potential disadvantages may be less visibility of radiologists to referring physicians and hospital administrators, diminished workplace engagement and negative effects on education and mentorships.

A large majority of practices allow some telework, and a large majority of radiologists currently telework or would like to in the future. “Some people associate telework with radiologists losing our connection with people, and we need to address that,” Rubin says. “Telework and teleradiology are not going away, so we have to start thinking of ways to improve upon what we have now.” 

Current housing markets and costs mean people aren’t moving for new jobs when they can do their work from anywhere. Telework is only going to become more popular because it increases the ability to choose to do the things that are becoming the norm within society and culture, Rubin says. “I just don’t see us going back to a time where people will uproot and move for an on-site job,” he notes.

AI’s Role in the Workforce

As radiology adapts to use everything in the toolbox, AI has the most potential to improve efficiencies in managing imaging volume within the strained workforce. “AI is not where it is going to be, but at some point it will get there,” says Dominick Parris, senior environmental intelligence analyst for the ACR.

“We don’t know the timeline, but radiologists who are AI-enabled now say it will be the most impactful on their workflows,” Parris says. “It won’t be interpretive AI right away, but rather AI tools that help radiologists focus on what they should be doing.”

New ACR research due to be released soon shows nearly half of practices are now using some form of AI, and at least three in 10 have been using it for the last five years, Parris says. No one should assume, however, that AI has been or will be a silver bullet. “In terms of impact, we wouldn’t be talking about a physician shortage if AI was having a great impact on the problem,” Parris notes.

It will be interesting to see how AI is incorporated on a large scale, Chertoff says. “When it comes to AI, people need to be behind the wheel,” she says. “That is key to AI delivering what we expect. And we have to change our perspective — not necessarily just looking at what AI is good at, but how AI tools can meet individual practice needs.” 

AI algorithms need to be constantly monitored and retrained. “You can’t just walk away and assume everything will be fine because it never is,” Chertoff says. “We have to upgrade equipment and tweak protocols regularly, and AI is no different.”

AI may help with connectivity issues. That is, it could bring together multiple platforms radiologists work from to make the process seamless. “When I was working every day, I had a minimum of two screens open along with doing administrative work,” Chertoff says. “There are a lot of clicks happening between studies and prior reports and clinical issues that may need clarity. Having things connect quickly and properly would get the pebbles out of your shoes that can annoy you all day.”

Too often with innovation, it becomes about what keeps physicians comfortable in what they do, Chertoff believes. “Using AI could flip that to making things easier for others. We can translate reports that are tailored to the person receiving it — be that a patient or a referrer — so they are getting only the information they want and need,” she says. “We could really demonstrate our value that way.”

Different Types of Practices

“Even when AI is in use in 100% of practices, it still won’t solve volume problems. It can help with efficiency, but not lessening volume,” Parris says. “And if we hope to stay ahead of future threats to the specialty in the next 10 years, IT and security will also need to drastically improve.” 

Unfortunately, radiology is one of the most susceptible areas of medicine because of its reliance on electronic data and image sharing. Much like the workforce crisis, it can be difficult to persuade leaders to address AI now when daily workloads take precedence.

“I think there is definitely potential for AI to help groups gain some efficiencies,” Seidel says. “Our department is using AI to prioritize exams with potentially critical findings.” 

Some sort of AI for smart scheduling for mammography is on Seidel’s wish list. “I think it is a challenging task because you never know how long a patient will be there — some cases are very quick and some patients end up being there for hours. It would be nice if there were a tool that could predict how long an appointment will take based on the patient’s reason for exam and prior images,” she says.

AI likely cannot help everyone. “It is not a great help for groups or practices where you must physically have people on the ground,” Rubin says. “That could be interventional radiology or fluoroscopy or anything we do that requires hands on patients. I’m not sure how AI is going to solve that.”

Where this is most problematic is not in urban areas or for practices operating out of urban-based centers, Rubin says. “It is extremely challenging in rural areas where we always have a shortage of radiologists.” Now more than ever, radiologists and other healthcare workers are urgently needed to preserve access to rural health facilities for communities that tend to be poorer, older and have more comorbidities. 

Capacity-Volume Prognosis

“We can’t assume that practices and radiology groups have the luxury of resources to do more than they are already doing. What we are looking at is a crisis,” Chertoff says. “It’s not just about working smarter, because we already work smart. We need to revitalize, to renew ourselves. There are many things we can do, but what we must not do is just stick our finger in the dike. We have to grow and innovate — to provide high-quality care without standing still.”

There are some things in medicine in general that are moving in the right direction in terms of easing physicians’ time burden, Chertoff says. “You don’t need your doctor to prescribe vaccinations now, for instance. And for things like colonoscopy, why would you need a referral to get one when the primary indication is being age 50? There are more and more healthcare services you can access without physically showing up in the doctor’s office, and this saves time for physicians and patients alike.”

“My prognosis for the workforce and volume crisis would have to be kind of guarded,” Chertoff says. “We know we are going to hit this shortage, and we do not have a lot of time for our smart people to come up with some innovative changes that will renew us as a profession. If we don’t burn them out and drive them out before they can put changes in play, that does give me hope.”

Rubin also sees promise in the way things are headed for radiology. “I believe in the collective intelligence of the ACR and our members,” he says. “I also believe you should never assume you are the smartest person in the room. If you do, you will not be listening to the person who has something important to say.”

Rubin says his goal at the annual meeting is not to tell people what they should be doing, but to  listen and then share with them some potential solutions that are now being considered. “I want to know what our members think the College, in collaboration with our other stakeholders, should be concentrating on to make those solutions viable,” Rubin says.

“We should be catching waves as they are building toward the shore, not when they crest and hit us with whitewater,” Rubin says. “We can’t tell groups what to do with their businesses, but we can be there to assist in making them more successful.”

We would love to hear what you think about the article. If you have questions or comments — or would like to share your own experience with workforce challenges — please send them to chudnall@acr.org. And don’t forget to explore new ACR Bulletin content each month, including more coverage of the workforce vs. capacity crisis, to stay current on the most important topics in radiology.

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