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Radiology has come a long way since the first CT scan and is now on the verge of a technological boom — not only in the equipment physicians use but also in emerging areas including AI. But radiologists are facing issues today that they couldn’t have predicted decades ago, including a shortage of new talent and an increase in venture capital being infused into private practices.
Those were among the topics explored in a recent panel discussion among seasoned radiologists who gave their take on the past, present and future of the specialty. It was one of two podcast episodes the ACR’s Radiology Leadership Institute® (RLI) recorded to mark the celebration of the College’s centennial in 2023–2024 — one speaking with a panel of radiologists who have decades of experience in the specialty and another with those who have been in practice less than 10 years.
In this article, we join host Geoffrey D. Rubin, MD, MBA, FACR, as he speaks with a panel of five longtime radiologists on what they have experienced in their careers and what they still hope to see accomplished in the specialty. The panelists are Johnathan S. Lewin, MD, FACR; Carolyn C. Meltzer, MD, FACR; Lawrence R. Muroff, MD, FACR; Mary H. Scanlon, MD, FACR; and Elliot L. Siegel, MD, FACR. They discuss what they’ve experienced in their long careers and what they hope to still see accomplished in the specialty.
Meet the Radiologists
Jonathan S. Lewin, MD, FACR, began his medical career as a physical chemist who was interested in the science side of medicine. After his radiology residency, Lewin was recruited back to where he served his residency at the University Hospitals of Cleveland as director of the MRI division. He went on to be recruited to John Hopkins as the chair of the department of radiology and radiological science. He is currently professor of radiology and imaging sciences, professor of biomedical engineering and professor of neurosurgery in the Emory School of Medicine. He is also a professor of health policy and management in the Rollins School of Public Health at Emory.
Carolyn C. Meltzer, MD, FACR, started out as a self-proclaimed “nerdy science person” with an interest in technology, specifically PET imaging, which she worked on during her training at John Hopkins. She followed that up by going to the University of Pittsburgh, where she worked in a young PET imaging center developing and testing the first PET-CT scanner. She is currently dean of the Keck School of Medicine at the University of Southern California (USC), where she holds the May S. and John H. Hooval Dean’s Chair in Medicine. Meltzer was awarded an ACR Gold Medal for 2023.
Lawrence R. Muroff, MD, FACR, eyed becoming a pelvic cancer surgeon until he discovered nuclear medicine from a friend who was in that field at the National Institutes of Health (NIH) when he was at the Bureau of Radiological Health. His switch to radiology was a last-minute one, but a move that would set him on a lifelong journey. He became an NIH fellow and got to attend the RSNA meeting every year. He has been involved with both the ACR and RSNA and even was appointed to the ACR BOC a few years later. He is currently an adjunct clinical professor of radiology at both the University of Florida and the University of South Florida Colleges of Medicine, as well as the president emeritus of Educational Symposia Inc., one of the largest educators of diagnostic imagers in the United States.
Mary H. Scanlon, MD, FACR, began at Einstein Health in Philadelphia for her residency, where the chair told her she wanted her to stay on and be a neuroradiologist. This led her to become the director of MRI, where she read 10,000 scans on a 0.15 Technicare until they got Supercon in 1990. She eventually left to become the chief of radiology at the U.S. Department of Veterans Affairs (VA). Scanlon is now a clinical professor of radiology at Penn Medicine and the vice chair of education, splitting her clinical practice between the division of neuroradiology at the University of Pennsylvania Health System (Penn Medicine) and the department of radiology of the Philadelphia VA Medical Center.
Elliot L. Siegel, MD, FACR, made his career decision very early on in medical school. After completing his undergraduate studies in computer science and visual physiology that determines optical illusions, he easily decided diagnostic imaging was meant for him. He began as chief of radiology at the VA after his residency and found out that you can’t be in charge administratively and try and have a schedule that lets you do IR. Siegel has transitioned to body imaging and nuclear medicine and has called his career “full of positive disruption and fun.” He is currently a professor and vice chair of the University of Maryland School of Medicine’s department of diagnostic radiology, and chief of radiology and nuclear medicine at the VA Maryland Healthcare System.
Technological Boom
Throughout the decades, technology has continued to be enhanced and improved. But with great change comes great opportunity. In the eyes of Siegel, working technology into radiology was the perfect fit.
“With a computer science background, I was really thrilled about the idea of beginning to apply computer technologies in diagnostic imaging,” he said. “What really excited me was the opportunity to be the first hospital in the world to go from analog to digital and to solve some of the issues that were plaguing us back then with regard to availability of medical images to allow image interpretation and stack mode. That ended up revolutionizing what we could do in MR and CT as far as visualization and making the transition to where the computer could actually assist us in detecting disease and making diagnoses. The whole idea of getting in just at the right time with a computer science background to be a pioneer in making the transition from analog to digital was really exciting and shaped so much of my career.”
Implementing technology into radiology meant changing the way everyone worked as they integrated more upgrades. From day-to-day operations to dealing with patients to running tests, everything changes with improvements in technology. Lewin noted this as he looked back at the growth of technology throughout his career.
“While the transformational change fundamentally altered how we look at radiology, it also changed how I looked at working with people,” Lewin said. “When it comes to processes, my first real job was running a technical division, the MRI division at the University Hospitals of Cleveland. Then I had the opportunity to build that into running both the faculty and technical side of a large department at Hopkins. These gave me the operational, financial and leadership opportunities to see how change management worked on processes. During that time, the processes within radiology markedly changed.”
Lewin highlighted how those changes made him look at the way he viewed radiology, specifically on the impacts on radiologists, their patients’ journeys and the bigger picture. “That was a critical part of reframing my understanding of how imaging impacts the broader healthcare system,” he said.
While the transformational change fundamentally altered how we look at radiology, it also changed how I looked at working with people.
Quick turnaround times are important to getting patients quality care. The quicker radiologists know what is going on, the quicker they can begin providing the appropriate treatment. Technology has been very important in increasing the speed of turnaround times on image readings in the digital age.
“Just going from the film alternator, the pedal to the metal, and having all those films up there and half of them falling down to what we now have in terms of digital imaging,” Scanlon said, it has been a big change. “To go from sitting there with a microphone and a tape, and you dictated something, and you put all the requests there, and then somebody would come, and a couple of days later they'd come back with reports and you'd have to fix them. Then they'd go out again. Then maybe the provider would get it two weeks later. And today, we’re dictating everything with our reports being instantaneously available — it’s monumental from two to three weeks turnaround time to what we have now. I think that's had the biggest impact.”
Muroff echoed this statement when he recounted a time when he was a chief resident and was shown by a group from Hounsfield’s colleagues a 64x64 matrix CT head scanners/images. He noted that it was the first body CT scanner on the Floridian west coast and only took 2.5 minutes to generate a two-slice image.
For Meltzer, technology kickstarted a positive change in the evolution of radiology. Better technology leads to better patient care, she said. It has led to the radiologist moving from the doctor’s doctor to the patient’s doctor.
“When I got out of training and worked at the University of Pittsburgh on the first combined PET-CT scanner that could be used clinically, the impact of having patients come from all over the world to see how their cancer might have progressed, and to use this unique modality in its first clinical trial, and talking to each patient individually who came to be part of that trial, very much felt not like the doctor's doctor, but certainly like the patient's doctor,” Meltzer said. Through all of these improvements in technology and patient care, she said, radiology has grown and thrived.
Evolution of a Specialty
All kinds of technological advancements have directly impacted the evolution of radiology, but one that has dominated headlines in recent years is AI. Many radiologists began to fear AI would take their jobs and move physicians to the unemployment line.
However, Siegel believes this technology will not only make radiologists more efficient but will help end burnout and allow radiologists to focus on more meaningful tasks. While it’s in the early years of use now, AI in the future will continue to improve and help radiologists.
“I think there's a tremendous amount of improvement we can make by having automation,” Siegel said. “We go to work every day and call up our images and just think the way things are done from an efficiency perspective really doesn't change,” he said. “But I believe there's the ability to increase our efficiency by five, six, seven times.”
He spoke about radiology groups that employ human scribes. “So, the whole idea that AI could essentially do what these scribes are doing to call up the studies, arrange them, have the radiologist give a very impression-type of report and then elaborate and turn that into a more structured report, I think that is incredible.”
Technology, no doubt, has had a huge impact on the evolution of radiology. From quicker turnaround times to new machines to train on, radiologists have been able to adapt with the evolving times to provide the best patient care possible. But the specialty has evolved in more ways than just technology.
Muroff sees the moment Congress moved radiologists from Medicare Part A to Medicare Part B as a significant moment of evolution in the specialty. “I think the most impactful for the benefit of all radiologists occurred in the late '60s when a small group of radiologists persuaded Congress to take radiologists out of Medicare Part A and put us in Part B, like other physician specialists,” he said. “Medicare Part B is where all physicians are compensated or considered to be unique specialists and practitioners. Medicare Part A basically is a hospital function, and if we had remained in A, we would've been an appendage of the hospital, much like a laboratory test.”
“So it was incredibly important to establish us as co-equal physicians in the physician community,” Muroff continued. “I mean, everybody who spoke before me mentioned how important it was for them to be involved with patient care and to interact with referring physicians in a co-equal way. That would probably not have been possible under the old construct.”
Seigel commented about how, as the specialty evolves, new branches of radiology could emerge, such as a branch that sees interventional radiology and molecular imaging work hand in hand.
As the specialty advances in the coming decades, Meltzer sees the radiologist’s role shifting toward being the driver of medical imaging innovation in the coming years, thanks to the drive and innovation of the radiology community. “We're always looking to make things better and to embrace technology to have greater impact on the patients we serve,” Meltzer says.
Radiologist Shortage and Academic Medical Centers
Radiology’s future continues to grow as treatments and technologies advance. However, there is an issue within the U.S. that some, like Seigel, have noticed: hiring issues in institutions across the country when it comes to bringing radiologists on board. “Other countries don't seem to have some of the same forces that seem to be driving decreased numbers of people in academics and some of the pressures that we're feeling,” Siegel said.
Although the panelists agreed it is wonderful to see radiology thrive in other parts of the world, Seigel asked whether there are ways to reverse the trend in the U.S.
Meltzer shared a few reasons why this is happening and how everyone can come together to reverse the trend. “We could get into the economics of medical education and how debt to our students continues to drive high salaries despite lower reimbursements, and shortages,” she said. “We are always predicting that we're going to have a surplus of radiologists. It has never been true. So we've had to think about that. And in this country, we don't do workforce planning very well, and I think COVID-19 has really laid that bare. I would love to have those more in-depth conversations, and the ACR is always a great place to bring minds together to think about these bigger issues.”
Radiologists’ journeys start in the classroom, and academic medical centers have been a great place for the next generation of radiologists to learn and grow. Lewin spoke about the importance of academic medical centers. “People may not realize that only 5% of hospitals in the U.S. are academic medical centers," he said, "but they operate over 70% of accredited Level 1 trauma centers, almost 70% of burn units, almost all of the comprehensive cancer centers in the country.”
The Rise of Venture Capitalists
One notable change within the specialty over the past few decades has been the rise of venture capitalists purchasing private radiology practices. It has been a topic of discussion not just for the college, but for the world of radiology. Muroff, after saying that his words are his own and not a reflection of the ACR or RLI, stated: “It's my opinion that corporatization is a disruptive and destructive force that has the potential to alter what we do, how we do it and how we're going to be compensated for the work that we do.”
Muroff asserted that venture capital companies are not bad for business, but they profit from the fact that there will be a sizable return on the investment they are making. “That return, at least to me, means that money has been taken out of the system and the major impact of this most likely will occur with radiologist compensation,” he said. “Now, the typical scenario for corporatization is that these entities exchange money in the form of cash or shares in exchange for the radiology practices they acquire. The narrative or justification they give is that medicine is a fragmented industry, and if consolidation is achieved, there will be a profit to be made for all.”
Muroff fears private practices could be displaced. “The entities can approach regional healthcare entities and directly compete with the existing groups for hospital contracts. These companies also now need to conserve money, and this can occur in a variety of ways, but the most troublesome is to significantly lower the compensation of radiologists practicing in their groups and by dropping out of the national organizations that they once had courted.”
When asked whether the government will step in and stop venture capital companies from buying practices, Muroff said he doesn’t believe that will happen. “I don't think there's anything on the regulatory horizon that will provide a soft landing,” he said. “These radiology practices are assets, and they're very significant assets, and they will go to the highest bidder in any kind of a bankruptcy. To me, that's frightening. If I were a radiologist, I worry about what would happen if my group then fell into this situation and was acquired by an entity that may have nothing to do with radiology and may not care about radiology and may only want to optimize profit and not focus on patient care that all of us find to be very important.”
The Next Wave
With eyes focused on the future of the specialty, the panelists explored how to prepare the next generation of radiologists as the specialty continues to evolve. Scanlon went back to the radiologist shortage topic of discussion, wondering whether a lack of proper training has been an issue. “Are we training them the way we should be? We have a competency-based medical education, but yet it’s still time served,” she said. “Do medical students really need three, four years in medical school? Can they get out sooner than that? Does one model fit everybody? I don't think so.” Scanlon also questioned the need for an internship and wondered whether removing that step would move people along in their careers faster, and she asked whether academic institutions should change the types of tests they administer to students.
Additionally, she said, budding radiologists should be trained to be comfortable with learning skills outside of their area of focus. Every generation learns differently, Scanlon said, and she sees the incoming generations of radiologists as no different.
“They may have to go out to an outpatient center, and they may need to do something that's outside of their specialty,” she said. “We have to be training people to be comfortable with being a little uncomfortable. … We need to make sure they understand they're lifelong learners and they have to keep these skills up or reconnect with these skills.”
Read the other articles in the project
Centennial Perspectives: A Look at Radiology From All Sides. To determine where the specialty is headed in the future, it's important to first understand where it has been and where it stands today.
Centennial Perspectives: Rising Leaders in Radiology Look at How the Specialty Will Evolve. In the second episode, Rubin talks to four radiologists who are early in their careers but have already made their impact in radiology: Kurt A. Schoppe, MD; Judy W. Gichoya, MD; Mathew Hawkins, MD; and Amy K. Patel, MD. They discuss how they’ve grown as leaders, how they define success, how they see the next decade of radiology shaping out and more. It’s a lively and informative discussion from some of radiology’s brightest rising minds.
Behind the Microphone with Geoffrey D. Rubin, MD, MBA, FACR. Rubin shares some of his thoughts on what radiology leaders revealed in both panels. He also talks about his observations from other leaders in the field based on previous podcast episodes.
Observations of a CEO: A Chat with William T. Thorwarth Jr., MD, FACR. The ACR's CEO discusses how the views of both panels align with the future vision for the College and its commitment to serving members — who, in turn, can best serve their patients today, tomorrow and always.