Mismatch between radiologist shortages, rising exam volumes a growing concern in medical imaging

The rapidly growing shortage of radiologists and technologists was one of the biggest topics covered at the 2023 Radiological Society of North America meeting this week. Ways to address it were discussed in numerous sessions and the concern was brought up in nearly every interview conducted by Radiology Business. 

"We have a great mismatch right now between the great resignation, the loss of manpower and the exploding increase in demand," explained Michael Bruno, MD, vice chair for quality and patient safety at Penn State Milton S. Hershey Medical Center, who also spoke on this topic in RSNA sessions. "We are seeing a huge rising volume, and a lot of this is for low-value, unnecessary care. We estimate that up to 30% of studies don't have a good clinical indication and are not likely to help the patient and don't really add value." 

He said attacking the overutilization of medical imaging would go a long way toward offsetting staffing shortages so radiologists and technologists could concentrate on exams that are actually needed.

"The large volume of wasteful procedures is impacting patients in bad ways. We are exposing people to radiation, there is a greater fraction of false positives that then lead to over treatment and over diagnosis, the cost is staggering, and we are frankly running up against a limitation of our capacity. Especially after the great resignation, we simply don't have enough manpower to keep up with this," Bruno said. 

There also is an urgent need to find ways to add more radiologists soon, Bruno noted, because many are retiring faster than the U.S. healthcare system can train their replacements. A shortage of radiology residency positions, due to a lack of funding, is further complicating the situation.

Bruno added that immigration policies and educational requirements should be changed to make it easier for foreign doctors to immigrate and practice in the United States. 

Can clinical decision support reduce the number of imaging exams?

Bruno has been involved in advocacy for the use of clinical decision support software to limit unnecessary exams that do not fit with guidelines for patient care. He was also involved in an American Collage of Radiology study that asked physicians why they order exams that many experts say offer no clinical benefit. 

"We found out that clinicians are very uncomfortable with diagnostic uncertainty, so they desire to order additional studies that are very unlikely to help them, sort of grasping at straws to get a little bit more certainty," Bruno said. 

The Centers for Medicare and Medicaid Services has sought to require clinical decision support software for advanced imaging and in an effort to reduce costs and waste in healthcare. However, clinicians, medical societies and vendors have resisted. The main issues have been that updating the software with new information from studies and new guidelines would be difficult to do in a timely manner. Buying and maintaining these systems also would not be reimbursed, adding significant costs to the providers without any ROI. Many doctors feel this would prevent them from using their clinical acumen in making decisions for their patients. Implementation of clinical decision support requirements for Medicare has been delayed for several years and is now shelved for the time being.

Instead, Bruno is an advocate for enhancing the role of the radiologist as a consultant so clinicians can ask which imaging tests might be best, rather than ordering studies that waste resources. 

"We could be more of a gatekeeper. Perhaps it is not something that we are completely comfortable doing, but it would be one approach to try and deal with the waste," he said. 

Lowering barriers to allow more foreign doctors into the U.S.

Another way to address the shortage of radiologists is to recruit more trained physicians from overseas. There are many who want to come to the U.S., but visa and training requirements hinder access. Experienced radiologists from other countries often need to go back through medical school programs to obtain an American medical degree, which many are not willing to do. Bruno said many countries have similar training programs and quality standards as the U.S., and policy changes could make it much easier for foreign doctors to immigrate here. 

"We have some artificial barriers that were put in place historically, but our situation has changed. Now we have a massive radiologist shortage that will not be improving in the foreseeable future," Bruno said. 

Technology can help address the radiologist shortage

Two technologies that can help augment the specialty are teleradiology and artificial intelligence. 

As hospitals everywhere are willing to pay more for radiologists and offer other incentives, Bruno said, it is drawing specialists away from smaller hospitals, especially in rural regions. Teleradiology is now picking up a lot of volume from such institutions, with some members of the specialty moving into remote reading as part of a semi-retirement plan.

Bruno gave the example of one top MSK radiologist thought leader who recently started reading exams for an eight-bed rural hospital as part of the teleradiology group they joined. This can allow experienced experts in the field to help resource-poor areas throughout the country, he said.  

AI may help augment radiologists by making them more efficient and offer a second set of eyes to help catch things they missed. The technology also is increasingly being used to orchestrate work lists, perform measurements, auto-populate report fields, perform first-pass reads to triage exams with critical findings, and speed up reading times. 

"Chances are AI is not going to replace us, but instead work with us. We need to see how AI can help radiologists improve their accuracy, efficiency and overall performance," Bruno said.