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Opinion |
1 Department of Radiology, Division of Education, Indiana University School of Medicine, 702 Barnhill Dr., Rm. 1053, Indianapolis, IN 46202-5200
Received January 11, 2001;
accepted after revision April 24, 2001.
Address correspondence to R. B. Gunderman.
Introduction
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There are few earthly things more beautiful than a university, a place where those who hate ignorance may strive to know and where those who perceive truth may strive to make others see. [1]
The health of academic radiology is vital to all radiologists, whether they are in private or academic practice. For one thing, a disproportionate share of radiologic research, the engine that drives scientific and technologic progress in the field, arises from academic centers. Moreover, academic radiologists based in medical schools play an especially large role in educating the next generation of physicians, both those who will choose radiology for their career and those who, choosing other specialties, will constitute radiology's referral base. Finally, academic radiologists frequently play important roles in the leadership of such professional organizations as the American College of Radiology, the Radiological Society of North America, and the American Roentgen Ray Society.
Because the vigor of academic radiology is so vital to the specialty of radiology as a whole, both private practice and academic radiologists have a strong interest in recruiting top-notch radiology residents into academic careers. Without first-rate leadership in research, education, and professional service, radiologists, our professional colleagues, and the patients we serve will suffer. The inducements to residents to opt for private practice are great; with the supply of radiologists lagging behind the demand, many private practice groups are offering outstanding salary and benefits packages to attract new members. Academic radiology cannot compete on these terms. Therefore, it is urgent that radiology training programs explicitly address the advantages of an academic career and provide radiology residents with a direct answer to the question, "What are the advantages of an academic career, and how do they compare with those of private practice" [2]? To provide an explicit answer to this question and to suggest some steps programs can take to ensure that academic radiology continues to thrive are the purposes of this article.
Advantages of Private Practice
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Another advantage of private practice is that it generally enables clinical radiologists to capitalize on a broader range of their training. Many private practice radiologists practice general radiology, meaning that they see a broad range of patients, potentially encompassing every radiologic subspecialty, including all organ systems and modalities. Whereas academic radiologists tend to focus on only a single area of practice, such as neuroradiology, interventional radiology, or mammography, or to rely primarily on only a single modality, such as sonography or nuclear medicine, the clinical work of a private practice generalist often encompasses them all. Many residents may enjoy imaging most of the human organism and interacting with a wide range of referring physicians, and, for such residents, private practice is likely to prove attractive.
In addition, the pressure on the private practice radiologist to conduct research and educate medical students and residents is not as great as that on the academic radiologist [4]. Private practice radiologists are generally free to invest most of their energies in the delivery of clinical care, and the private practitioner can succeed by excelling in the clinical sphere alone. In the academic sphere, by contrast, advancement may be contingent on parameters such as the number and quality of publications and research grants [5].
Residents who think they might like to do a small amount of research and teaching might consider a clinical track appointment in an academic department. On a clinical track, faculty members are expected to devote the bulk of their efforts to clinical work but enjoy the resources of an academic program to conduct occasional research or to teach medical students and residents on a regular basis.
Another advantage of choosing private practice stems from recent economic threats to the character of academic radiology that have caused many academic radiologists to resemble more and more closely their private practice counterparts [6]. During the 1990s, managed care and the cost-containment mentality that spawned it not only reined in the rate of increase of health care costs but produced real reductions in the reimbursement levels for many radiologic services. To sustain clinical revenues and incomes, both private practice and academic radiologists have found it necessary to increase their productivity. In short, they have had to work harder, interpreting more chest radiographs or performing more angiographic studies per day than they once did to generate the same revenue. For the private practitioner, this change meant working harder at the same clinical tasks, but for the academic radiologist, it frequently meant shifting the allocation of time away from research and teaching to clinical service.
In short, academic radiologists were forced to behave more like private practitioners, spending proportionately more of each day on clinical service. This reallocation meant that academic radiologists tended to have less and less time during the workday for the distinctively academic pursuits of research and teaching. Not only were there fewer hours left for academic work, but many academic radiologists found that they had less energy remaining for such pursuits. As a result, many people originally drawn to academic radiology by a genuine interest in research and teaching found themselves frustrated by increasing pressure to behave like private practitioners and decided to leave academic practice. If such people are replaced by radiologists with a strong academic commitment, the net impact could be positive, but in many cases, such replacements have not been immediately forthcoming. Residents may raise a legitimate question when they wonder why academic radiologists have to work every bit as hard clinically as their private practice counterparts for less pay and without protected time for teaching or research.
Advantages of an Academic Career
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Not only do academicians approach clinical work with an especially inquisitive outlook, but their clinical practice exhibits an especially self-critical attitude and tends to be more evidence-based as well.
Academic radiology also offers important service opportunities. Through participation in organized medicine, hospital governance committees, civic organizations, and the like, all radiologists enjoy important opportunities to represent the best interests of radiology, medicine, and the patients we serve. Because academic radiology is frequently practiced in medical school and university settings, however, academic radiologists enjoy special opportunities in this regard. What happens in medical schools today will exert a considerable impact on radiology's role in health care in the future. Likewise, what happens in universities today will exert a considerable impact not only on the health status but also on the economic welfare and overall quality of life that the members of our society enjoy in the future. Academic radiology provides an important opportunity for radiologists to play a formative role in the ongoing evolution of these institutions of higher learning. Academic radiologists can become not only chairs of radiology departments but also deans of medical schools and provosts and presidents of universities—leadership opportunities that can provide both extra challenges and extra rewards for those who undertake them.
All physicians are teachers, and teaching medicine is a primary precept of the Hippocratic Oath. Yet teaching is especially essential to the work of most academic radiologists, who teach not only colleagues, support staff, and patients but residents and medical students as well. Although it is obvious that an academic environment generally provides greater opportunities than private practice to teach, the true rewards of these opportunities may not be so obvious. Generally speaking, those who teach a subject understand it better than those who do not. Anyone who has ever been called on to deliver a lecture knows that the experience of teaching a subject leads to a better understanding of it. As an old Yiddish saying puts it, "He who teaches learns twice."
Many senior academic radiologists, reflecting on their careers, report that teaching has constituted the most enjoyable and rewarding aspect. The very word "doctor" means teacher, and for the right person, teaching represents not only one of the most rewarding aspects of a career in medicine but also one of the most rewarding callings in life. To foster educational excellence, good academic radiology departments need to provide radiologists opportunities to improve the quality of their teaching through the application of educational theory, the use of new instructional technologies, and the opportunity to work side by side with master teachers.
If radiologists—both those in academic settings and in private practice—do not do a good job of educating these constituencies, the quality of radiology practice is liable to suffer. For example, if we do not recruit more radiologic technologists, radiology's ability to provide high-quality, timely imaging services will be compromised. Similarly, if health care administrators fail to understand the importance of medical imaging in contemporary medical practice, radiologists may lack the resources they need to excel. In this information age, those who create and transmit new knowledge effectively are likely to flourish, and this changing environment represents a special opportunity for academic radiologists.
Research is another characteristically academic pursuit that offers many less-than-obvious advantages. As people who are inclined to ask questions, clinician—researchers tend to understand the nuts and bolts of their clinical practice especially well. Hence, academic radiologists are often the opinion leaders in radiology practice, the ones to whom clinical colleagues turn with questions and to whom they refer their toughest cases. Moreover, there is something especially enjoyable and rewarding about understanding what you do that can only partially be explained in terms of the advantage it gives you in being able to do it better. The pursuit of knowledge is one of the defining attributes of human beings that separates us from other living creatures, and physicians working in academic centers enjoy a special opportunity to engage and develop the inquisitive side of their nature. There is also something deeply satisfying about seeing the practice of radiology change because of your research; for example, you might see the device or technique that you developed used by radiologists in another hospital, or even on the other side of the earth, because they recognize the benefits it brings to the patients for whom they care.
The full range of possibilities for radiologic research needs to be emphasized. One rich and productive area of radiologic research, often pursued in collaboration with scientists and engineers, is basic imaging science, which includes the development of new imaging technologies, such as ongoing research in positron emission tomography, functional MR imaging, and ultrafast CT. Another important area of radiologic research concerns day-to-day clinical practice, such as the detection and characterization of lesions and the analysis of case series. Health services research, incorporating such disciplines as biostatistics, epidemiology, and decision science, will play an increasingly important role in medical imaging as we develop more robust assessments of the effectiveness and efficiency of various imaging techniques and strategies. Another area of research ripe for radiologic investigation is education, including the development of educational outcomes measures, enhanced decision analysis tools, and economic assessments of educational programs. To an increasing degree, quality radiologic research will incorporate not only the biological and physical sciences but the social sciences as well.
Academic radiology also affords the opportunity to subspecialize. Confronted by the daunting array of organ systems and modalities that comprise contemporary radiology practice, some residents may decide that they would prefer to gain greater expertise in one or two areas of radiology, rather than attempt to cover them all. The trend toward subspecialization is manifest even in large private practice groups where a small number of members may specialize in areas such as interventional radiology and mammography, but subspecialization is the rule throughout academic radiology. National and international authorities in clinical radiology tend to be individuals who focus on one particular area, and residents who aspire to that level of expertise may wish to give special consideration to an academic career.
Because academic radiologists are relatively more likely to be recognized as authorities in their area of expertise and to play a role on the national and international scene, they also enjoy special opportunities to form collaborative relationships and friendships with individuals around the world. Clinical work also contributes to these relationships, but teaching and research play at least equally important roles in fostering such ties.
Implications for Academic Radiology
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At a more global level, radiology leaders need to decide whether radiology's academic mission is one for which they are prepared to fight. Traditionally, health services provided in academic medical centers were reimbursed at a higher rate than in community hospitals because health care payers—both public and private—recognized that it costs more to provide those services in an environment with a strong commitment to research and education. Over the past decade, however, the "academic premium" has diminished, with the result that there is a smaller supplement for clinical work delivered in academic centers. Will the leadership of the profession of radiology succeed in convincing payers that it lies in our society's best interest to foster first-rate academic medical centers and that the research and education they produce are worth their price?
For academic radiology to thrive, residency programs need to provide their trainees with a meaningful degree of firsthand exposure to characteristically academic activities such as research and teaching [7]. If residents never experience what it is like to add to the body of knowledge of radiology or to play a role in passing on that knowledge to others, how can they make a truly informed choice about whether they might want to pursue an academic career [8]? With the recent demands on academic radiologists to increase their clinical throughput, faculty members are likely to focus more and more on getting the clinical work done and spend less and less time in mentoring residents. As a result, residents are receiving less and less exposure to what an academic career looks like on the inside and at the very time when such exposure is more important than ever. All residency programs should make a concerted effort to involve residents in research and education at some point during their training, including protected time and incentives for them to take part. Paying lip service is not enough, and both departmental administration and faculty should manifest a commitment strong enough that residents receive exposure and enjoy a realistic opportunity to succeed.
Another implication concerns the structure of academic practice. If department heads aim to build and sustain thriving academic enterprises, they need to reevaluate the academic work environment. Above all, they need to be creative in providing substantial time and resources for education and research. Faculty members should not be expected to be as productive as private practice radiologists in the clinical sphere and yet to also excel in their academic pursuits. Opportunities to make the clinical enterprise more efficient without sacrificing education should be sought, and new sources of financial support for excellence in teaching and research should be developed. All radiologists, whether in academic or private practice, should lend their support to such initiatives, and national radiology organizations should devote a substantial portion of their resources to such efforts.
The opportunity to excel as an academic radiologist may provide sufficient enticement to lure many of the most outstanding radiology residents into academic careers and to keep the most committed and productive of them within the academic fold, but only so long as that opportunity is backed up by an ongoing, passionate commitment to academic excellence.
In sum, a career in academic radiology probably makes the most sense for radiology residents who are curious and take pleasure in pursuing knowledge, who enjoy teaching and think they might be good at it, who feel at home in an academic environment where people tend to think critically and creatively about what they do, and who wish to make special leadership contributions in their field. To ensure that residents can make informed judgments about these matters, radiology training programs need to provide meaningful learning experiences in education and research. Moreover, programs should try to provide all residents, whether they are contemplating an academic career or not, with vocational counseling that will enable them to make informed choices and prepare themselves for successful careers [9].
At a human level, residents should be encouraged from time to time to step back and think about what they want to accomplish in their career [10]. How important to them is each of the following goals: to make the most money possible, to feel that they are raising the quality of clinical practice, to sustain and enrich our academic institutions, to educate the next generation of health professionals, and to contribute to the advancement of human knowledge? Academic radiology is not right for everyone, but it is in the vital interests of all radiologists to ensure that some of the best and brightest among each class of residents find their calling in an academic career and that the academic departments they join provide them with the resources they need to excel in their academic pursuits.
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  S. Tigges and R. B. Gunderman Today's Academic Radiologists Am. J. Roentgenol., June 1, 2002; 178(6): 1567 - 1568. [Full Text] [PDF]
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