BIRGIT ERTL-WAGNER
A VIEW FROM ABROAD
International Perspectives on Radiology Practice Metrics: Australia, France, Germany, Japan, New Zealand, Spain, the UK and USA Frank J. Lexa, MD, MBA, Geraldine McGinty, MD, MBA, Mark J. Adams, MD, MBA, Erika R. E. Denton, MD, Richard Duszak Jr, MD, Shigeru Ehara, MD, Bruce B. Forster, MSc, MD, Howard Galloway, MD, Pamela J. Kassing, MPA, RCC, Luis Martı´-Bonmatı´, MD, Peter Mildenberger, MD, Elisabeth Schouman-Claeys, MD INTRODUCTION
The delivery of health care around the world is remarkably diverse in 2015. A comparison of the approximately 200 national entities on the planet reveals marked differences in national measures, both on the input side, such as health care spending, and in outcomes, such as life span. Using the percentage of gross domestic product as a metric for comparing health care spending, the current variation among nations is almost an order of magnitude, from the Marshall Islands and the United States at close to 20% to Myanmar at about 2% [1]. Outcomes are also highly variable, with an almost 2-fold difference in life span between the best and worst nations [2]. Within the nations represented in this report, the longest lived is Japan, and yet that nation spends significantly less of its gross domestic product on health care than the United States, which spends the highest fraction of gross domestic product of nations in this group [3]. This is a reminder that simplistic comparisons and correlations may miss important insights into how medical systems work. Almost all nations struggle to some degree with challenges in managing their commitment to the health of their citizens. These challenges include deciding how much to spend on health care as well as how to measure outcomes (and the impact health care has on those
outcomes). Other challenges include balancing health spending with expenditures on other social goods and balancing those expenses against higher levels of revenue collection and the consequences thereof through increased taxation and other means. Imaging plays a central role in modern health care and has also found itself (for good and for ill) at the center of many current efforts in health planning and in reforms to try to limit those societal costs. Although the extremes may not lend themselves to useful comparisons that could lead to actionable results, it can be very helpful to start by looking at nations that are relatively similar and then to examine core issues in radiologic practice and to look for best practices. We hope to then be able to share best practices (and also pitfalls in radiologic service ideas) for the benefit of one another’s nations. Since 2012, the International Economics Committee of the ACR has carried out discussions both among its members and with outside experts to better understand the reality (and myths) regarding national differences in the practice of radiology. Our purpose is to help radiologists understand how health system practices differ among a selected set of nations. The goals of this enterprise are several. First, we aim to improve the exchange of information and understanding
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.07.031
among radiologists across national boundaries. Second, we hope to examine the challenges our nations and others face, such as aging populations, budget limitations, and (in some cases) labor shortages, and to highlight the fact that these challenges are not unique; in fact, all nations face them in one form or another. Finally, and most important, our goal is to consider how best (or perhaps better) health care practices can be shared across national boundaries to improve the quality and lives of our patients as well as the lives and careers of our fellow radiologists during this era of challenge and change. In this inaugural white paper from the International Economics Committee, we examine baseline structural and statistical differences among the nations in our comparison group. All of the nations in our group are members of the Organization for Economic Cooperation and Development (OECD) [4]. In the future, we will go into greater depth and explore a diverse set of vexing issues that affect radiologists around the globe from medical malpractice to utilization and other issues. METHODOLOGY
We began our discussion with the members of the International Economics Committee. They were each sent an e-mail that requested information regarding 15 topics 1081
1082 A View From Abroad
that have a direct bearing on the present and future conditions of radiologic practice in the members’ nations. In addition to their own opinions, the members all consulted with peers and with their national radiology societies to gain additional insights and to obtain statistics. The authors of this report acknowledge that there is room for additional detail and potentially disagreement over the data presented. We have strived to provide a fair basis for the profiles provided, but we acknowledge that the experiences of radiologists within a nation can be very diverse, depending on many variables, such as the locations of their practices, public versus private versus academic or other practice as appropriate, and the ages and positions of the respondents. As an example, the annual salary in one of the nations presented here can vary by a factor of about 4, depending on practice setting (L. R. Muroff, personal correspondence, October 24, 2013). This type of experiential diversity and sampling variability is fully acknowledged. The purpose of the profiles in this report is to provide a starting point for understanding the national settings in which radiology is practiced, not to purport to be the final word on the statistical abstracts of national radiologic practice data. We then analyzed the answers to evaluate for completeness and coherence in their value for reporting. RESULTS: PROFILES OF THE NATIONS STUDIED AND THEIR CORE METRICS
After analyzing the results of the committee’s discussion, it was decided that the answers to questions about annual salary and the cost and reimbursement for a head CT study did not merit reporting at this time. There were too many issues related to context and too much variability to make useful comparisons. Specifically, the local,
regional, and national taxation schemes in each nation, the benefits provided through taxation (retirement, health care, and college tuition), and the work hours and content required to earn an annual salary all combine to make a meaningful comparison of the annual salary in this group of nations out of the scope of this report. How many radiologists do you have in your country? Table 1 lists the demographics from the various countries. The table shows substantial variation (approximately 4-fold) in the number of radiologists available on a per capita basis to provide care for their countries’ populations. However, when this is compared with the question about whether these countries’ representatives believed that there are enough radiologists to provide care, the number of radiologists per capita appears consistent with the experiences of the radiologists locally. The United Kingdom and Japan were the lowest of the nations examined. They reported severe shortages and
the need for more radiologists in their workforces. Australia and Germany did not report shortages overall but did report that there is an imbalance of distribution within their countries, with too many radiologists in metropolitan areas and too few in rural areas. How are radiologists split between generalists, specialists and interventionalists? It is interesting that 7 of the 8 countries reported that most radiologists in their countries are general radiologists (Table 2). It was reported that all of these general radiologists do provide some interventional radiologic services. In most of the countries, radiologists are trained in subspecialties, but they are not recognized separately. The United States is unique among the nations in this report in that general radiology is a minority, with interventional radiologists and other specialty radiologists making up the majority. This could be because the United States has chosen to credential the
Table 1. Number of radiologists per 100,000 population Full-Time Equivalent Population Total Number Radiologists per 100,000 Population Country (Millions) of Radiologists Australia France Germany Japan New Zealand Spain United Kingdom United States
22.6† 63.7‡ 81.9§ 126jj 4.4† 47.2¶ 63# 313.9†
1,761 8,338 7,500* 6,300 319 5,300 2,323 34,000
7.79 13.09 9.2 5.00 7.25 11.22 3.69 10.83
*Number of board-certified radiologists (without residents), but about 25% are not actively performing radiology. The number of residents is about 1,500. †Data from the World Bank, accessed April 8, 2013, via Google Public Data Explorer (http://www.google.com/publicdata/). ‡Countrymeters. France population. Available at: http://countrymeters.info/en/ France/. Accessed November 18, 2013. §Countrymeters. Germany population. Available at: http://countrymeters.info/en/ Germany/. Accessed February 20, 2013. jjCountrymeters. Japan population. Available at: http://countrymeters.info/en/ Japan/. Accessed February 20, 2013. ¶Countrymeters. Spain population. Available at: http://countrymeters.info/en/Spain/. Accessed February 20, 2013. #The World Bank. Data: United Kingdom. Available at: http://data.worldbank.org/ country/united-kingdom. Accessed February 24, 2014.
A View From Abroad 1083
Table 2. General radiologists versus specialists General Country Radiologists Specialists Australia France Germany Japan New Zealand Spain United Kingdom United States
78.5% 100%† 94% 100%† 73% 70% 100%† 35%
Interventional Radiologists
21.5%
11.5%*
6%‡
Not available 12%*
27% 25%
5%*
57%
8%
*Interventional radiologists (8%) are included in the general radiologist percentage (78.5%), meaning that they are in the general category but are members of interventional radiology societies. †These countries reported that most radiologists are general radiologists. A few of these countries recognize that there are interventional radiologists, cardiac radiologists, and pediatric radiologists who are separately credentialed, but the numbers are minimal. ‡Only pediatric radiology and neuroradiology are recognized by special qualifications; interventional radiology is part of general radiology. Die Deutsche Gesellschaft für Interventionelle Radiologie (The German Society for Interventional Radiology) counted 1,079 members in 2013, but not all radiologists performing interventional radiology are members.
subspecialties separately. Spain is the only other country that reported a percentage of radiologists who consider themselves purely interventional radiologists. How are radiologists split between academics and nonacademic practice? If you have private practice please include that as well. Most countries reported that the majority of radiologists work in the public sector, under the government health program or programs (Table 3). In France and
Spain, significant numbers of radiologists work in private practice. All countries emphasized that the radiology workforce could not be broken down neatly into the 3 categories. Most radiologists work in a mixture of settings, including for the public programs, supplemented with private practice. A mixture also meant that academic radiology is not considered a separate practice setting but that radiologists who work in the public setting do so in both the academic and nonacademic settings.
Table 3. Split of academic and nonacademic radiologists Country
Public
Australia France Germany Japan New Zealand Spain United Kingdom
22% 29% 54% 57% 28% 80% Majority
United States‡
1% government
Private 31.4% 57% 46% 10% 13% 20% Minor and supplemental 53% private, 18% employee
Mixed Public Academic and Private * * 13%† 33% *
46.6% 14%
58%
2% 29%
*Academic work is part of the public program. Purely academic positions are very few. †As part of the public group. ‡ACR data (E. Bluth, personal communication).
How much is an average radiologist paid in your country per year in local currency? Has that gone up or down in the past five years? Although the representatives from each of the countries tried to report some kind of salary amount, each had to qualify that “it depends” on the context in which it is earned. There is a big difference between being a government employee and providing public services and being self-employed in private practice. Some were paid a wide range within categories (eg, employment or academics) on the basis of other factors, such as years of experience. If a salary level was reported, it was mostly likely because of the availability of public data on employees of public programs. However, a majority of these radiologists also supplement their incomes by providing services in private practice. Therefore, reporting purely public data would not be completely accurate or comparative. Most countries reported that income has remained the same or has decreased. Only one country reported a slight increase (Germany). In your nation is it common practice to provide bonuses to radiologists for doing extra clinical work? Please explain where this happens, where it does not happen, and when it does happen how it is handled. There is potential in most of the participating countries to be paid extra for extra clinical work, but it varies significantly (Table 4). For the two countries that have shortages of radiologists and huge workloads (the United Kingdom and Japan), it is interesting that there are two extremes. In the United Kingdom, radiologists are paid for overtime to help keep up with the workload, whereas Japanese radiologists typically cover the extra work with no additional pay. In the other countries surveyed,
1084 A View From Abroad
Table 4. Bonus incentives Country Australia France Germany
Japan New Zealand Spain United Kingdom United States
Bonus Structure
Yes, but varies by individual arrangements Yes, for on-call and night coverage Yes, in public hospitals for on-call and night coverage, overtime, and service for patients with private insurance; in private practice by individual arrangements Not standard to be paid for extra work Not available Not as much because of economic crisis; some opportunity for overtime on a fixed number of studies per extra time Yes, for overtime to cover heavy workload Yes, but varies by individual arrangements
additional compensation can be earned for a variety of reasons, including overtime, night coverage, being on call, and taking on private-pay patients. How many hours a week does an average radiologist work, and how many weeks per year? Has that gone up or down in the past five years? On average, radiologists in nations studied here worked within a range of 40 to 50 hours per week. Most reported workload increases. In those countries where there are severe shortages of radiologists (the United Kingdom and Japan), the workloads are increasing without concomitant increases in salaries. There was large variation in how many weeks per year were allowed for professional education and personal vacation. The largest number of duty weeks per year was 46, in Japan. Is the perception in your country that you have: too many, Table 5. Residents’ salaries Country Australia France Germany Japan New Zealand Spain United Kingdom United States
too few or about the right number of radiologists for your nation now? Most countries reported current shortages of radiologists and continued concern for the future. Only the United States reported about the right amount, with the proviso of a short-term excess likely to be balanced with a longer term shortfall. The effect that this is having in most nations is longer work hours, less time off, the possible need for more ancillary staff members to assist, and longer wait times for results. As stated earlier (see Table 2), several countries reported excesses of radiologists clustering in metropolitan areas, leaving rural areas with shortages. Is the perception in your country that you are training enough, not enough or the right amount of radiologists to serve your nation? The United Kingdom and France reported that they believe that there
First Year Varies by state $25,140 $63,121 $20,000 Not available $22,000 $49,510 $41,500
Fifth Year $34,404 $79,588 $48,969 $29,000 $77,850 $62,500
Note: These dollar amounts are based on a currency conversion conducted in the first quarter of 2014. The numbers displayed are based on typical pretax payments. Institutional variation in pay and in associated benefits and tax treatment by country will cause substantial variation in the actual monetary values received by individual trainees.
are not enough trainees to meet the demand. The United States also sees a likely shortfall for the future, while weathering a current excess based on difficulties in new trainees’ finding jobs. Germany, Spain, Japan, and Australia believe that there are just the right amounts of radiologists who will be trained, with a sense that New Zealand may be producing too many. Japan is making a concerted effort to remedy its shortage and to improve the working conditions as they currently stand. How much do you pay a radiology resident during their training? Has that gone up or down in the past five years and by how much? In most countries, residents’ salaries have standard payment rates that progress over the years of residency (Table 5). These salaries have remained flat or have increased only slightly. In most countries, there is potential to earn extra income by providing moonlighting services. The average number of poste medical school training years that a radiologist is in required training to achieve the status of certified radiologist (exclusive of subspecialty training) varies (Table 6). If you or your hospital pays for malpractice insurance for the work that you do, what does that cost compared with your salary? In general, it seems that radiologists in all countries do pay for some kind of malpractice insurance (Table 7). The rate is usually not fixed for all radiologists but can vary by practice setting, specialty, and level of income. In at least half of the countries, the health systems or hospitals pay for malpractice insurance that covers patient care under the public system. Then small additional fees are paid in order to be insured for practicing in the public system and separate fees to cover incidents that might take place in private practice. Interventional radiologists usually
A View From Abroad 1085
Table 6. Resident training Country Australia France Germany Japan
New Zealand Spain United Kingdom United States
Years
2 nonradiology þ 5 radiology 1 nonradiology (can be nuclear medicine) and 4 radiology 5 2 nonradiology, 2 general radiology, and 3 additional radiology for a total of 7; a qualifying examination for employment occurs in the eighth year 2 nonradiology þ 5 radiology 4 3 nonradiology þ 5 radiology 1 nonradiology þ 4 radiology
pay more because of a higher risk factor. DISCUSSION
In this introductory white paper, we have shared the perceptions of a group of top radiology leaders about key radiology metrics and issues in their respective countries. We understand that these are the views of individuals and that others both within and outside these nations may differ in how they view these issues. However, we hope that this provides a starting point for an ongoing discussion within a wider audience. This will be
helpful in determining where the similarities and dissimilarities are and how these may affect decisions in these nations and others. Our spirit is one of a committee of correspondence, and our hope is that we will provoke greater exchanges of information and perception in our radiology communities. In future white papers, the International Economics Committee will discuss challenges and best practices on issues of imaging screening examinations, paying for radiology infrastructure, credentialing and certification, ordering practices,
Table 7. Malpractice insurance rates Country Annual Amount* Australia
Approximately 3%e5% of annual salary
France
Physicians pay $208 for public and $1,752 for private practice; IRs pay $382 in both settings $1,485 for DRs in practice; a department head may pay up to 10 times that and a resident about one-fifth DRs pay $400 for private practice
Germany
Japan
New Zealand Spain
United Kingdom
Not available DRs pay $139e$277 for public and $277e$416 for private practice; IRs pay $555e$832 for private practice Approximately 10% of private practice salary
United States
3%e10% or more of gross salary
training issues, and other topics. We look forward to expanding the range of topics and number of nations involved in this important dialogue. TAKE-HOME POINTS
Even among a select group of somewhat similar Organisation for Economic Co-operation and Development nations, there are very substantial differences in the practice of radiology, with an approximately 4-fold difference in the number of active radiologists per capita. Many of the nations surveyed expressed concerns regarding their ability to match the number of radiologists in training to the needs of their nations. National systems in this report show very different distributions of generalist versus specialist radiology practice patterns. In most of the nations in this cohort, the perception is that workload has been increasing over the past 5 years. Conditions
The cost varies depending on the state in which radiologists are required to be insured, the dates for which they wish to be insured, whether they work in the private or public health system, and whether insurance is required for any other previous employment. The health system pays for the insurance. Employees pay an additional small fee. Hospital covers most risk insurance; numbers reflect additional payment amounts. Hospitals pay insurance for most workers. Radiologists pay an additional small fee for private practice. Both the health system and radiologists pay for malpractice insurance. Depends on the type of radiology specialty, time spend in private practice and amount earned. Public work is insured by the state. Varies considerably by region and is higher for those involved in interventional work.
Note: DR ¼ diagnostic radiologist; IR ¼ interventional radiologist.
*All currency converted to US dollars at current exchange rates at the time of writing.
1086 A View From Abroad
REFERENCES 1. The World Bank. Health expenditure, total (% of GDP). Available at: http://data.worldbank. org/indicator/SH.XPD.TOTL.ZS?order¼ wbapi_data_value_2010þwbapi_data_valueþ wbapi_data_value-last&sort¼asc. Accessed June 25, 2012.
2. Central Intelligence Agency. The World Factbook. Available at: https://www.cia.gov/ library/publications/the-world-factbook/rank order/2102rank.html. Accessed June 25, 2012. 3. Organisation for Economic Co-operation and Development. Compare your country—health
profile. Available at: http://www.compareyour country.org/chart?project¼health&&lg¼en. Accessed July 18, 2014. 4. The Organisation for Economic Co-operation and Development (OECD). Available at http:// www.oecd.org/about/history/. Accessed July 2014.
Frank J. Lexa, MD, MBA, is from the Wharton School and the Drexel University College of Medicine, University of Pennsylvania, Wynnewood, Pennsylvania. Geraldine McGinty, MD, MBA, is from Weill Cornell Medical College, New York, New York. Mark J. Adams, MD, MBA, is from University of Rochester School of Medicine and Dentistry, Rochester, New York. Erika R. E. Denton, MD, is from University of East Anglia and Norfolk & Norwich University Hospital, Norfolk, United Kingdom. Richard Duszak Jr, is from Emory University, Atlanta, Georgia. Shigeru Ehara, MD, is from Iwate Medical University School of Medicine, Morioka, Japan. Bruce B. Forster, MSc, MD is from University of British Columbia, Vancouver, British Columbia, Canada. Howard Galloway, MD, is from Canberra Imaging Group, Canberra, Australia. Pamela Kassing, MPA, is from American College of Radiology, Reston, Virginia. Luis Martı´-Bonmatı´, MD, is from Universidad de Vale`ncia, Vale`ncia, Spain. Peter Mildenberger, MD, is from Mainz University, Mainz, Germany. Elisabeth Schouman-Claeys, MD, is from Hoˆpital Bichat, Paris, France. Frank J. Lexa, MD, MBA, Wharton School and the Drexel University College of Medicine, University of Pennsylvania, Wynnewood, Pennsylvania, 306 Gypsy Lane Wynnewood PA 19096, 215 762 8394; e-mail: [email protected].
A VIEW FROM ABROAD
International Perspectives on Radiology Practice Metrics: Australia, France, Germany, Japan, New Zealand, Spain, the UK and USA Frank J. Lexa, MD, MBA, Geraldine McGinty, MD, MBA, Mark J. Adams, MD, MBA, Erika R. E. Denton, MD, Richard Duszak Jr, MD, Shigeru Ehara, MD, Bruce B. Forster, MSc, MD, Howard Galloway, MD, Pamela J. Kassing, MPA, RCC, Luis Martı´-Bonmatı´, MD, Peter Mildenberger, MD, Elisabeth Schouman-Claeys, MD INTRODUCTION
The delivery of health care around the world is remarkably diverse in 2015. A comparison of the approximately 200 national entities on the planet reveals marked differences in national measures, both on the input side, such as health care spending, and in outcomes, such as life span. Using the percentage of gross domestic product as a metric for comparing health care spending, the current variation among nations is almost an order of magnitude, from the Marshall Islands and the United States at close to 20% to Myanmar at about 2% [1]. Outcomes are also highly variable, with an almost 2-fold difference in life span between the best and worst nations [2]. Within the nations represented in this report, the longest lived is Japan, and yet that nation spends significantly less of its gross domestic product on health care than the United States, which spends the highest fraction of gross domestic product of nations in this group [3]. This is a reminder that simplistic comparisons and correlations may miss important insights into how medical systems work. Almost all nations struggle to some degree with challenges in managing their commitment to the health of their citizens. These challenges include deciding how much to spend on health care as well as how to measure outcomes (and the impact health care has on those
outcomes). Other challenges include balancing health spending with expenditures on other social goods and balancing those expenses against higher levels of revenue collection and the consequences thereof through increased taxation and other means. Imaging plays a central role in modern health care and has also found itself (for good and for ill) at the center of many current efforts in health planning and in reforms to try to limit those societal costs. Although the extremes may not lend themselves to useful comparisons that could lead to actionable results, it can be very helpful to start by looking at nations that are relatively similar and then to examine core issues in radiologic practice and to look for best practices. We hope to then be able to share best practices (and also pitfalls in radiologic service ideas) for the benefit of one another’s nations. Since 2012, the International Economics Committee of the ACR has carried out discussions both among its members and with outside experts to better understand the reality (and myths) regarding national differences in the practice of radiology. Our purpose is to help radiologists understand how health system practices differ among a selected set of nations. The goals of this enterprise are several. First, we aim to improve the exchange of information and understanding
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.07.031
among radiologists across national boundaries. Second, we hope to examine the challenges our nations and others face, such as aging populations, budget limitations, and (in some cases) labor shortages, and to highlight the fact that these challenges are not unique; in fact, all nations face them in one form or another. Finally, and most important, our goal is to consider how best (or perhaps better) health care practices can be shared across national boundaries to improve the quality and lives of our patients as well as the lives and careers of our fellow radiologists during this era of challenge and change. In this inaugural white paper from the International Economics Committee, we examine baseline structural and statistical differences among the nations in our comparison group. All of the nations in our group are members of the Organization for Economic Cooperation and Development (OECD) [4]. In the future, we will go into greater depth and explore a diverse set of vexing issues that affect radiologists around the globe from medical malpractice to utilization and other issues. METHODOLOGY
We began our discussion with the members of the International Economics Committee. They were each sent an e-mail that requested information regarding 15 topics 1081
1082 A View From Abroad
that have a direct bearing on the present and future conditions of radiologic practice in the members’ nations. In addition to their own opinions, the members all consulted with peers and with their national radiology societies to gain additional insights and to obtain statistics. The authors of this report acknowledge that there is room for additional detail and potentially disagreement over the data presented. We have strived to provide a fair basis for the profiles provided, but we acknowledge that the experiences of radiologists within a nation can be very diverse, depending on many variables, such as the locations of their practices, public versus private versus academic or other practice as appropriate, and the ages and positions of the respondents. As an example, the annual salary in one of the nations presented here can vary by a factor of about 4, depending on practice setting (L. R. Muroff, personal correspondence, October 24, 2013). This type of experiential diversity and sampling variability is fully acknowledged. The purpose of the profiles in this report is to provide a starting point for understanding the national settings in which radiology is practiced, not to purport to be the final word on the statistical abstracts of national radiologic practice data. We then analyzed the answers to evaluate for completeness and coherence in their value for reporting. RESULTS: PROFILES OF THE NATIONS STUDIED AND THEIR CORE METRICS
After analyzing the results of the committee’s discussion, it was decided that the answers to questions about annual salary and the cost and reimbursement for a head CT study did not merit reporting at this time. There were too many issues related to context and too much variability to make useful comparisons. Specifically, the local,
regional, and national taxation schemes in each nation, the benefits provided through taxation (retirement, health care, and college tuition), and the work hours and content required to earn an annual salary all combine to make a meaningful comparison of the annual salary in this group of nations out of the scope of this report. How many radiologists do you have in your country? Table 1 lists the demographics from the various countries. The table shows substantial variation (approximately 4-fold) in the number of radiologists available on a per capita basis to provide care for their countries’ populations. However, when this is compared with the question about whether these countries’ representatives believed that there are enough radiologists to provide care, the number of radiologists per capita appears consistent with the experiences of the radiologists locally. The United Kingdom and Japan were the lowest of the nations examined. They reported severe shortages and
the need for more radiologists in their workforces. Australia and Germany did not report shortages overall but did report that there is an imbalance of distribution within their countries, with too many radiologists in metropolitan areas and too few in rural areas. How are radiologists split between generalists, specialists and interventionalists? It is interesting that 7 of the 8 countries reported that most radiologists in their countries are general radiologists (Table 2). It was reported that all of these general radiologists do provide some interventional radiologic services. In most of the countries, radiologists are trained in subspecialties, but they are not recognized separately. The United States is unique among the nations in this report in that general radiology is a minority, with interventional radiologists and other specialty radiologists making up the majority. This could be because the United States has chosen to credential the
Table 1. Number of radiologists per 100,000 population Full-Time Equivalent Population Total Number Radiologists per 100,000 Population Country (Millions) of Radiologists Australia France Germany Japan New Zealand Spain United Kingdom United States
22.6† 63.7‡ 81.9§ 126jj 4.4† 47.2¶ 63# 313.9†
1,761 8,338 7,500* 6,300 319 5,300 2,323 34,000
7.79 13.09 9.2 5.00 7.25 11.22 3.69 10.83
*Number of board-certified radiologists (without residents), but about 25% are not actively performing radiology. The number of residents is about 1,500. †Data from the World Bank, accessed April 8, 2013, via Google Public Data Explorer (http://www.google.com/publicdata/). ‡Countrymeters. France population. Available at: http://countrymeters.info/en/ France/. Accessed November 18, 2013. §Countrymeters. Germany population. Available at: http://countrymeters.info/en/ Germany/. Accessed February 20, 2013. jjCountrymeters. Japan population. Available at: http://countrymeters.info/en/ Japan/. Accessed February 20, 2013. ¶Countrymeters. Spain population. Available at: http://countrymeters.info/en/Spain/. Accessed February 20, 2013. #The World Bank. Data: United Kingdom. Available at: http://data.worldbank.org/ country/united-kingdom. Accessed February 24, 2014.
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Table 2. General radiologists versus specialists General Country Radiologists Specialists Australia France Germany Japan New Zealand Spain United Kingdom United States
78.5% 100%† 94% 100%† 73% 70% 100%† 35%
Interventional Radiologists
21.5%
11.5%*
6%‡
Not available 12%*
27% 25%
5%*
57%
8%
*Interventional radiologists (8%) are included in the general radiologist percentage (78.5%), meaning that they are in the general category but are members of interventional radiology societies. †These countries reported that most radiologists are general radiologists. A few of these countries recognize that there are interventional radiologists, cardiac radiologists, and pediatric radiologists who are separately credentialed, but the numbers are minimal. ‡Only pediatric radiology and neuroradiology are recognized by special qualifications; interventional radiology is part of general radiology. Die Deutsche Gesellschaft für Interventionelle Radiologie (The German Society for Interventional Radiology) counted 1,079 members in 2013, but not all radiologists performing interventional radiology are members.
subspecialties separately. Spain is the only other country that reported a percentage of radiologists who consider themselves purely interventional radiologists. How are radiologists split between academics and nonacademic practice? If you have private practice please include that as well. Most countries reported that the majority of radiologists work in the public sector, under the government health program or programs (Table 3). In France and
Spain, significant numbers of radiologists work in private practice. All countries emphasized that the radiology workforce could not be broken down neatly into the 3 categories. Most radiologists work in a mixture of settings, including for the public programs, supplemented with private practice. A mixture also meant that academic radiology is not considered a separate practice setting but that radiologists who work in the public setting do so in both the academic and nonacademic settings.
Table 3. Split of academic and nonacademic radiologists Country
Public
Australia France Germany Japan New Zealand Spain United Kingdom
22% 29% 54% 57% 28% 80% Majority
United States‡
1% government
Private 31.4% 57% 46% 10% 13% 20% Minor and supplemental 53% private, 18% employee
Mixed Public Academic and Private * * 13%† 33% *
46.6% 14%
58%
2% 29%
*Academic work is part of the public program. Purely academic positions are very few. †As part of the public group. ‡ACR data (E. Bluth, personal communication).
How much is an average radiologist paid in your country per year in local currency? Has that gone up or down in the past five years? Although the representatives from each of the countries tried to report some kind of salary amount, each had to qualify that “it depends” on the context in which it is earned. There is a big difference between being a government employee and providing public services and being self-employed in private practice. Some were paid a wide range within categories (eg, employment or academics) on the basis of other factors, such as years of experience. If a salary level was reported, it was mostly likely because of the availability of public data on employees of public programs. However, a majority of these radiologists also supplement their incomes by providing services in private practice. Therefore, reporting purely public data would not be completely accurate or comparative. Most countries reported that income has remained the same or has decreased. Only one country reported a slight increase (Germany). In your nation is it common practice to provide bonuses to radiologists for doing extra clinical work? Please explain where this happens, where it does not happen, and when it does happen how it is handled. There is potential in most of the participating countries to be paid extra for extra clinical work, but it varies significantly (Table 4). For the two countries that have shortages of radiologists and huge workloads (the United Kingdom and Japan), it is interesting that there are two extremes. In the United Kingdom, radiologists are paid for overtime to help keep up with the workload, whereas Japanese radiologists typically cover the extra work with no additional pay. In the other countries surveyed,
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Table 4. Bonus incentives Country Australia France Germany
Japan New Zealand Spain United Kingdom United States
Bonus Structure
Yes, but varies by individual arrangements Yes, for on-call and night coverage Yes, in public hospitals for on-call and night coverage, overtime, and service for patients with private insurance; in private practice by individual arrangements Not standard to be paid for extra work Not available Not as much because of economic crisis; some opportunity for overtime on a fixed number of studies per extra time Yes, for overtime to cover heavy workload Yes, but varies by individual arrangements
additional compensation can be earned for a variety of reasons, including overtime, night coverage, being on call, and taking on private-pay patients. How many hours a week does an average radiologist work, and how many weeks per year? Has that gone up or down in the past five years? On average, radiologists in nations studied here worked within a range of 40 to 50 hours per week. Most reported workload increases. In those countries where there are severe shortages of radiologists (the United Kingdom and Japan), the workloads are increasing without concomitant increases in salaries. There was large variation in how many weeks per year were allowed for professional education and personal vacation. The largest number of duty weeks per year was 46, in Japan. Is the perception in your country that you have: too many, Table 5. Residents’ salaries Country Australia France Germany Japan New Zealand Spain United Kingdom United States
too few or about the right number of radiologists for your nation now? Most countries reported current shortages of radiologists and continued concern for the future. Only the United States reported about the right amount, with the proviso of a short-term excess likely to be balanced with a longer term shortfall. The effect that this is having in most nations is longer work hours, less time off, the possible need for more ancillary staff members to assist, and longer wait times for results. As stated earlier (see Table 2), several countries reported excesses of radiologists clustering in metropolitan areas, leaving rural areas with shortages. Is the perception in your country that you are training enough, not enough or the right amount of radiologists to serve your nation? The United Kingdom and France reported that they believe that there
First Year Varies by state $25,140 $63,121 $20,000 Not available $22,000 $49,510 $41,500
Fifth Year $34,404 $79,588 $48,969 $29,000 $77,850 $62,500
Note: These dollar amounts are based on a currency conversion conducted in the first quarter of 2014. The numbers displayed are based on typical pretax payments. Institutional variation in pay and in associated benefits and tax treatment by country will cause substantial variation in the actual monetary values received by individual trainees.
are not enough trainees to meet the demand. The United States also sees a likely shortfall for the future, while weathering a current excess based on difficulties in new trainees’ finding jobs. Germany, Spain, Japan, and Australia believe that there are just the right amounts of radiologists who will be trained, with a sense that New Zealand may be producing too many. Japan is making a concerted effort to remedy its shortage and to improve the working conditions as they currently stand. How much do you pay a radiology resident during their training? Has that gone up or down in the past five years and by how much? In most countries, residents’ salaries have standard payment rates that progress over the years of residency (Table 5). These salaries have remained flat or have increased only slightly. In most countries, there is potential to earn extra income by providing moonlighting services. The average number of poste medical school training years that a radiologist is in required training to achieve the status of certified radiologist (exclusive of subspecialty training) varies (Table 6). If you or your hospital pays for malpractice insurance for the work that you do, what does that cost compared with your salary? In general, it seems that radiologists in all countries do pay for some kind of malpractice insurance (Table 7). The rate is usually not fixed for all radiologists but can vary by practice setting, specialty, and level of income. In at least half of the countries, the health systems or hospitals pay for malpractice insurance that covers patient care under the public system. Then small additional fees are paid in order to be insured for practicing in the public system and separate fees to cover incidents that might take place in private practice. Interventional radiologists usually
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Table 6. Resident training Country Australia France Germany Japan
New Zealand Spain United Kingdom United States
Years
2 nonradiology þ 5 radiology 1 nonradiology (can be nuclear medicine) and 4 radiology 5 2 nonradiology, 2 general radiology, and 3 additional radiology for a total of 7; a qualifying examination for employment occurs in the eighth year 2 nonradiology þ 5 radiology 4 3 nonradiology þ 5 radiology 1 nonradiology þ 4 radiology
pay more because of a higher risk factor. DISCUSSION
In this introductory white paper, we have shared the perceptions of a group of top radiology leaders about key radiology metrics and issues in their respective countries. We understand that these are the views of individuals and that others both within and outside these nations may differ in how they view these issues. However, we hope that this provides a starting point for an ongoing discussion within a wider audience. This will be
helpful in determining where the similarities and dissimilarities are and how these may affect decisions in these nations and others. Our spirit is one of a committee of correspondence, and our hope is that we will provoke greater exchanges of information and perception in our radiology communities. In future white papers, the International Economics Committee will discuss challenges and best practices on issues of imaging screening examinations, paying for radiology infrastructure, credentialing and certification, ordering practices,
Table 7. Malpractice insurance rates Country Annual Amount* Australia
Approximately 3%e5% of annual salary
France
Physicians pay $208 for public and $1,752 for private practice; IRs pay $382 in both settings $1,485 for DRs in practice; a department head may pay up to 10 times that and a resident about one-fifth DRs pay $400 for private practice
Germany
Japan
New Zealand Spain
United Kingdom
Not available DRs pay $139e$277 for public and $277e$416 for private practice; IRs pay $555e$832 for private practice Approximately 10% of private practice salary
United States
3%e10% or more of gross salary
training issues, and other topics. We look forward to expanding the range of topics and number of nations involved in this important dialogue. TAKE-HOME POINTS
Even among a select group of somewhat similar Organisation for Economic Co-operation and Development nations, there are very substantial differences in the practice of radiology, with an approximately 4-fold difference in the number of active radiologists per capita. Many of the nations surveyed expressed concerns regarding their ability to match the number of radiologists in training to the needs of their nations. National systems in this report show very different distributions of generalist versus specialist radiology practice patterns. In most of the nations in this cohort, the perception is that workload has been increasing over the past 5 years. Conditions
The cost varies depending on the state in which radiologists are required to be insured, the dates for which they wish to be insured, whether they work in the private or public health system, and whether insurance is required for any other previous employment. The health system pays for the insurance. Employees pay an additional small fee. Hospital covers most risk insurance; numbers reflect additional payment amounts. Hospitals pay insurance for most workers. Radiologists pay an additional small fee for private practice. Both the health system and radiologists pay for malpractice insurance. Depends on the type of radiology specialty, time spend in private practice and amount earned. Public work is insured by the state. Varies considerably by region and is higher for those involved in interventional work.
Note: DR ¼ diagnostic radiologist; IR ¼ interventional radiologist.
*All currency converted to US dollars at current exchange rates at the time of writing.
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REFERENCES 1. The World Bank. Health expenditure, total (% of GDP). Available at: http://data.worldbank. org/indicator/SH.XPD.TOTL.ZS?order¼ wbapi_data_value_2010þwbapi_data_valueþ wbapi_data_value-last&sort¼asc. Accessed June 25, 2012.
2. Central Intelligence Agency. The World Factbook. Available at: https://www.cia.gov/ library/publications/the-world-factbook/rank order/2102rank.html. Accessed June 25, 2012. 3. Organisation for Economic Co-operation and Development. Compare your country—health
profile. Available at: http://www.compareyour country.org/chart?project¼health&&lg¼en. Accessed July 18, 2014. 4. The Organisation for Economic Co-operation and Development (OECD). Available at http:// www.oecd.org/about/history/. Accessed July 2014.
Frank J. Lexa, MD, MBA, is from the Wharton School and the Drexel University College of Medicine, University of Pennsylvania, Wynnewood, Pennsylvania. Geraldine McGinty, MD, MBA, is from Weill Cornell Medical College, New York, New York. Mark J. Adams, MD, MBA, is from University of Rochester School of Medicine and Dentistry, Rochester, New York. Erika R. E. Denton, MD, is from University of East Anglia and Norfolk & Norwich University Hospital, Norfolk, United Kingdom. Richard Duszak Jr, is from Emory University, Atlanta, Georgia. Shigeru Ehara, MD, is from Iwate Medical University School of Medicine, Morioka, Japan. Bruce B. Forster, MSc, MD is from University of British Columbia, Vancouver, British Columbia, Canada. Howard Galloway, MD, is from Canberra Imaging Group, Canberra, Australia. Pamela Kassing, MPA, is from American College of Radiology, Reston, Virginia. Luis Martı´-Bonmatı´, MD, is from Universidad de Vale`ncia, Vale`ncia, Spain. Peter Mildenberger, MD, is from Mainz University, Mainz, Germany. Elisabeth Schouman-Claeys, MD, is from Hoˆpital Bichat, Paris, France. Frank J. Lexa, MD, MBA, Wharton School and the Drexel University College of Medicine, University of Pennsylvania, Wynnewood, Pennsylvania, 306 Gypsy Lane Wynnewood PA 19096, 215 762 8394; e-mail: [email protected].
