Socioeconomic Cynthia

H. Deitch,

PhD

Recruiting The 1991

Ronald

#{149}

G. Evens,

MD

Jonathan

H. Sunshine,

#{149}

R

ECENT studies

present

conflicting

how the supply of radiologists compares with the need. In a study that was published in the mid-1980s, the Graduate Medical Educalion National Advisory Committee (GMENAC) projected a massive surplus of more than 6,000 radiologists by 1990 (1). In contrast, one recent study from within the radiology community suggested that we entered the 1990s with a shortage of 5,000 radiologists and that the shortage would grow (2). To cast light on the surplus/shortage situation, the American College of

recruit

Radiology

smaller

ones.

Groups

filled 1,348 (71%) of these positions, while 552 positions remained unfilled, which was 2.8% of groups’ total staff. Remaining vacancies ranged from 5% of total staff in the Northeast and 3% in the Midwest to 2% in the South and 1% in the West. The percentage of positions filled was higher (76%) in nonmetropolitan areas than elsewhere. The authors conclude that the supply of radiologists is very close to balancing the number of positions available; the disparity is about 1/io of some numbers mentioned previously and is probably shrinkbig. Also, recruiting is not less suc-

cessful small

in nonmetropolitan cities

than

areas

and

estimates

gists,

Index terms: Radiology and radiologists Radiology and radiologists, departmental management #{149} Radiology and radiologists, socioeconomic issues

some

1

From

185:47-51

the Research

Department,

American

College of Radiology, 1891 Preston White Dr. Reston, VA 22091 (C.H.D.,J.H.S.); George Washington University, Washington, DC (C.H.D.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis (R.G.E.). Received May 6, 1992; accepted June 3. Address reprint requests to J.H.S. 0

RSNA,

1992

the

principal

pro-

practices

may experience

difficulty in recruiting than others. The second research question considered therefore is, for what types of positions and in what geo-

locations most

are unfilled

posi-

likely?

The interview included specific, factual questions about the number of radiologists in the group, the exact number of radiologists

the group

recruited

compare

actually

hired

with

the number

for, and

the

in the 1991 hiring season. Interviewers also elicited more subjective responses about decisions to recruit or not and reasons for not filling positions. To facilitate comparison with an earlier survey, the interview also induded the subjective question, “How does the number of radiologists . . . in your group number

that would

be ideal?” without requesting that the “ideal” figure meet any “reality test” such as actual recruiting activity. Both the quantitative and the qualitative data are discussed

in this

artide.

The ACR maintains a listing, which is updated on a continuing basis, of all radiologic practices in the United States. This data base was used to design the

sampling sample. tically

frame and to select the actual sample design ensured statisadequate representation of groups The

in each

of four

east, Midwest,

U.S.

census

South,

and

regions

West),

(North-

as well

MATERIALS and

AND Sampling

METHODS Methods

The research department of the ACR conducted a national sample telephone survey of radiology group practices in May and June of 1991. The interview focused on the 1991 hiring season-that is, hiring done of radiologists who would start their new positions in the summer of 1991. (Many of those hired completed training programs that ended June 30.) Whenever possible, the interviewer spoke directly to the president of the group. Established

telephone

ods were

employed.

survey

research

meth-

as

each of three different group sizes, based on number of radiologists in the group (two to four, five to seven, and eight or more). Within each of the 12 sampling strata (four regions with three size categories within each region), groups were selected randomly for telephone interviews. Only group practices were sampled; solo pracrices were omitted. The overall response rate was 78% . Attempts were made to contact 192 radiolrepresentation

within

each

region

of

ogy groups for telephone interviews. these, a total of 150 interviews were

Survey 1992;

(ACR),

greater

graphic

elsewhere.

of

fessional organization of radiologists in the United States, conducted a stratified national sample of radiology group practices, studying their actual recruitment and hiring experience in 1991. The survey was designed to evaluate two concerns. The first is whether, nationally, there is an adequate supply of radiologists to meet the recruitment needs of groups. Beyond this question of an overall nalional shortage or surplus of radiolo-

lions

Radiology

PhD

Radiologists: Hiring Survey’

Recent studies present widely varying views on the radiologist staffing situation, ranging from a projected surplus of over 6,000 radiologists to an estimated shortage of 5,000. To help clarify the situation, the Amencan College of Radiology undertook a stratified random sample survey of radiology groups’ recruitment efforts and hiring results in 1991. This survey of 192 groups achieved a 78% response rate. It found that half of all groups recruited, seeking to fill a nationwide total of 1,900 positions. Larger groups were more likely to than

Issues

Of

completed, with a minimum of 10 interviews in each of the 12 sampling strata. Only five of the 192 groups actually declined an interview (some asked to have the survey mailed instead). For most of the other 37 nonresponding groups, an appropriate person to interview was not reached despite

repeated

leave

messages.

call-backs

and

efforts

to

ACR = American College of Radiology, FFE = full-time equivalent, GMENAC = Graduate Medical Education National Advisory Committee, SE = standard error. Abbreviations:

47

The responses

and group

were

weighted,

by region

practices

size, to represent all group in the United States. The per-

centage weighted

tables in this report show the population estimates and thus

show figures sponses from States.

Table

1 Success

Radiologist-level

by Group

and Vacancy

No.

Variable

Variables

(weighted)

Central),

West. Metropolitan four categories:

population

South,

over

3 million,

is, with

100,000. Group ber of radiologists any 1991 hiring.

For type

area population

size

which their

55 60 82 88

(4)

4.9(1.8)

(4)

3.3 (1.5)

Over3milhion

512

500,000-3 million 100,000-499,999 Outside a metropolitan

721 901

area Group size (no. of radiolo-

492

ology

group,

office,

were

or nonteaching

Because “private

1.8 (1.1)

(3)

0.9(0.8)

70(4) 65 (4)

3.4(1.5) 2.5(1.3)

75 (4)

2.5(1.3)

76 (3)

2.9(1.4)

539 391

79 (3) 66 (4) 64 (4)

2.4(1.2) 3.6(1.5) 2.7(1.3)

445

71 (4)

2.6 (1.3)

2,264

71 (4) 70 (4)

2.7(1.3) 3.1 (1.4)

1,251

11 Type of group Private radiology All othei4

of the following best depractice: (a) primarily acaor teaching (b) government (city or hospital, Veterans Administration, military, etc); (c) radiologists part of a private multispecialty group; (d) private radital; and (e) other. groups answered

(3)

s)

under

interviewees

hospi-

* Success rate = no. of radiologists t Vacancy rate = (no. of radiologists Numbers in parentheses are SEs. t Includes academic, government,

Table 2 Group Level

86% of the radiology

362

Recruitment

hired/no.

recruited. Numbers no. hired)/(FTE

recruited and

and Hiring

and

other”

includes

(ii) all other

ment,

and

Data

Analysis

groups,

where

the academic,

multispecialty

recruited.

The

Percentage

“all

Variable

govern-

rate is the

of unfilled positions remaining cruiting was completed as a total need. The hiring success tal number of positions filled age of the number for which

100,000-499,999 Outside metropolitan

Group

number

1). Because estimates reports

in reporting

the results

(Table

the numbers

we present

are

based on a sample from every practice,

.05) if that difference square second

48

Radiology

48* 55*

52

79*

45

82*

63 47

70 53 69

50 40

76

size (no. of radiologists)

Type of group Private radiology All other

For the

which A

in interpreting the between two significant (P


of Groups

Region Northeast

as North

of

Recruitment

Hiring

as if we had obtained reall groups in the United

Total

known

Rates for 1991

Practices

the

plus

the

analysis

of group-level

data,

is shown

in Table 2, the dependent variables are (a) for all groups, whether or not the group recruited at all, and (b) for recruiting lions were

groups, ifiled.

whether

x2statistics

or not all posi-

(Table 3) of group-level data to assess which of the independent variables exammed (region, metropolitan area size, group size, and type of group) are statistically

significant

or not a recruiting

test the significance

are used to of differences between

categories

in Table

variables

of groups

We employ

logistic

regression

2.

analysis

tions cruited.

after

determinants

group

controlling

for all of the other

and the number Logistic

of whether

filled all posi-

regression

of positions

re-

is a standard

October

1992

Table

by metropolitan group size were

3

Factors

Affecting

Whether

Group

Recruiting Logistic

a

Parameter Variable Region:

Estimate

Northeast

west Area population Metropolitan million Metropolitan

and

Mid-1.29

(#{216}.54)*

and

(65%)

0.50 0.01

type: private radiology No. of radiologists recruited Intercept Note-Numbers * x2 significant

Of the

(0.91) (0.06)

groups,

50%

Another 35% (n just one position, (n = 260) recruited and about 5% (n

three

are SEs.

or more

percent

906)

=

groups

are

(whether

or not all positions

some

measured

independent

group

were

variables

as interval-level

data.

interval-level independent cluded number of positions

(The

variables recruited

inand

size.)

RESULTS Radiologist-level

Analysis

When the data across all groups, sents 17,527 (SE diologists

are aggregated the sample repre-

1,129) counting

with

and,

ra-

radiologists, an FTE of 18,007 (SE = 1,142) radiologists in a total

2,626

groups.

Overall,

these

of

groups

filled

the 1991 hiring rate (positions

as a percentage

as

rate (positions filled of positions recruited approximately 71% nation-

hiring

success

a percentage

for) was ally.

As shown

bers

varied

The

vacancy

in Table

1, these

substantially rate

was

num-

by region. highest

in the

Northeast (5%) and lowest in the West (1%). The hiring success rate was and

lowest highest

in the Northeast (55%) in the West (88%).

The differences in vacancy rates associated with other variables in Table 1-metropolitan area size, group size, and type of group-were not statistically significant. For the hiring success rate, some of the differences

Volume

185

Number

#{149}

1

silions

recruited

politan variate

area. The results analysis, conducted

two

regression,

or po-

the

that

filled

all positions

and

left with vacancies. that the percentage

actively

recruiting

Taof

in 1991

var-

ied slightly by region, size of metropolitan area, size of group practice, and type of group practice. tests indicate that only the differences in

x2

by group size were statissignificant (P < .01). In general, groups were more likely to re-

recruitment

lically larger

than

Table

smaller

groups.

2 also shows

of groups

that

ing succeeded openings.

were

percentage

actively

recruit-

in filling

At the

individual silions was South than

what

1991 hiring.

regression,

For region, observed

Northeast

and

and

the

South

Group groups

group

radiology

groups

fill all their

types ment,

were

positions

of groups

(academic,

or mullispecialty),

the

egory

were

other

govern70%

versus

Midwest

on

one

hand,

on the

other.

West

size

that

of community

are

this analysis with

499,999. The lion in opposed related cessful negative

of these categories from the equation,

convention with the most

consisted

is to omit the cases, which

data in Table the Northeast to the South to a reduced recruiting, as coefficient.

catin

of metropolitan of 100,000-

a population

3 show that locaand Midwest (as or West) was likelihood of sucindicated by the This difference

controlling ables listed.

significant (P < .05), for all of the other variOther variables were not

significant.

Thus,

was statistically

sion

in Table

sis, confirms Table

Subjective

logistic

regresanaly-

the univanate

finding

of

Questions

If a group

were the successful

indicated been

filled,

“What

main reasons in hiring?”

respondents, with unfilled swers

the

3, a multivariate

2.

asked

more

than

and

viewer

private likely to

the

the

not linear, we compared each metropolitan size category to all others.

level,

in fillsig-

we tested between

we observed

by

had

west. The differences by region ing all positions were statistically nificant (P < .05). “Ordinary,”

group

and

Because

silions

as at the

in

type is private radiology versus all others, as previously

all of their

level, success in filling p0higher in the West and in the Northeast or Mid-

are presented

logistic

areas

those groups ble 2 shows

of this multiby using

size was measured as FTE of practicing radiologists in the group prior to

differences

three more

might

3.

defined.

positions

in

for or size of metro-

one unfilled position, and 8% had more than one vacant slot. We sought to identify differences between groups that recruited cornpared with those that did no recruiting, and between the recruiting

un-

2.8% nationally.

posi-

by region

Technically, one must be omitted

cruit

the

of all positions)

was approximately The

season, remaining

differences

sitions recruited for, the more likely one or more positions would go unfilled. Among the 1,310 groups that did recruit, 66% successfully filled all their positions, 25% were left with

groups

reported recruiting to fill a total of 1,900 (SE = 197) openings in 1991. Of these 1,900 positions, 1,348 (SE = 168) were filled, leaving 552 (SE = 110) unfilled positions. After vacancy

for

one

in their to 49% of

is

in success

disappear (or become more salient) once we controlled for number of po-

differences

sought to fill Seventy-five

144)

groups

recruiting

groups

full-time part-time

=

10%

and 44% for groups seeking more radiologists. Thus, the

technique used for such an analysis, where there is a dichotomous dependent

for

for two positions, =

ample,

For

recruited

we addressed

differences

filling positions evident in the last column of Table 2 persisted after controlling for the other factors. For ex-

=

approximately

positions.

of the

(n

at all in 1991.

question

of the

Table

1,316) did no recruiting

0.18(0.75) -0.74(0.46) 2.38 (0.72)

in parentheses at P < .05.

2,626

next

which

logistic

Analysis

lion to fill were successful hiring efforts, compared

and

in areas

with a population of 500,000 to 3 mulion and highest (76%) in nonmetropolitan areas. It was higher (79%) for groups of two to four radiologists than for larger groups, for which it averaged approximately 67%.

Group-level

-0.54(0.68)

Group

filled)

suc-

0.40(0.74) area million

area size: FTE of group

variable

The

by

The

area over 3

500,000-3 Outside a metropolitan

Group

size

cess rate was lowest

Filled All Positions: Analysis

Regression

area

significant.

to this

that

not

the

inter-

do you

all po-

think

you weren’t Twenty-five

or 81 % of those groups positions, offered anopen-ended

question.

Although the small number of actual (unweighted) responses and the open-ended nature of the question make it difficult to generalize from the answers,

the

answers

nonetheless

are

differences area and

by size of metropolitan by size of group practice

of interest because they confirm some of the patterns evident from the more quantitative data and they suggest additional factors for future invesliga-

were

statistically

tion.

45%.

cal

This

difference significance (P

not

is close to statisti< .08). Observed

significant.

Radiology

#{149} 49

Most

of the answers contain a few themes. Thirty-six percent of those giving a reason cited location as a problem; 20% specified difficulty finding someone in a particular specialty; 20% mentioned that they had common

selective

very

criteria

or complained

to their

geographic

location

as

or only reason cited were located in the Northeast or Midwest regions. Of those groups in the South or West that mentioned location as a problem, one group in New Mexico cited “low academic performance” of candidates as the first reason mentioned and added location as a second reason; one group in Texas listed “poor location” as the third reason mentioned, after citing poor working conditions

and

heavy

workload.

None of the groups that mentioned location as a problem were located in the largest metropolitan areas, and none were in the smallest (nonmetropolitan) areas. Thus, the respondents’ perceptions of location as a problem appear fairly consistent with the geographic differences we found in the quantitative data analysis presented earlier. Some groups reported difficulties in finding candidates with the specific qualifications group desired,

and specialties while others

the

found new graduates looking for greater specialization than the group could offer. For example, one respondent indicated that the need for a general radiologist was the problem. Another suggested that the reason for not hiring was that the group performed mostly ultrasound phy, which was

and

mammogra-

limited for new grads.” One stated that it was hard to find a clinic radiologist because “the supply is limited and the money is low.” Another respondent offered that there were “not many candidates in neuroradiology.” Yet another reported that the group had been looking “for years” for an angiography/

interventional a shortage 50

#{149} Radiology

“too

specialist in that

specialty.

but found Other

wanting more exonly boardqualified candidates, and requiring a fellowship and subspecialization as their reasons for not ifiling positions. The question about ideal staffing drew

the poor qualifications of applicants; 20% indicated salary was a problem, including one who mentioned a low conversion factor; and 16% noted a less than full-fledged search-they started late or did not advertise except by word of mouth. In addition, 8% mentioned that a radiologist had been hired but backed out at the last minute. (Some groups cited more than one reason; therefore, the responses noted above total more than 100%.) All of the groups that mentioned experiencing difficulty attracting canabout

didates the first

groups perience,

mentioned considering

response

a

2,220 radiologists than groups had cruited

radiologists

showing

a wish

for

(SE = 242) more before newly rejoined them.

The

question

shortage

expect

or Balance?

Shortage,

of whether

of radiologists

there

is a

has important

for the medical commuthe public. Within the profession, it has implications for young physicians choosing a specialty, for residency programs, and for group practices, among others. The data presented herein indicate

implications nity and

that

the

approximate

supply

of radiologists

balance

with

is in

the number

of positions available. This conclusion of approximate balance is supported by a number of considerations. First, the number of unfilled posilions (approximately 550) was less than 3% of the total number of posilions, and the number of 550 is probably an overstatement. According to groups’ own reports, some of the recruitment efforts were started late or not pursued at full force. Also, on the other side of the ledger, there are likely to be some number of radiologists who would haved liked to obtain practice positions but were unable to find them. Relative to the surplus of approximately 6,000 radiologists that GMENAC predicted (1), or the 5,000-and-growing shortage that one radiologist reported (2), 550 is a small number. It is less that one-half of the annual number of newly minted radiologists emerging from residency

programs

(diagnostic

and

each year and about equal to the annual growth in the number of radiologists in the United States (3). A useful way of recognizing how small this number of 550 is is to note that 550 radiologists working full-lime are approximately equivalent to 1 hour of work a week of the radiologists currently in groups. In other words, if current radiologists worked 1 hour a week more (or just over 10 minutes a day) that would be equivalent to having approximately 500 more radiologists at work in the United States. Another indication of approximate overall balance is the fact that the vacancy rate varies widely by region. oncology)

throughout

the

United

States,

with

regional differences being relatively small. In other words, if there really were a substantial national surplus of radiologists, on the order of that projected by GMENAC, we would not

DISCUSSION Surplus,

The Northeast vacancy rate was nearly twice the national average, while the Western vacancy rate was only one-third of the national average. If a shortage or surplus were major, one might expect it to dominate

to find the shortfall

observed

in some regions. Conversely, if there really were a substantial shortage of radiologists of the magnitude some have suggested, we would not expect to find a vacancy rate of less than 1% in one major region of the country (the West). The 1991 ACR Hiring Survey offers some limited evidence that the supply of radiologists is increasingly meeting demand. In the ACR’s 1989 Group Practice Survey (4), radiology groups indicated that they would have liked 1,100 more radiologists than they had at that time. The Group Practice Survey’s question was similar to the question on the 1991 Hiring Survey about how many radiologists would be “ideal,” in that neither question was grounded in a reality test. (A standard

finding

on

surveys

is that

ungrounded questions about what respondents would like draw more expansive answers than questions based on real actions.) Comparing answers

to the

Hiring

Survey’s

ques-

lion about “ideal” staffing with its data on recruitment suggests approximately 870 would be the 1991 number that corresponds to the number of 1,100 from 1989. (For 1991, 870 equals the 2,220 “ideally” desired radiologists minus the 1,348 actual hires.) Thus,

relative

supply

seems

to demand

between

1989 and

noted, however, and time of year the two surveys,

improvement

to have

increased

by roughly

200

1991. It should that the questions were not identical and the apparent

might

be in

be a statistical

artifact.

In any case, one of us (R.G.E.) has pointed out that revenues available to radiology are likely to become considerably more constrained in future years (5). This may well decrease the demand for radiologists, with radiologists a!ready in practice choosing to work an hour (or more) longer each week-or to curtail their lime off-in order to keep their incomes up. As noted, only a minor increase in working hours would be needed to change the current apparent tiny shortfall of radiologists into a corresponding excess. October

1992

Reasons Positions

Why

Groups

Do

Not

Fifi

Although we do not find evidence of a substantial national shortage from the experience of radiology groups in 1991, we do observe some problems in the matching of available radiologists with groups seeking to fill positions.

In response

to an open-

ended question about why they were unable to fill all their positions, groups most frequently cited location. The quantitative data analyses support these open-ended responses in showing significant differences by region of the United States. On severa! different measures-percentage of positions filled, remaining vacancy rate, and percentage of recruiting groups that filled all positions-we found that recruiting was more successful in the South and West than in the Northeast and Midwest. This finding is counterintuitive. Radiologist training programs are concentrated in the Northeast and Midwest, so one would expect vacancies in these areas to be easiest to fill. Also, growth of the general population is most rapid in the South and West,

Volume

185

Number

#{149}

1

should make for a more rapidly growing need, more open posilions, and more remaining vacancies. Also counterintuitive is our finding of no empirical support for the conventional belief that nonmetropolitan areas have the most difficulty in obwhich

taming

radiologists.

Our

finding

nonetheless, is quite clear; no measures show above-average difficulties in obtaining radiologists in nonmetropolitan areas. Another possible source of difficulty in filling positions that the openended answers suggest is a mismatch

between qualifications hand, and

opportunities

the specialties, the

interests,

of applicants requirements

offered

imaging

and mammography are recent examples. How training programs could “turn on” and “turn off” rapidly enough to meet such short-lived peaks of hiring demand for specific subspecialties is difficult to foresee. These are questions for which further research might be of use. #{149} likely

ACR’s research

We thank William Chan, and Michael Mabry of the department for taking on the

extensive

of carrying

Acknowledgments: Pamela Kassing,

by the recruit-

groups on the other hand. We do not have enough data to assess the scope of this problem. To the extent the problem exists, it may reflect larger trends in the radiology profession such as growing subspecializalion, or a gap between the areas em-

1.

fellowship

in radiology

residency

or

programs and the needs of radiology group practices. Also, there may be large but short-lived surges of hiring demand for certain subspecialties as particular fields undergo growth spurts. Magnetic resonance

the

survey.

WillsJ,

Garrison

LPJr,

Evens

RG.

ply of requirements

for diagnostic

apeutic

Radiology

radiologists.

The

sup-

and ther1984;

151:9-

14. 2.

Brogden

equation:

ing

phasized

out

References

and

on one of and

work

BC.

a new

The radiology manpower look. AJR 1990; 154:1111-

1115. 3.

Sunshine

accurate review radiologists.

4.

5.

JH, Evens

RG, Chan

WC.

How

was GMENAC?: a retrospective of supply projections for diagnostic Radiology

1992;

182:365-368.

Sunshine fessional,

JH, Bansal S. Operational, proand business characteristics of radiology groups in the United States. Radiology 1992; 183:535-540. Evens RG. The impact of new payment systems on the specialty of radiology. Radiology 1992; 182:613-620.

Radiology

#{149} 51