Pediatr Radiol (1992) 22:331-336
Pediatric Radiology 9 Springer-Verlag 1992
Subspecialization in pediatric radiology M. D. Cohen 1, A. Daneman:, St. A. Royal 3, and J. A. Haggstrom 4 Department of Radiology, Riley Hospital for Children, Indianapolis, USA, 2Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada, 3Department of Pediatric Imaging, University of Alabama at Birmingham, Birmingham, USA 4Department of Radiology, Children's Memorial Hospital, Omaha, USA Received: 23 March 1992;accepted: 1 May 1992
Abstract. Within radiology there is an increasing trend towards specialization in North America [1]. Although some radiologists still consider themselves as generalists, every radiologist has eliminated some aspect of imaging from his repertoire [2]. Within some specialty areas of radiology further subspecialization is beginning to take place. This subspecialization is being affected by conflicting forces, some of which are pushing us towards increased subspecialization in our daily clinical work, while other forces are inhibiting such subspecialization.
This study was undertaken to determine the existing status of subspecialization within pediatric radiology and to seek the opinions of major pediatric radiology centers with regard to their philosophy, current status of subspecialization, and their solutions to problems of subspecialization.
Methods The Society of Chairman of Radiology in Children's Hospitals was formed 3 years ago. It represents all free standing children's hospitals in North America. A questionnaire (see appendix) was sent to all members of the Society. A total of 65 questionnaires were sent out. Thirty-six replies were received.
Results The average size of the hospitals replying to the questionnaire was 206 + 83 beds. Each hospital had a mean of 5.6 + 3.5 pediatric radiologists. The results of answers to the questionnaire are summarized in Tables 1-12.
containing the most subspecialization within pediatric radiology as a whole. The factors driving subspecialization are a desire to achieve parity of knowledge with clinicians, a response to the increased complexity of medical care (1), a desire to improve the quafity of care (2), a desire for better research opportunities, and expectations of increased pay, prestige and job gratification.
Current status of subspecialization Just over 2/3 of the departments have some subspecialization, and within these departments, it involves all members in 13 and some members in 12 (Table 1). Those departments with no subspecialization have a mean of 3.2 radiologists compared to a mean of 6.7 radiologists in those departments with subspecialization. Few services are covered by a subspecialist radiologist greater than 50 % of the time (Table 2). For none of the services listed in the table is subspecialized service provided for more than 50 % of the time in more than 12 pediatric hospitals (1/3 of the total number of hospitals).
Philosophical attitudes There is a strong opinion that some degree of subspecialization is desirable. Eighteen institutions want to increase their degree of subspecialization (Table 3). Of the 17 who want no change only 4 have no subspecialization at the
Table 1. Current status of subspecialization in 36 children's hospitals No. of departments
Discussion Pediatric radiology is considered a specialized area within radiology. For purposes of this study subspecialization within pediatric radiology was defined as "an individual spending more of his time in one particular area (by formal assignment) than in other areas of the department". This study is of the largest pediatric centers in North America with a mean size of 206 beds and a mean of 5.6 radiologists. It therefore probably represents the end of the spectrum
Complete subspecialization Some subspecialization No subspecialization Involves all department members Involves some department members Involves no department members Covers all clinical services Covers most clinical services Covers some clinical services Covers few clinical services Covers no clinical services
1 24 11 13 12 11 3 6 12 4 11
332 Table 2. Services covered by a subspecialized radiologist for greater
than 50 % of time (36 replies) Service Neurology Angio/interventional Nuclear medicine Ultrasound MRI CT Cardiovascular Reading room Intensive care Oncology
No. of departments 12 12 11 10 9 7 6 3 2 2
Table 3. Desired change in current status of subspecialization
Number of depa~-tments Would like to: Increase subspecialization 18 Not change subspecialization 17 Decrease subspecialization 1
Mean no. of radiologists in department
Obviously the world of subspeciatization is not a neat and tidy one. Pediatric radiologists m a y desire to subspecialize by clinical orientation and organ systems. However, the design and function of virtually all of our pediatric radiology departments does not follow this format. We are divided by ultrasound, CT, nuclear medicine, fluoroscopy, M R and general reading r o o m (plain film radiography) areas. Another difficulty is that subspecialization within clinical pediatrics is extremely complex and also not neat and tidy. Subspecialization occurs by organ system (eg. neuro, cardiovascular, respiratory, gastrointestinal, etc.), age (newborn), clinical service (eg. general surgery) or by pathology (eg. oncology, infectious diseases, etc.). Subspecialization may occur differently in the areas of routine clinical responsibility, clinical conferences, and research. T h e r e was a very strong feeling that the amount of Table 4. Perceived ideal % of total time A pediatric radiologists
should devote to an area of subspecialization 5.5• 5.6•
present time. The m a x i m u m benefits of subspecialization might be achieved through complete subspecialization. There is no desire to see this happening. Only i of 36 departments expressed a desire to see greater than 80 % of a pediatric radiologists time devoted to an area of subspecialization (Table 4). Many departments see the idealpercentage time devoted to a subspecialized area as less than 60 %. Reasons for this are the fact that subspecialization need not be 100 % to be successful, pediatric radiologists come from a strong background of total patient care, and there are inadequate numbers of pediatric radiologists to achieve complete subspecialization even if this were deemed desirable. Two of the leading areas of subspecialization are neuroradiology and nuclear medicine. One reason for this may be that some full time pediatric neuroradiologists and pediatric nuclear medicine doctors have entered pediatric radiology from a background of adult neuroradiology or adult nuclear medicine and that some of these individuals have not received formal training in pediatric radiology. These individuals would obviously be reluctant to assume more general responsibilities within a pediatric radiology department. With strong pediatric radiology fellowships covering all of these areas it is possible that neuroradiology and nuclear medicine may no longer remain as areas in which people function 100 % of their time as subspecialists. A mixed format for subspecialization is preferred (Table 5). There are 5 different options as to how subspecialization may be divided up within pediatric radiology (Table 6). There are some conflicting conclusions to be drawn from these results. While we believe that subspecialization should be orientated toward defined clinical areas we rate subspecialization in the area of neonatology extremely low (Table 6). We believe that subspecialization should be clinically orientated and this is reflected by the highest rating for the method of subspecialization to be by anatomical region (i. e. by organ system). However, we rate subspecialization by imaging technique virtually equally.
% of time 0 1-40 41 50 51-60 61-80 81-100 No answer
No. of departments 3 7 9 8 4 1 4
Table 5. Ideal format for subspecialization in ranked order
Method of subspecialization Mixed (partial in some areas and complete in other) Only partial in all areas Only complete or not at all
Mean ranked order + SD 1.4 + 0.5 1.6 + 0.5 2.9 -+0.16
Table 6. Idealmethodofsubspecializationinranked order
Method of subspecialization By anatomical region By imaging technique By clinical pathology (eg. oncology) By age of patient (eg. newborn) By clinical technique (eg. surgery, intensive care)
Mean ranked order +_SD 1.6 +_0.6 1.6 + 0.8 3.3 + 0.9 4.1 + 0.9 4.2 + 0.6
Table 7. Subspecialization in the 3 areas of clinical workload, clinical
conferences and research Can be varied in the above 3 areas Is desirable to vary it, in the above 3 areas
Yes 30 24
No 4 10
Table 8. Potentialbenefitsofsubspecializationinpediatricradiology
(Maximal score is 5 on scale of 1-5) More efficient use of radiologist's expertise Improved liaison with clinicians Better opportunities for research Improved job satisfaction Better use of radiologist's time
Mean + SD 4.3 + 1.2 4.3 _+1.2 4.3 + 1.1 3.8 + 1.0 2.9 + 1.4
333 Table 9. 12 potentialproblemsinhibitingsubspecializationinpediatric radiology (Maximal score is 5 on a scale of 1-5) Designing the system of subspecialization Cross coverage Less efficient utilization of staff Increased complexity of monthly rotation schedule Conflict between clinical orientation of subspecialization and department work areas Friction between radiologists Pediatric radiologists don't want it Chief of pediatric radiology doesn't want it Inadequate staff Increase departmental costs Increase space needs Clinicians don't desire it
Mean +_SD 4.3 _+1.0 4.2 _+1.2 3.9 + 1.3 3.6 + 1.1 3.5 + 1.5 3.3 + 1.2 3.2 _+1.2 2.8 _+1.6 2.8 + 1.6 2.5 _+1.3 2.3 + 1.3 2.1 +_1.2
Table 10. Ranking of the top 4 problems of the 12 potential problems inhibiting subspecialization in pediatric radiology Statement
No. of times Ranked Ranked 1st 2nd 9 9 8 5
Cross coverage Inadequate staff Conflict between clinical orientation and department work areas 4 Designing the system of subspecialization 2
Ranked 3rd 7 2
2
3
6
6
The advantages of subspecialization include an increased knowledge in one area. This enhances our communication with the subspecialized clinicians, improves patient care, teaching,job satisfaction, and research. More efficient use of the radiologists expertise was ranked as the best benefit of subspecialization (Table 8). Subspecialization may be inhibited by certain problems and may in itself result in problems (Tables 9, 10). One of the major issues with subspecialization is adequate coverage on the daily and nightly roster. This becomes extremely difficult if we do not retain as wide a clinical competence as possible while excelling at our chosen areas of subspecialization. Of even greater importance is the lack of communication between radiologists that may result from too great a degree of subspecialization. Subspecialists may try to keep all of the work that interests them to themselves and in this way manage to keep others out and thus decrease the scope of the clinical competence of the other radiologists. Subspecialization also brings with it potential friction between radiologists, each perceiving the other as doing less than himself. Subspecialization also results in less efficient utilization of staff. Additional staff may be required. This may contribute to a national manpower shortage in pediatric radiology [1] and decreased flexibility in utilization of staffcan potentially cause patient delays [1]. Lesser problems are difficulties in assigning staff. There is a tendency for people to prefer to do the high technology studies.
Economics
subspecialization can and should be varied within these 3 areas (Table 7). We need not be too depressed or frustrated by our inability to alter the structure of our departments (CT, fluoro, MR, ultrasound, etc.). In fact, it should be pointed out that these areas naturally fall into some degree of clinical subspecialization. For example, the radiologists spending more time in the reading room could relate to services such as intensive care, newborn, respiratory, and to some extent cardiovascular. A radiologist spending more than his share of time in CT might relate particularly to oncology or neurology, while a radiologist spending a predominant amount of time in ultrasound or fluoroscopy could relate to services such as urology or gastrointestinal. Nuclear medicine relates especially to oncology, urology and cardiology.
Advantages, disadvantagesand problems of subspecialization Advantages of a general (nonspecialized) practice radiology system are efficient use of manpower, a simplified salary structure, more potential research time and a simple call schedule. With many radiologists competent in all the specialty areas, peer review is enhanced and credentialing is easier. Internal turf battles regarding patients' work up and equipment purchase can be lessened, which can lead to an improved esprit de corp in the department.
Subspecialization may impact on departmental finances. Table 9 shows that this was not believed to be important as an increase in departmental costs was ranked 10th of 12 potential problems of subspecialization. However, the less efficient utilization of staff is ranked third and this can obviously increase departmental costs by requiring the appointment of additional radiologists. There is an overwhelming consensus that the salaries for subspecialized pediatric radiologists should not vary dependent on the area of subspecialization (Table 11). However, 31 of 36 heads of pediatric radiology departments did anticipate problems and they felt that subspecialization will result in some staff requesting differential payment.
Training Training for subspecialization in pediatric radiology is not formalized, with on the job self training being the most common method of acquiring subspecialty skills (Table 12). Of interest is that of the 4 possible methods of receiving subspecialty training in pediatric radiology, the least common (for existing personnel) was a formal fellowship in the subspeciatity area of pediatric radiology. In the adult area it has been suggested that organ orientated subspecialization could be improved by requiring all fellows to do a "major" in one particular area during their fellowship [2]. In order to achieve subspecialization appropriate fellowship programs need to be designed. An integrated fellowship program addressing all organ systems and mo-
334 Table 11. Compensation for subspecialized radiologists
Yes No Should vary by area of subspecialization 2 34 Will result in some staff requesting differential payment 31 5 Table 12. Methodoftrainingforsubspecialization (ofsubspecialized
radiologists in your department) in ranked order Mean ranked order _+SD Self training "on the job" "Mini" fellowship (2-3 months) Formal fellowship in an adult hospital Formal fellowship in a pediatric hospitaI
1.5 + 0.8 2.3 + 0.9 2.9 +_0.9 3.0 _+0.9
dalities lasting one year will be a d e q u a t e for most radiologists intent on practicing a m o r e generalized type of pediatric radiology. H o w e v e r , a second y e a r of a fellowship prog r a m could be used to e n h a n c e subspecialty interests, eg. cardiovascular, neuroradiology, interventional.
Conclusions Subspecialization is desired and is occurring within the large pediatric radiology d e p a r t m e n t s in N o r t h America. Subspecialization within Pediatric R a d i o l o g y enhances m a n y aspects of practice including service, teaching, research and c o m m u n i c a t i o n with clinicians. T h e r e is no desire within the pediatric radiology departments for c o m p l e t e subspecialization. T h e m a j o r factor for this feeling is p r o b a b l y that even if it were desired, there would be i n a d e q u a t e staff in almost all d e p a r t m e n t s to achieve it. Questions are raised as to the appropriateness of the direction of subspecialization. While professing a desire for a clinically orientated organ subspecialization system (which is m o s t desirable), the system is being driven by dep a r t m e n t structure orientated a r o u n d techniques. This technique orientated d e p a r t m e n t structure is p r o b a b l y impossible to change but a d e q u a t e clinical orientation can p r o b a b l y still be achieved by a m o r e clinically focused conference and research element to subspecialization. F u t u r e subspecialists should be trained first in general pediatric radiology. Subspecialization within pediatric radiology requires compromises, tradeoff and flexibility. T h e r e is no universally applicable solution or f o r m u l a and the wide variety and size of pediatric radiology d e p a r t m e n t s will require a wide variety of different patterns of subspecialization. A l t h o u g h subspecialization is easier in large departments, no d e p a r t m e n t is too small to start developh~g subspecialization.
3. Forman HR Leonidas JC, Kirks DR (1990) Clinical activities of pediatric radiologists in the United States and Canada: 10-year follow-up. Radiology 175:127 Dr. M. D. Cohen Department of Radiology Riley Hospital for Children 702 Barnhill Drive Indianapolis, IN 46202-5200 USA
Appendix:
Subspecialization
in pediatric
radiology
Background This questionnaire was initiated because of my belief that all of us face conflicting forces, some of which are pushingus toward increased subspecialization in our daily clinical work, while others are inhibiting such subspecialization. I appreciate your willingness to participate in the survey. My hope is to get a better understanding of those factors that are driving and inhibiting subspecialization so that we can help each other by sharing philosophy, thoughts and solutions. I will dwell solely with the issue as it pertains to our daily clinical practice. I will not touch on the more esoteric issues such as subspeciality certification, etc.
Basic information Name of your institution Name of person completing this questionnaire Number of pediatric beds Number of full time equivalent pediatric radiologists
Philosophy Assuming that you can overcome the problems involved would you like to: -a. Increase the degree of subspecialization in your department --
b. Not change the degree of subspecialization in your department --c. Decreasethedegreeofsubspecializationinyourdepartment In your ideal world, how far should a pediatric radiologist subspecialize? What percentage of total time should each pediatric radiologist devote to their area of subspecialized interest? -100% - 50% 80% 60%
--
40% 0%
How should subspecialization be achieved in the Pediatric Radiology Department? Please score the following statements (rank in order from l-5, with i being the most important). - - - By anatomical area (eg. neuro, cardiovascular, genitourinary, gastrointestinal) --
By age (eg. newborn)
--
By imaging technique (eg. CT, ultrasound, MR, nuclear medicine, interventional)
References
--
By clinical pathology (eg. oncology)
1. Thrall JH, Wittenberg J (1991) Radiology summit 1990: specialization in radiology-trends, implications, and recommendations. A JR 156:1273 2. Forrest JV (1991) Generalists vs specialists: timeto decide. A JR56: 1277
- - By clinical technique (eg. general surgery, intensive care) Please score the following statements (rank in order from 1-3, with 1 being the most important). - - - Subspecialization within pediatric radiology should be an all or none phenomenon
335 --
Subspecialization in pediatric radiology can be partial
GU
Subspecialization in pediatricradiology can be a mixture of the above (eg. complete in some areas, but partial in others)
-
Current status of your department What is the status of subspecialization in your pediatric radiology department: (please check) -
-
-
-
-
-
All members
--
Problems The following is a list of statements which could be considered as problems inhibiting subspecialization in pediatric radiology. For each statement please score on a scale of 1-5.1 signifies that you feelit is of little or no importance. 5 signifies that you feel it is of extreme importance.
Some members
Does subspecialization in your department cover:
-
-
-
-
I
No subspecialization
--
-
Orthopedics GI Endocrine Oncology Infectious disease
Complete subspecialization Some subspecialization
Does subspecialization in your department involve:
-
General radiography --Fluoroscopy MRI
1 2 3 4 5 A. Pediatric radiology staff do not want subspecialization
All of the clinical services Most of the clinical services
1 2 3 4 5 B. Chiefofpediatricradiologydoesnotwantsubspecialization
Some of the clinical services
--
Only a few clinical services
1 2 3 4 5 C. Clinicians do not want subspecialization in pediatric radiology
Please list the percentage of time that each of the following areas is covered by a pediatric radiologist with a professed and acknowledged subspecialty interest in the particular area (i. e., a radiologist spends more than a proportionate share of his total time in this area).
1 2 3 4 5 D. Subspecialization is inhibited by problems with cross coverage
Neurology - - CT C a r d i o v a s c u l a r - - U/S Chest - - Angio/ interventional Intensivecare - - Nuclearmedicine - Newborn - - Reading room
1 2 3 4 5E
1 2 3 4 5 E. There are major problems in dividing the work and whatever system is utilized causes overlap and gaps (subspecialization may be by organ system, patient age, machine, patient pathology) There are problems with cross coverage (eg. due to vacations or for call schedules)
1 2 3 4 5 G. Subspecialization results in a less efficient utilization of staff
% of total clinical time that each radiologist spends in each area Radiologist
1
2
3
4
5
6
7
8
9
10
Neurology Cardiovasc Chest Intens Care Newborn GU Orthopedics GI Endocrine Oncology Infect Dis CT Angio/Interv Nuclear Med Gen Read Rm Ultrasound MRI Fluoroscopy Other In answering this question please put percentages for which each radiologist is actually formally assigned to each area. I have included both anato mical and machine orientated assignments to cope with variations between departments as to how assignments are made. Please choose the most appropriate from the above list to fit in with your own department's structure and organization.
336 12345H.
1 2 3 4 5 I.
1 2 3 4 5 J.
You do not have adequate numbers of staffto achieve subspecialization. Partial subspecialization is undesirable and one should not attempt it unless complete subspecialization can be achieved
Subspecialization might be broken down into three areas which are clinical work load, clinical meetings, and research.
The monthly rotation schedule for the pediatric radiologists becomes more complex with subspecialization You want to orientate subspecialization to clinicians but your daily department rotation is orientated by department work areas (CT. ultrasound, angio, fluoroscopy, reading room, nuclear medicine)
Yes/no
Do you think it is possible to vary the subspecialization within these three areas (eg. a radiologist may take an even rotation in the clinical workload of the department, be primarily responsible for one clinical meeting, and have research interest clearly defined in only one subspecialized area)?
Yes/no
Do you think it desirable that subspeciatization be equal in each of the above three categories?
1 2 3 4 5 K. Subspecialization would require more space which you do not have (eg. more reading areas might be required)
Clinical conferences
1 2 3 4 5 L.
Please list the clinical services for which you have regularly formal scheduled dailyconferences.
Subspecializationwillincrease department costs
1 2 3 4 5 M. Subspecialization is a potentialsource of department friction as each radiologist may perceive him/herself as doing more work than the others
Please list the clinical services for which you have regularly scheduled weeklyconferences.
Of all the above potential problems of subspecialization pleaselist the three most important in rank order.
Please list the clinical services for which you have daily regularly scheduled monthlyconferences.
Benefits Please score the following benefits of subspecialization on a score of 1-5.
Yes/no
Do you think that increased subspecialization in your department would result in increased clinical conferences?
Yes/no
Would this be desirable?
12345
How important is conference continuity (i. e., the same radiologist conducting the conference each day)? (1 = not important, 5 = extremely important)
Yes/no
Do you think increasing subspecialization will improve conference continuity?
1 2 3 4 5 A. Subspecializationresultsinamoreefficientuseofradiologists time 1 2 3 4 5 B. Subspecializationresultsinamoreefficientuseofradiologists expertise
Monthly schedule
1 2 3 4 5 C. Improvedliaisonwithclinicians 1 2 3 4 5 D. Improved personalsatisfaction for each radiologist
These questions attempt to get information about your radiology schedule. (please check)
1 2 3 4 5 E.
Betteroppormnitiesforresearch
Is your monthly schedule always done by one person or do your rotate it on a regular basis?
Please list any additional disadvantages of subspecialization in pediatric radiology.
Same person ---
Rotated
- - - - Is the monthly schedule: Please list any other benefits of subspecialization within pediatric radiology.
-
-
--
-
Stable from month to month Varies slightly from month to month Varies greatly from month to month
Does in creasing subspedalization add to the corn plexity of your rotation schedule?
Miscellaneous
--
Within a subspecialized department compensation for pediatric radiologists should vary depending on the subspecialty interest.
-
--
-
-
-
-
Subspecialization within pediatric radiology may result in some radiologists requesting differential payment.
-
-
-
-
-
-
-
-
No effect Decreases complexity of monthly scheduling
In preparing your monthly schedule do you:
Agree/disagree
Agree/disagree Of those individuals in your department with a subspecialty interest, how was the subspecialty training achieved (please rank from 1 4 reflecting the most common method of training). Self training on the job
Increases complexity
Attempt to build in all time away (vacation, meetings, etc.) up front Do the schedule first and then permit informal coverage to evolve as it is determined that people are away
Definitions
Mini fellowship (eg. 2-3 months) Formal fellowship in the area of interest in a pediatric hospital Formal fellowship in the area of interest in an adult hospital
For purposes of this questionnaire subspecialization is defined as an individual spending more of his time in one particular area (by formal assignment) than in other areas of the department.
Pediatric Radiology 9 Springer-Verlag 1992
Subspecialization in pediatric radiology M. D. Cohen 1, A. Daneman:, St. A. Royal 3, and J. A. Haggstrom 4 Department of Radiology, Riley Hospital for Children, Indianapolis, USA, 2Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada, 3Department of Pediatric Imaging, University of Alabama at Birmingham, Birmingham, USA 4Department of Radiology, Children's Memorial Hospital, Omaha, USA Received: 23 March 1992;accepted: 1 May 1992
Abstract. Within radiology there is an increasing trend towards specialization in North America [1]. Although some radiologists still consider themselves as generalists, every radiologist has eliminated some aspect of imaging from his repertoire [2]. Within some specialty areas of radiology further subspecialization is beginning to take place. This subspecialization is being affected by conflicting forces, some of which are pushing us towards increased subspecialization in our daily clinical work, while other forces are inhibiting such subspecialization.
This study was undertaken to determine the existing status of subspecialization within pediatric radiology and to seek the opinions of major pediatric radiology centers with regard to their philosophy, current status of subspecialization, and their solutions to problems of subspecialization.
Methods The Society of Chairman of Radiology in Children's Hospitals was formed 3 years ago. It represents all free standing children's hospitals in North America. A questionnaire (see appendix) was sent to all members of the Society. A total of 65 questionnaires were sent out. Thirty-six replies were received.
Results The average size of the hospitals replying to the questionnaire was 206 + 83 beds. Each hospital had a mean of 5.6 + 3.5 pediatric radiologists. The results of answers to the questionnaire are summarized in Tables 1-12.
containing the most subspecialization within pediatric radiology as a whole. The factors driving subspecialization are a desire to achieve parity of knowledge with clinicians, a response to the increased complexity of medical care (1), a desire to improve the quafity of care (2), a desire for better research opportunities, and expectations of increased pay, prestige and job gratification.
Current status of subspecialization Just over 2/3 of the departments have some subspecialization, and within these departments, it involves all members in 13 and some members in 12 (Table 1). Those departments with no subspecialization have a mean of 3.2 radiologists compared to a mean of 6.7 radiologists in those departments with subspecialization. Few services are covered by a subspecialist radiologist greater than 50 % of the time (Table 2). For none of the services listed in the table is subspecialized service provided for more than 50 % of the time in more than 12 pediatric hospitals (1/3 of the total number of hospitals).
Philosophical attitudes There is a strong opinion that some degree of subspecialization is desirable. Eighteen institutions want to increase their degree of subspecialization (Table 3). Of the 17 who want no change only 4 have no subspecialization at the
Table 1. Current status of subspecialization in 36 children's hospitals No. of departments
Discussion Pediatric radiology is considered a specialized area within radiology. For purposes of this study subspecialization within pediatric radiology was defined as "an individual spending more of his time in one particular area (by formal assignment) than in other areas of the department". This study is of the largest pediatric centers in North America with a mean size of 206 beds and a mean of 5.6 radiologists. It therefore probably represents the end of the spectrum
Complete subspecialization Some subspecialization No subspecialization Involves all department members Involves some department members Involves no department members Covers all clinical services Covers most clinical services Covers some clinical services Covers few clinical services Covers no clinical services
1 24 11 13 12 11 3 6 12 4 11
332 Table 2. Services covered by a subspecialized radiologist for greater
than 50 % of time (36 replies) Service Neurology Angio/interventional Nuclear medicine Ultrasound MRI CT Cardiovascular Reading room Intensive care Oncology
No. of departments 12 12 11 10 9 7 6 3 2 2
Table 3. Desired change in current status of subspecialization
Number of depa~-tments Would like to: Increase subspecialization 18 Not change subspecialization 17 Decrease subspecialization 1
Mean no. of radiologists in department
Obviously the world of subspeciatization is not a neat and tidy one. Pediatric radiologists m a y desire to subspecialize by clinical orientation and organ systems. However, the design and function of virtually all of our pediatric radiology departments does not follow this format. We are divided by ultrasound, CT, nuclear medicine, fluoroscopy, M R and general reading r o o m (plain film radiography) areas. Another difficulty is that subspecialization within clinical pediatrics is extremely complex and also not neat and tidy. Subspecialization occurs by organ system (eg. neuro, cardiovascular, respiratory, gastrointestinal, etc.), age (newborn), clinical service (eg. general surgery) or by pathology (eg. oncology, infectious diseases, etc.). Subspecialization may occur differently in the areas of routine clinical responsibility, clinical conferences, and research. T h e r e was a very strong feeling that the amount of Table 4. Perceived ideal % of total time A pediatric radiologists
should devote to an area of subspecialization 5.5• 5.6•
present time. The m a x i m u m benefits of subspecialization might be achieved through complete subspecialization. There is no desire to see this happening. Only i of 36 departments expressed a desire to see greater than 80 % of a pediatric radiologists time devoted to an area of subspecialization (Table 4). Many departments see the idealpercentage time devoted to a subspecialized area as less than 60 %. Reasons for this are the fact that subspecialization need not be 100 % to be successful, pediatric radiologists come from a strong background of total patient care, and there are inadequate numbers of pediatric radiologists to achieve complete subspecialization even if this were deemed desirable. Two of the leading areas of subspecialization are neuroradiology and nuclear medicine. One reason for this may be that some full time pediatric neuroradiologists and pediatric nuclear medicine doctors have entered pediatric radiology from a background of adult neuroradiology or adult nuclear medicine and that some of these individuals have not received formal training in pediatric radiology. These individuals would obviously be reluctant to assume more general responsibilities within a pediatric radiology department. With strong pediatric radiology fellowships covering all of these areas it is possible that neuroradiology and nuclear medicine may no longer remain as areas in which people function 100 % of their time as subspecialists. A mixed format for subspecialization is preferred (Table 5). There are 5 different options as to how subspecialization may be divided up within pediatric radiology (Table 6). There are some conflicting conclusions to be drawn from these results. While we believe that subspecialization should be orientated toward defined clinical areas we rate subspecialization in the area of neonatology extremely low (Table 6). We believe that subspecialization should be clinically orientated and this is reflected by the highest rating for the method of subspecialization to be by anatomical region (i. e. by organ system). However, we rate subspecialization by imaging technique virtually equally.
% of time 0 1-40 41 50 51-60 61-80 81-100 No answer
No. of departments 3 7 9 8 4 1 4
Table 5. Ideal format for subspecialization in ranked order
Method of subspecialization Mixed (partial in some areas and complete in other) Only partial in all areas Only complete or not at all
Mean ranked order + SD 1.4 + 0.5 1.6 + 0.5 2.9 -+0.16
Table 6. Idealmethodofsubspecializationinranked order
Method of subspecialization By anatomical region By imaging technique By clinical pathology (eg. oncology) By age of patient (eg. newborn) By clinical technique (eg. surgery, intensive care)
Mean ranked order +_SD 1.6 +_0.6 1.6 + 0.8 3.3 + 0.9 4.1 + 0.9 4.2 + 0.6
Table 7. Subspecialization in the 3 areas of clinical workload, clinical
conferences and research Can be varied in the above 3 areas Is desirable to vary it, in the above 3 areas
Yes 30 24
No 4 10
Table 8. Potentialbenefitsofsubspecializationinpediatricradiology
(Maximal score is 5 on scale of 1-5) More efficient use of radiologist's expertise Improved liaison with clinicians Better opportunities for research Improved job satisfaction Better use of radiologist's time
Mean + SD 4.3 + 1.2 4.3 _+1.2 4.3 + 1.1 3.8 + 1.0 2.9 + 1.4
333 Table 9. 12 potentialproblemsinhibitingsubspecializationinpediatric radiology (Maximal score is 5 on a scale of 1-5) Designing the system of subspecialization Cross coverage Less efficient utilization of staff Increased complexity of monthly rotation schedule Conflict between clinical orientation of subspecialization and department work areas Friction between radiologists Pediatric radiologists don't want it Chief of pediatric radiology doesn't want it Inadequate staff Increase departmental costs Increase space needs Clinicians don't desire it
Mean +_SD 4.3 _+1.0 4.2 _+1.2 3.9 + 1.3 3.6 + 1.1 3.5 + 1.5 3.3 + 1.2 3.2 _+1.2 2.8 _+1.6 2.8 + 1.6 2.5 _+1.3 2.3 + 1.3 2.1 +_1.2
Table 10. Ranking of the top 4 problems of the 12 potential problems inhibiting subspecialization in pediatric radiology Statement
No. of times Ranked Ranked 1st 2nd 9 9 8 5
Cross coverage Inadequate staff Conflict between clinical orientation and department work areas 4 Designing the system of subspecialization 2
Ranked 3rd 7 2
2
3
6
6
The advantages of subspecialization include an increased knowledge in one area. This enhances our communication with the subspecialized clinicians, improves patient care, teaching,job satisfaction, and research. More efficient use of the radiologists expertise was ranked as the best benefit of subspecialization (Table 8). Subspecialization may be inhibited by certain problems and may in itself result in problems (Tables 9, 10). One of the major issues with subspecialization is adequate coverage on the daily and nightly roster. This becomes extremely difficult if we do not retain as wide a clinical competence as possible while excelling at our chosen areas of subspecialization. Of even greater importance is the lack of communication between radiologists that may result from too great a degree of subspecialization. Subspecialists may try to keep all of the work that interests them to themselves and in this way manage to keep others out and thus decrease the scope of the clinical competence of the other radiologists. Subspecialization also brings with it potential friction between radiologists, each perceiving the other as doing less than himself. Subspecialization also results in less efficient utilization of staff. Additional staff may be required. This may contribute to a national manpower shortage in pediatric radiology [1] and decreased flexibility in utilization of staffcan potentially cause patient delays [1]. Lesser problems are difficulties in assigning staff. There is a tendency for people to prefer to do the high technology studies.
Economics
subspecialization can and should be varied within these 3 areas (Table 7). We need not be too depressed or frustrated by our inability to alter the structure of our departments (CT, fluoro, MR, ultrasound, etc.). In fact, it should be pointed out that these areas naturally fall into some degree of clinical subspecialization. For example, the radiologists spending more time in the reading room could relate to services such as intensive care, newborn, respiratory, and to some extent cardiovascular. A radiologist spending more than his share of time in CT might relate particularly to oncology or neurology, while a radiologist spending a predominant amount of time in ultrasound or fluoroscopy could relate to services such as urology or gastrointestinal. Nuclear medicine relates especially to oncology, urology and cardiology.
Advantages, disadvantagesand problems of subspecialization Advantages of a general (nonspecialized) practice radiology system are efficient use of manpower, a simplified salary structure, more potential research time and a simple call schedule. With many radiologists competent in all the specialty areas, peer review is enhanced and credentialing is easier. Internal turf battles regarding patients' work up and equipment purchase can be lessened, which can lead to an improved esprit de corp in the department.
Subspecialization may impact on departmental finances. Table 9 shows that this was not believed to be important as an increase in departmental costs was ranked 10th of 12 potential problems of subspecialization. However, the less efficient utilization of staff is ranked third and this can obviously increase departmental costs by requiring the appointment of additional radiologists. There is an overwhelming consensus that the salaries for subspecialized pediatric radiologists should not vary dependent on the area of subspecialization (Table 11). However, 31 of 36 heads of pediatric radiology departments did anticipate problems and they felt that subspecialization will result in some staff requesting differential payment.
Training Training for subspecialization in pediatric radiology is not formalized, with on the job self training being the most common method of acquiring subspecialty skills (Table 12). Of interest is that of the 4 possible methods of receiving subspecialty training in pediatric radiology, the least common (for existing personnel) was a formal fellowship in the subspeciatity area of pediatric radiology. In the adult area it has been suggested that organ orientated subspecialization could be improved by requiring all fellows to do a "major" in one particular area during their fellowship [2]. In order to achieve subspecialization appropriate fellowship programs need to be designed. An integrated fellowship program addressing all organ systems and mo-
334 Table 11. Compensation for subspecialized radiologists
Yes No Should vary by area of subspecialization 2 34 Will result in some staff requesting differential payment 31 5 Table 12. Methodoftrainingforsubspecialization (ofsubspecialized
radiologists in your department) in ranked order Mean ranked order _+SD Self training "on the job" "Mini" fellowship (2-3 months) Formal fellowship in an adult hospital Formal fellowship in a pediatric hospitaI
1.5 + 0.8 2.3 + 0.9 2.9 +_0.9 3.0 _+0.9
dalities lasting one year will be a d e q u a t e for most radiologists intent on practicing a m o r e generalized type of pediatric radiology. H o w e v e r , a second y e a r of a fellowship prog r a m could be used to e n h a n c e subspecialty interests, eg. cardiovascular, neuroradiology, interventional.
Conclusions Subspecialization is desired and is occurring within the large pediatric radiology d e p a r t m e n t s in N o r t h America. Subspecialization within Pediatric R a d i o l o g y enhances m a n y aspects of practice including service, teaching, research and c o m m u n i c a t i o n with clinicians. T h e r e is no desire within the pediatric radiology departments for c o m p l e t e subspecialization. T h e m a j o r factor for this feeling is p r o b a b l y that even if it were desired, there would be i n a d e q u a t e staff in almost all d e p a r t m e n t s to achieve it. Questions are raised as to the appropriateness of the direction of subspecialization. While professing a desire for a clinically orientated organ subspecialization system (which is m o s t desirable), the system is being driven by dep a r t m e n t structure orientated a r o u n d techniques. This technique orientated d e p a r t m e n t structure is p r o b a b l y impossible to change but a d e q u a t e clinical orientation can p r o b a b l y still be achieved by a m o r e clinically focused conference and research element to subspecialization. F u t u r e subspecialists should be trained first in general pediatric radiology. Subspecialization within pediatric radiology requires compromises, tradeoff and flexibility. T h e r e is no universally applicable solution or f o r m u l a and the wide variety and size of pediatric radiology d e p a r t m e n t s will require a wide variety of different patterns of subspecialization. A l t h o u g h subspecialization is easier in large departments, no d e p a r t m e n t is too small to start developh~g subspecialization.
3. Forman HR Leonidas JC, Kirks DR (1990) Clinical activities of pediatric radiologists in the United States and Canada: 10-year follow-up. Radiology 175:127 Dr. M. D. Cohen Department of Radiology Riley Hospital for Children 702 Barnhill Drive Indianapolis, IN 46202-5200 USA
Appendix:
Subspecialization
in pediatric
radiology
Background This questionnaire was initiated because of my belief that all of us face conflicting forces, some of which are pushingus toward increased subspecialization in our daily clinical work, while others are inhibiting such subspecialization. I appreciate your willingness to participate in the survey. My hope is to get a better understanding of those factors that are driving and inhibiting subspecialization so that we can help each other by sharing philosophy, thoughts and solutions. I will dwell solely with the issue as it pertains to our daily clinical practice. I will not touch on the more esoteric issues such as subspeciality certification, etc.
Basic information Name of your institution Name of person completing this questionnaire Number of pediatric beds Number of full time equivalent pediatric radiologists
Philosophy Assuming that you can overcome the problems involved would you like to: -a. Increase the degree of subspecialization in your department --
b. Not change the degree of subspecialization in your department --c. Decreasethedegreeofsubspecializationinyourdepartment In your ideal world, how far should a pediatric radiologist subspecialize? What percentage of total time should each pediatric radiologist devote to their area of subspecialized interest? -100% - 50% 80% 60%
--
40% 0%
How should subspecialization be achieved in the Pediatric Radiology Department? Please score the following statements (rank in order from l-5, with i being the most important). - - - By anatomical area (eg. neuro, cardiovascular, genitourinary, gastrointestinal) --
By age (eg. newborn)
--
By imaging technique (eg. CT, ultrasound, MR, nuclear medicine, interventional)
References
--
By clinical pathology (eg. oncology)
1. Thrall JH, Wittenberg J (1991) Radiology summit 1990: specialization in radiology-trends, implications, and recommendations. A JR 156:1273 2. Forrest JV (1991) Generalists vs specialists: timeto decide. A JR56: 1277
- - By clinical technique (eg. general surgery, intensive care) Please score the following statements (rank in order from 1-3, with 1 being the most important). - - - Subspecialization within pediatric radiology should be an all or none phenomenon
335 --
Subspecialization in pediatric radiology can be partial
GU
Subspecialization in pediatricradiology can be a mixture of the above (eg. complete in some areas, but partial in others)
-
Current status of your department What is the status of subspecialization in your pediatric radiology department: (please check) -
-
-
-
-
-
All members
--
Problems The following is a list of statements which could be considered as problems inhibiting subspecialization in pediatric radiology. For each statement please score on a scale of 1-5.1 signifies that you feelit is of little or no importance. 5 signifies that you feel it is of extreme importance.
Some members
Does subspecialization in your department cover:
-
-
-
-
I
No subspecialization
--
-
Orthopedics GI Endocrine Oncology Infectious disease
Complete subspecialization Some subspecialization
Does subspecialization in your department involve:
-
General radiography --Fluoroscopy MRI
1 2 3 4 5 A. Pediatric radiology staff do not want subspecialization
All of the clinical services Most of the clinical services
1 2 3 4 5 B. Chiefofpediatricradiologydoesnotwantsubspecialization
Some of the clinical services
--
Only a few clinical services
1 2 3 4 5 C. Clinicians do not want subspecialization in pediatric radiology
Please list the percentage of time that each of the following areas is covered by a pediatric radiologist with a professed and acknowledged subspecialty interest in the particular area (i. e., a radiologist spends more than a proportionate share of his total time in this area).
1 2 3 4 5 D. Subspecialization is inhibited by problems with cross coverage
Neurology - - CT C a r d i o v a s c u l a r - - U/S Chest - - Angio/ interventional Intensivecare - - Nuclearmedicine - Newborn - - Reading room
1 2 3 4 5E
1 2 3 4 5 E. There are major problems in dividing the work and whatever system is utilized causes overlap and gaps (subspecialization may be by organ system, patient age, machine, patient pathology) There are problems with cross coverage (eg. due to vacations or for call schedules)
1 2 3 4 5 G. Subspecialization results in a less efficient utilization of staff
% of total clinical time that each radiologist spends in each area Radiologist
1
2
3
4
5
6
7
8
9
10
Neurology Cardiovasc Chest Intens Care Newborn GU Orthopedics GI Endocrine Oncology Infect Dis CT Angio/Interv Nuclear Med Gen Read Rm Ultrasound MRI Fluoroscopy Other In answering this question please put percentages for which each radiologist is actually formally assigned to each area. I have included both anato mical and machine orientated assignments to cope with variations between departments as to how assignments are made. Please choose the most appropriate from the above list to fit in with your own department's structure and organization.
336 12345H.
1 2 3 4 5 I.
1 2 3 4 5 J.
You do not have adequate numbers of staffto achieve subspecialization. Partial subspecialization is undesirable and one should not attempt it unless complete subspecialization can be achieved
Subspecialization might be broken down into three areas which are clinical work load, clinical meetings, and research.
The monthly rotation schedule for the pediatric radiologists becomes more complex with subspecialization You want to orientate subspecialization to clinicians but your daily department rotation is orientated by department work areas (CT. ultrasound, angio, fluoroscopy, reading room, nuclear medicine)
Yes/no
Do you think it is possible to vary the subspecialization within these three areas (eg. a radiologist may take an even rotation in the clinical workload of the department, be primarily responsible for one clinical meeting, and have research interest clearly defined in only one subspecialized area)?
Yes/no
Do you think it desirable that subspeciatization be equal in each of the above three categories?
1 2 3 4 5 K. Subspecialization would require more space which you do not have (eg. more reading areas might be required)
Clinical conferences
1 2 3 4 5 L.
Please list the clinical services for which you have regularly formal scheduled dailyconferences.
Subspecializationwillincrease department costs
1 2 3 4 5 M. Subspecialization is a potentialsource of department friction as each radiologist may perceive him/herself as doing more work than the others
Please list the clinical services for which you have regularly scheduled weeklyconferences.
Of all the above potential problems of subspecialization pleaselist the three most important in rank order.
Please list the clinical services for which you have daily regularly scheduled monthlyconferences.
Benefits Please score the following benefits of subspecialization on a score of 1-5.
Yes/no
Do you think that increased subspecialization in your department would result in increased clinical conferences?
Yes/no
Would this be desirable?
12345
How important is conference continuity (i. e., the same radiologist conducting the conference each day)? (1 = not important, 5 = extremely important)
Yes/no
Do you think increasing subspecialization will improve conference continuity?
1 2 3 4 5 A. Subspecializationresultsinamoreefficientuseofradiologists time 1 2 3 4 5 B. Subspecializationresultsinamoreefficientuseofradiologists expertise
Monthly schedule
1 2 3 4 5 C. Improvedliaisonwithclinicians 1 2 3 4 5 D. Improved personalsatisfaction for each radiologist
These questions attempt to get information about your radiology schedule. (please check)
1 2 3 4 5 E.
Betteroppormnitiesforresearch
Is your monthly schedule always done by one person or do your rotate it on a regular basis?
Please list any additional disadvantages of subspecialization in pediatric radiology.
Same person ---
Rotated
- - - - Is the monthly schedule: Please list any other benefits of subspecialization within pediatric radiology.
-
-
--
-
Stable from month to month Varies slightly from month to month Varies greatly from month to month
Does in creasing subspedalization add to the corn plexity of your rotation schedule?
Miscellaneous
--
Within a subspecialized department compensation for pediatric radiologists should vary depending on the subspecialty interest.
-
--
-
-
-
-
Subspecialization within pediatric radiology may result in some radiologists requesting differential payment.
-
-
-
-
-
-
-
-
No effect Decreases complexity of monthly scheduling
In preparing your monthly schedule do you:
Agree/disagree
Agree/disagree Of those individuals in your department with a subspecialty interest, how was the subspecialty training achieved (please rank from 1 4 reflecting the most common method of training). Self training on the job
Increases complexity
Attempt to build in all time away (vacation, meetings, etc.) up front Do the schedule first and then permit informal coverage to evolve as it is determined that people are away
Definitions
Mini fellowship (eg. 2-3 months) Formal fellowship in the area of interest in a pediatric hospital Formal fellowship in the area of interest in an adult hospital
For purposes of this questionnaire subspecialization is defined as an individual spending more of his time in one particular area (by formal assignment) than in other areas of the department.
