Welcome to RSNA session W6CNPM10, Conquering 2024 Radiologist Workforce Challenges. Shortly, I'll introduce my esteemed panel to all of you. So what are some of the challenges we're dealing with right now? First of all, we know that there are higher and increasing volumes that we've ever seen than ever before from 2002 to 2016. The annual growth of imaging studies and utilization for ultrasound, CT, and MRI increased anywhere from 1% to 5% per year. At the same time, imaging volumes in the emergency room have been increasing. Over and above that, we should not forget that many of these studies now have increased number of images that we are expected to read as radiologists. Per US census data, there is an aging population. So over time, the prediction is that we'll probably have higher and higher studies. And as was pointed out in some of the sessions earlier this meeting, part of the contribution to these higher volumes is probably unnecessary studies, which at this point, we always can't control. When we look at the actual ratio of supply and demand, it's best to dissect this and look at it systematically. According to the study that was carried out by the AMC, in 2021, there was approximately 27,191 radiologists practicing in the United States. The great resignation happened during COVID where an estimated 20% of all health care workforce in the United States resigned and included radiologists. And the AMC predicted that the gap between the physicians we have now and that we'll need in 2034 will be somewhere between 10,300 to 35,600, all specialty physicians included. Right now, we train approximately 4,600 diagnostic radiology residents annually. And there's no immediate short-term solution to raise that, although there are external funding sources being investigated by groups, et cetera, to try and address that. The other thing we have to look at, though, is also the radiologists themselves and some of the dynamics that we're looking at. If we look historically, based on Medicare-Carolines data from the studies that have been carried out, the one-year separation rate increased for radiologists from 13.8% in 2015 to over 19% in 2018. COVID, with all its pluses and minuses, definitely accelerated the teleradiology workforce, which we can talk about in terms of pros and cons in terms of retaining radiologists. We know that there is repeated studies that have been carried out that have demonstrated a high-consistence prevalence of radiologist burnout across multiple subspecialties and across multiple practice models with the United States. This year alone, the American College of Radiology Career Center had over 1,700 job listings available. So the question becomes, how do we deal with these challenges? And we have our esteemed panel in front of us today to help us answer these questions by looking at individual topics. I'd like to first introduce Dr. Eric Rubin. Dr. Rubin recently took on a new position as a staff radiologist for the Ochsner Clinic in New Orleans, Louisiana. He had previously been a partner with Southeast Radiology in Pennsylvania, where he served amongst many roles on the board of directors as a private practice radiologist. In addition, Dr. Rubin denotes his volunteer time on a pretty consistent level and multiple roles for the ACR as chair of the ACR Commission on Human Resources, member of the American College of Radiology Board of Chancellors, and, of course, well-known for his role as advisor to the CPT editorial panel. Look forward to Dr. Rubin's talk. He'll be presenting the subject, Cultural Solutions to Increased Radiologist Retention. Thanks, Jay. That background's supposed to be orange, but we'll work with it. So I'm going to start talking to, from the outset, with some generic concepts about business culture, things that you may have heard before and would be applicable in most business situations. Then I'm going to talk a little bit more specifically about radiology and how to create a practice culture within that works in today's environment. And I'm going to start with a little bit within that works in today's environment. And many of these slides that you'll see, at least from the outset, will be from a company called J3P Health in Princeton, New Jersey, just so I don't have to reference that every single time I show a slide like that. And the later pictures are examples of what you can do with ChatGPT. This is only going to scratch the surface of the topic of practice culture. People make a career on this, and I have 10 minutes. So what is practice culture? I'm going to have to enlarge this a little bit, because I did not bring my reading glasses. That works better. These are some of the buzzwords that you'll see, shared values, beliefs, and behaviors, and attitudes with these key elements that are listed here. Patient-centered care, professionalism, integrity, teamwork, collaboration, continuous learning and improvement. All that whole list, all really, really good stuff. But what does it really mean? How do you make it work? Well, you have to start with who defines your practice culture. It doesn't develop organically. It's leadership that really has to define practice culture through these core behaviors that you see, the humility, empathy, curiosity. And culture is really a manifestation of behavior. And to establish culture, the practice leaders need to understand behavior. And that, in turn, will help them For example, you really shouldn't be asking closed-ended questions of your teams. You should, as it says here, you should be curious. You should be asking open-ended questions to really get feedback from your team so you can try to develop and work and help your team to develop an appropriate culture that works. And as far as you as a leader, you need to be strategically self-directed. You need to be strategic. You need to be strategic in your leadership. You need to be strategic in your practice. As a leader, you need to be strategically self-aware. You need to not only be able to manage yourself, but you really need to truly think about what your strengths and challenges are so that you can be an influence, an influencer, an instrument to drive that culture through all elements of your practice. And you can use that recognition and skill associated with it to influence the relationships that you have in a meaningful manner with your colleagues, with your staff, and ultimately, with the patients, as we should. One thing you shouldn't be using is the word weaknesses. Use the word challenges. Weaknesses would imply that those are things that you can improve. Challenges are things that you can look at. You can try to figure out how to solve them. And that's the way we really should look to face and overcome those things if we deal with them properly. And we need a solid foundation of intrapersonal knowledge. And we don't talk about this intrapersonal enough. And it can't be effective with others if you don't truly understand yourself first. So you need to drive the ability to lead a cultural transformation from what you are, that intrapersonal knowledge that you have. Did this advance? No. Let's see. Let's try that. Uh-oh. We're stuck. Try the N and P. P is previous. Perfect. Jay is the expert here. So thank you. So we're going to switch up a little bit. One of the things we do is we do a lot of multimodality communication. But that communication doesn't necessarily always translate into comprehension. There's no fidelity. So this results in a lack of comprehension. And that lack of comprehension degrades the trust that your team has in you and your ability to develop that culture. So the only way to establish the trust is to ensure that your communications are understood by those that you are expecting to hear it from you. And is it understood? Can you validate that it was understood? You need to understand your audience and craft a communication to their needs and ensure comprehension. And comprehension, I will keep saying it, is the key. So now we're getting into the chat GPT photos. These are really cool. They're fun, too. So how does this apply to radiology practice? Well, we all know that we're seeing more work and finding it harder to find people to do the work. And one practice I spoke to is seeing a 20% increase in their volume relative to pre-COVID times. And I was once told by my group president that a 10% decrease in volume isn't really noticeable to us. But to most people, a 10% increase in your volume feels like you're getting crushed, and it's beyond manageable. So we have to recognize that. That's the way our people feel. And leadership styles have had to change as cultural and societal norms have evolved over time. The old leadership styles tended to be more hierarchical, autocratic, control-oriented, with leaders making decisions independently and dictating tasks to their team, while new leadership styles are more collaborative, they're democratic, and people-focused, encouraging team input, open communication, and employee empowerment to really achieve your goals, essentially shifting from a command and control position to a more supportive and coaching approach. And the new leadership style will likely be more in sync with our newest generation of radiologists who want to be heard. They will let us know that they want to be heard. And I think that this is all really good for all of us. One of the, I call them Ruben's rules, never assume that you're the smartest person in the room, because you aren't. And there is always someone in that room who can teach you something new, and you should always be listening to those people. And a new leadership style requires innovative leaders. You need to deal with the complexity of what we do, head on. And our processes are complex, often heterogeneous, with respect to how they impact our radiologists, the radiologists in our group. So we need to meet people where they are, not necessarily where the leaders want them to be. Take all the feedback that you're getting seriously. In this hiring environment, we don't have the luxury of losing people because they don't feel like they're being heard. And at the same time, you need to acknowledge and deal with both the successes and challenges in a manner, and I'm trying not to use buzzwords, just culture. Finally, while the thinking of leaders is complex, or may be complex, we need to simplify the communication to the team so that everyone can understand what they are hearing. So how do you do it? Well, money works. Financial incentives to clear your lists can work, but not every case should be valued. The same strictly adhering to your RVU values per case is unlikely to be fully successful. The best approach would be to create a system that not only accounts for the RVU values, but also such factors such as complexity of the studies relative to other studies read by the team, or adding value for studies that are older, for example. You probably also need to find ways to reward your on-site radiologists, and this is a fine line, and I wanna make this clear. What I'm seeing is we don't want to penalize people for being on-site, but you do want to reward people for being on-site, and you have to figure out how to communicate that to your team, that it is a reward for being on-site, and you're not penalizing those people that you truly need off-site at this point in this environment that we're in. So you don't lose those remote readers, because they're critical to the way that things are happening right now. But it's a difficult balance to do this, and to avoid cherry-picking of the lists, and what works for one practice may not work for another. And this is an iterative process, just like process improvement, it never ends. And consider creating a strategic team within your own practice, including a non-physician managerial level employee who understands the finances and the medical reimbursement side of things so that they can help you with that. And recognize that marketing not only is something that you do externally, and you need to market to your existing team so they both understand what is great about your practice, and so that they can have talking points when someone who is applying to the group calls them. You don't want that to be out in the wild. You really want to have them understand what's good about their group, and it helps you to control that messaging. And most group members don't truly understand what is great about their practice. It's easy for people to feel the things that go wrong, and leaders need to find ways to help everyone understand what is good and great about that practice. Finding a new radiologist to replace a radiologist that has left your practice, sometimes over things that probably could have been fixed is not where you want to be in this environment. You may even have to hire a marketing firm to evaluate your practice internally and develop those internal marketing strategies, and it might be actually cheaper than losing people. And a few last words here. Remote work is certainly diminishing the feeling of practice cohesiveness, and it's harder to maintain job satisfaction as it's disruptive to culture. Face-to-face interactions are harder to come by. Almost all meetings are remote and seemingly increasing in number. It's very easy to schedule a meeting these days. I certainly know it because they're not easy. They can be too easy to schedule, and side-by-side teaching is changing, but our profession is constantly evolved, and we are evolving it as it happens. So think to yourself how all these challenges are actually opportunities for us, and I expect that you will see as bright a future as I do. Thank you. Thank you. Thank you, Dr. Rubin, for that excellent presentation. Our next speaker will be Dr. Elizabeth Dibble. Dr. Dibble is a radiologist at Rhode Island Medical Imaging who is fellowship trained in breast imaging and in nuclear medicine and molecular imaging. She's an associate professor of diagnostic imaging at the Warren Alpert Medical School at Brown University. She has extensive research, which centers on multiple topics, including optimizing risk-based breast cancer screening, improving breast cancer staging with functional imaging modalities, and radiology and nuclear medicine diversity, as well as workforce issues. Today, Dr. Dibble will present the topic Operational Solutions to Increase Radiologist Retention. Thank you so much, Jay. Good afternoon, everybody. I'm excited to be here today to talk to you all about this topic of Operational Solutions to Increase Radiologist Retention. So as you have already heard today, and as you're all well aware from clinical practice, the volume of our radiology exams has exploded per patient, and we know that this is gonna continue to increase over time as the U.S. population is aging. Unfortunately, the availability of additional radiologists to assist with this increase in imaging volume has not kept pace. Groups are reporting difficulty hiring with actual hiring of fewer radiologists than they had planned to hire, as well as difficulty hiring radiologists with needed subspecialty skills. As these imaging volumes are increasing and groups are struggling to staff adequately, radiologists are reporting higher burnout rates compared to physicians and many other specialties of medicine. Currently, 70% of radiologists are reporting that they are currently working in an understaffed practice. And 11% of radiologists are self-reporting that they are extremely or very likely to seek new employment in the next year. At the same time, 6% of radiologists are planning to retire in the upcoming year. So what can practices do to increase radiologist retention? So first, who's at risk for leaving a practice? We know that among radiologists respondents to the ACR Workforce Survey that respondents say they're more likely to seek new employment when they work overnight call, when they say that they feel their life is balanced more toward work than life, and when they're in the first five years of their career. So what is it that radiologists want? And I boiled this down to two big ideas. First, one thing radiologists are looking for now is more flexibility. We know that nearly half of radiologists are now saying that they want to work remotely in some capacity in the future. This is a slide from the ACR Workforce Survey. And that doesn't mean completely remotely, but at least some component of working remotely in the future. So that's a big change from the past. We also know that more radiologists went from full-time to part-time in 2022 compared to 2021, the most recent publication of this data. And we also know that practices hired more part-time radiologists in 2022 compared to 2021. So radiologists want some flexible work options. And so in order to allow for that, one thing that we need to do as practices are to provide clear options for part-time employment based on time worked, provide options for full call, partial call, and no call with appropriate salary adjustments. Consider seasonal contract work to cover the busiest months like October for breast imaging and provide remote work options for our employees. We also need to have transparent FMLA policies. And this is especially important for young radiologists. So remember, those are among the highest groups of radiologists that are most likely to leave a practice within the next year. Those are radiologists who are within five years of graduating. So we know that almost a quarter of practices are now reporting that employees took an FMLA type leave in the past year. This was the most recent year that we looked at this data. And that was a substantial increase compared to just a few years ago. And these leaves are taken nearly equally now by men and women. And that was also a big change compared to a few years ago when we previously looked at this. And the most common reason for a leave is to care for a newborn or adopted child. But of course, to enable this type of flexibility, we need to have more people working. So that might include some creative staffing that we have to do, things like allowing fellows to work as an attending. So in our practice, we let our fellows take some call shifts early in their year, and then halfway through the year, we let them actually work as attendings one day a week, which they love. But paid as an attending, and which we love, because it helps our staffing. And then it might require things like hiring more international medical graduates. And I know this is controversial, but hiring non-physician radiology practitioners is something that is happening, whether we like it or not. So we know that practices are employing more PAs and NPs, not radiology assistants, but PAs and NPs in the most recent survey data compared to prior years. This might also look like internal moonlighting. So this is a great way to allow people who are willing or able to work more to work more and get paid for it, and not requiring everybody to do so, especially those who are not interested in that. This might also look like hiring 1099 contractors to help cover some of the work. So the other big thing radiologists are looking for is improved workflow. And that might include things like IT solutions, things like communicating results. So we have a great system in our practice. We call it the RADCAT3 system, modeled after the BI-RADS3 system, where we have an IT process for closing the loop on important non-urgent findings. So we insert a little character in our reports if, say, a patient has a pulmonary nodule and we're recommending follow-up, and it automatically goes into a work list for staff members who fax the report to the referring physician's office, and then call the follow-up to make sure that report's been received, and then document that communication. So this is a great way to save radiologists time, but ensure that those results are communicated. Similarly, we have an IT solution in our practice for clinical follow-up. So that can take a lot of time. If you recommend a biopsy or you recommend surgery, you've got to write down the patient's name, and then a few days later or a week later, you have to go and look it up. We have an automated system where we get a PHI email, HIPAA-compliant email, that has clinical follow-up information. So if a patient has a pathology result or an operative note, we'll get that in an email. Also, of course, AI tools can help to improve workflow. So we know that there's been a significant growth in recent years in the proportion of practices that are using both clinical and non-clinical AI, and that nearly half of practices are now reporting that they use some form of AI. Non-clinical uses of AI might include for billing coding, research, exam assignments, patient scheduling, and prior auth. And then for clinical uses, of course, we have image interpretation, then we also have non-image interpretation clinical uses as well. A relatively easy thing to do is to employ a reading room assistant to help with non-interpretive tasks, things like answering the phone and communicating results. We know that radiologists are interrupted very frequently in the reading room. In this recent study, radiologists had an average of over more than five interruptions per hour, so that really interferes with workflow. And then, of course, administrative support, things like completing documentation for billing, appropriate reimbursements beyond RVU measurements. So, in conclusion, our staffing needs are continuing to increase, with 70% of practices now saying they're currently understaffed, and planned hiring increasing steadily. Flexible work options are growing, and this includes things like part-time work and remote work opportunities. There has been an evolution in benefits offered by practices and used by radiologists, and some actionable solutions include things like improving flexibility, getting creative with our staffing, and improving workflow. Ultimately, acknowledging the changing needs of the radiology workforce can help practices retain the current and next generation of radiologists. Thank you so much for your attention. Our next speaker will be Dr. Sherry Wang. Dr. Wang is an associate professor in radiology and a board-certified radiologist with a focus on abdominal imaging and ultrasound. Dr. Wang completed her body imaging fellowship at the University of Washington, Seattle, and completed her radiology residency training in Australia. Dr. Wang is currently the chair of equity, inclusion, and diversity for the Mayo Clinic Midwest Radiology Department. She's highly qualified and will present the topic, Practical Solutions to Improve Diversity and Increase Radiologist Retention. Thank you, everybody, for being here. So, diversity. This is not a dirty word. And I want to first talk about what I mean by diversity. So given the political and social climate, this word is charged with all sorts of connotations and labels. Some of these are not great. So I want to first clarify what I mean by diversity. We should not just hire for diversity's sake, but hire using the essence of diversity, which is we hire for the best candidate, but with a holistic view of this candidate, taking into consideration their life experiences and how that may have affected what is on their CV that is presented in front of us. We should also examine our own unconscious bias in the recruitment period, the interview period, and in the retention period. And I want to start by giving an example. I would like you to think about the introverted candidate. I'm sure some of you have interviewed introverted candidates. Looking back, were there any assumptions made about this candidate? And if you are an introvert yourself, has assumptions been made about you? What you need, what you want, not just in recruitment, but in the interview stage and as well as in when people are trying to retain you. So I want to think of diversity as something very wide. It's not just what you look like, what your gender is, what your religion is. It's far more greater than that. And this is an example of diversity in personality. So now that I have given this example, I want to lead this to the next point. What does diversity entail? So this is an example that a few things I've thought of that off the top of my head, but you can probably come up with more things than on this list. And I've divided this list into things that we can see more easily and things that we probably cannot see. I want to talk about the idea of majority and non-majority. What is that? Well, it depends on the part of diversity we're talking about, right? For example, in radiology, I would be part of the non-majority if you looked at my gender. But in terms of physical ability and neurodiversity, in most places I'm in, I would be in the majority. So if we think about diversity in this way, there's a few lessons for us. The first one is we all have something to contribute in terms of diversity because we are all unique and diversity belongs to all of us. And the second thing is think of situations where you're not the majority. How did that make you feel? How can we make things better in terms of psychological safety and in terms of inclusion and belonging? Now we can draw on those experiences and empathize with those who are in the non-majority group in situations where we are in the majority group. Now with everything we have just discussed, I want to look at some strategies. And I'm going to break this into different parts of the radiologist's life cycle. So we're going to start with recruitment. We need to cast a wide net in order to increase our pool of candidates and making sure that they're diverse. Again, diversity being everything we talked about and more. Think about where your ad is located. What demographic is likely to access these? So for example, social media. If you place your ad on social media, what demographic are you going to attract? You're probably going to attract more junior candidates and you might miss out on some really great, more senior candidates who do not use social media routinely. And if you put it on social media, maybe you'll grab a bunch of candidates who are more geographically diverse than your usual candidates compared to if you just post it on the bulletin board near your hospital. Even social media is very nuanced. Facebook versus Instagram versus Twitter slash X versus TikTok, they're all going to give you access to very different groups of people. And the other thing about social media is that these ads are free. Well, they're just a post. They're free. So it may be the best bang for your buck if you are somewhere that the budget may be really tight. Now, targeted recruitment and meetings. Meeting your targeted audience where they are. So one member of Marissa's team has been going to the National Medical Association and setting up a booth. Very much like how they do at RSNA and various other radiological society annual meetings. This year, they'll actually be hosting an alumni reception at the National Medical Association annual meeting. And for those of you who don't know, the NMA is a collective voice of African-American physicians and the leading force for parity and justice in medicine and the elimination of disparities in health. Now the interview stage, the interview and recruitment committee should actually come together and be cohesive and deliberate with exactly what they're looking for in a candidate. And things that we talk about is we list out very objective skill sets that's needed and wanted for a particular position. The committees themselves should also be diverse in all sense of the word, as we already discussed. And it may be helpful to have an appointed diversity leader who keeps everyone accountable. And Marissa, our physician recruiter, gives a great presentation to all of us on unconscious bias. Now I'm going to move on to retention. Equity, inclusion, diversity, and belonging is part of culture and therefore an inseparable part of wellness. And wellness is an integrable part of retention. So think of it this way. Would you be well in a workplace where you do not feel you belong or feel like you cannot be comfortable because you know people may not accept you or include you or your ideas simply because one portion of your identity? And because of these biases, you do not know if there's ever going to be any career advancement for you or that you are diminished because people do not value what you bring to the table because one thing is all they choose to see about you. So for me, DEI is about improving our work culture and improving our wellness through sense of belonging. So what is belonging? Belonging is when a person feels that different parts of their identity are welcome, accepted, and even valued. This is an accumulation of day-to-day activities, not like you just do one thing and people feel like they belong. People who feel like they belong, they feel safe to bring their entire selves to work. Diversity is being invited to the party, inclusion is being asked to dance, and belonging is dancing like nobody is watching because that is how free you feel to be yourself. And you know, the sense of belonging, it's not just a feeling. It's not like a fuzzy feeling. It's actually a human need. From this slide, you can already see why belonging matters. And this has huge implications in both retention and recruitment. And it's especially important at this time and age where the radiology market is so good. Why should people choose you? Well, for belonging, retention, because people want to stay. People feel like they belong. They're going to stay. And for recruitment, because people want to be part of this work culture. They see that nobody's leaving this work institution, organization, or practice. And they think, well, if people are not leaving, this must be a great place to work. So ultimately, you're recruiting people to your place of work. Now there are a few important things to consider building belonging and retention. The first one is transparency. Everyone should have access to the same information and everyone should be on the same page. In terms of practical things to do, we have open calls for leadership positions. And we want to also make sure that the same principles of recruitment in terms of diversity of the committee, which makes the decision on these appointments. Clear promotion criteria, processes, and guidelines, whether it's for academic promotion, for leadership positions, or for partnership status. Avoid favoritism. Leaders should strive to treat all employees fairly and without bias. Transparency can help leaders be accountable to avoid favoritism. This leads to my next point, which is fairness. This directly ties in with equity. Promotions are your organization's opportunity to demonstrate its values. Create a fair and transparent promotions process and ensuring everyone has equal advancement in promotions opportunities as well. If your leaders tell the importance of women in leadership, but keeps overlooking them for promotion, trust is then lost. Before I move on to that, pay equity is a really important topic I want to bring up here. The pay gap is still well and truly alive in 2024, especially for women and minority groups. I want to make a very special note here. I say pay equity and not necessarily pay equality, as we know that equity and equality, they're not the same. I'm a huge proponent that our pay do not have to be the same, but for those people who are willing to work more hours, more days, undesirable shifts, and work more efficiently in terms of their RBU generation, they should be paid fairly for their work. When people feel like they have a say in the organization, they're more invested in its success and growth, and this directly links to inclusion and making sure that there is diversity at this table too. We often neglect this, which is welcoming new employees from day one and helping them connect with all those around them socially, making them feel welcome, included, and this can be done through very thoughtful onboarding processes, introductions to colleagues, and opportunities to get involved in any sort of projects on team activity. Embrace employees' whole selves. We can create a sense of belonging and inclusivity beyond just tolerating someone. It sends a strong message that all employees are valued regardless of their difference. And when we say, and only when we embrace employees' whole selves, we'll understand their unique needs for career advancement and their needs for staffing support. So career advancement, and I have to say, not everyone's career development trajectory is going to be the same, nor do they happen at the same time for everybody, and that's important to note. Staffing support is also very important. People feel like you care about them and they're not just a cog in the wheel, and understaffing and unbearable volumes are definitely a source of discontent, burnout, and moral injury. So coming back to embracing the employee's whole self, staffing structures should support the employee, especially in the setting of flexibility, in terms of timing of shifts, nature of shifts, hybrid, on-site, telework options. Inclusion and belonging is not asking people to assimilate to, I'm so sorry, to assimilate into the majority group. People will feel excluded if there is favouritism, unfairness, no say in decision-making, not being welcomed, and feeling unsafe to be themselves. So those who have unique attributes should be seen as a cultural add. You should be looking for cultural adds rather than just cultural fits. At the end of the day, belonging is acknowledging that we are all different and unique in so many ways, but treating those differences with dignity. And lastly, I want to leave you with this. Thank you.

radiologist workforce

imaging volumes

COVID-19 impact

burnout rates

retention strategies

diversity and inclusion

work-life balance