Ozier Muhammad/The New York Times
From left, Drs. Samia Sayegh, Nirav Shelat, Luke Gerges and David Zelman last month at St. Barnabas Hospital in the Bronx.
By NINA BERNSTEIN
Published: March 27, 2013
For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.
Not anymore. Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline. Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees. On Internet forums, younger radiology residents agonize about whether it is too late to switch tracks.
At St. Barnabas Hospital in the Bronx, a dozen radiologists in training, including Dr. Luke Gerges, 28, are suddenly stranded on an expensive road to nowhere. All received termination notices recently because their hospital is ending their residency program next year as part of a plan to replace its radiologists with a teleradiology company that reads diagnostic images remotely.
“Those days of raking in the dough with radiology are gone,” said Dr. Gerges, who is four years beyond medical school and $300,000 in debt. He said he chose a specialty he loves without caring that big salaries were waning, but never imagined it would be this hard to finish his postgraduate training and get a job.
“No one is going to hire me to be a radiologist without my training,” he said.
Few specialties have been immune to the same factors depressing radiology: deep Medicare cuts, cut-rate competition driven by technology, doubts about the health value of many tests and procedures and new measures to tilt public money to primary care.
The case of St. Barnabas may be extreme, said Dr. Paul H. Ellenbogen, chairman of the American College of Radiology, the principal organization of the nation’s 30,000 radiologists, who called the hospital’s treatment of the residents “unconscionable.” But it is part of a larger pattern that has made radiology the target of a dozen cuts in Medicare reimbursement since 2006, he said, totaling $6 billion.
“We were somewhat victims of our success,” said Dr. Ellenbogen, in Dallas, whose career spans what radiologists call the golden years, when the cost of diagnostic imaging grew faster than other items in health care.
Starting in the 1980s, the advent of technology like M.R.I.’s and CT scans, combined with a fee-for-service system, created ballooning demand for imaging and drove the compensation of radiologists to unsustainable heights, he said. “That led to a sense of entitlement in some people’s minds,” he said. “And that led to this development of offshore remote reading of cases.”
By 2001, with the supply of radiologists limited by a 1997 Congressional cap on all Medicare-supported residencies, nighttime demand was unmanageable for smaller emergency rooms. So-called nighthawk radiology services began pooling the diagnostic imaging loads of several hospitals and transmitting them electronically to American radiologists stationed overseas or working from home.
Though outsourcing to India grabbed headlines, the big growth in teleradiology was domestic. Now the nighthawk companies, staffed by recent radiology graduates, are competing for the daytime work, too.
St. Barnabas pays radiology residents $48,000 to $60,000 a year and collects about $150,000 for each in “direct graduate medical education” Medicare payments, which, besides their pay, is supposed to cover malpractice insurance and education in the program, accredited by the American Osteopathic Association. But the hospital will not release the money to other programs where the radiology residents could complete their training, Steven Clark, a hospital spokesman, said, because it plans to use the money to expand primary-care residencies.
That decision could be seen as a small victory for national policies intended to bolster primary care. But to many St. Barnabas residents, it mainly shows that the system of graduate medical education is broken.
“If the model becomes that everything is remote reading, it comes at the expense of training,” said Dr. Nirav Shelat, another third-year radiology resident. “Are we going to allow our trainees to essentially be kicked out by corporations?”
St. Barnabas, a 461-bed community hospital that lost $10 million last year and pays its chief executive nearly $1 million annually, now contracts with a traditional group practice of 18 radiologists to be its radiology department. Mr. Clark would not name the companies competing to replace the group practice, but said, “From a cost-cutting perspective and from a quality perspective, you can have a lot more people reading X-rays remotely than you can inside the hospital.”
In desperation to find a new traineeship. Dr. David Zelman, a fourth-year resident, offered to work without pay. He said hospitals told him that it would be unethical to accept free labor, or that training him would still be too costly without additional money for malpractice insurance and benefits.
One hospital, McLaren Macomb, in suburban Detroit, instead offered several residents slots in its “unfunded program,” in which most radiology residents essentially pay for their own positions through donations, typically from a spouse or parents: $65,000 a year to cover a $42,000 salary and $2,000 for expenses.
“Obviously it would be your last choice, but if there are no open funded positions and you can scrounge up the funds, keep it in mind,” the program director, Dr. Eli Shapiro, wrote in an e-mail to Dr. Gerges.
Dr. Shapiro, 57, added in an interview that every specialty was clamoring for more residents. “They’re nice to have,” he said, “especially when there’s a call at 3 o’clock in the morning. They’re around and I’m not.”
Despite declining prospects, competition for many traineeships is fiercer because the number of medical school graduates has grown by a third since 2002. “The way this whole medical education is, you’re essentially just in an indentured servitude position,” said Dr. Tom Chen, a first-year radiology resident at St. Barnabas from Queens.
The demand for imaging began to slow after 2006, even as technology increased productivity, studies show. Besides reimbursement cuts and rising deductibles, factors that curbed the scans included new concerns about radiation and useless tests. Compensation began to drop.
Last year, an annual salary survey of 24,000 physicians by Medscape, an online resource for doctors, found radiologists and orthopedic surgeons still topped the list of specialties, but their mean incomes had dropped by 10 percent between 2010 and 2011, to $315,000 from $350,000.
Anesthesiologists, facing competition from nurse anesthetists and Medicare cutbacks, were down by 5 percent, to $309,000. Ophthalmologists were up by 9 percent, to $270,000, but have not recovered from earlier cuts for procedures like cataract surgery, sped up by technology.
Only dermatology, despite a 2 percent dip to $283,000, seems to have kept its luster; lucrative cosmetic work is unaffected by Medicare and managed care. On the radiologists’ Web site AuntMinnie.com, amid complaints that radiology reading rooms have become sweat shops and jobs are scarce, one response to a wavering resident was succinct: “Derm! Now!!”
But longings for other once “hot” specialties, from cardiology to emergency medicine, brought warnings of slashed reimbursements and few jobs.
“The times of graduating from medical school and driving a Porsche are done,” said Dr. Dana Lowenthal, a first-year radiology resident and fourth-generation doctor. “It was never easy, but there was light at the end of the tunnel. This is new territory.”