By Dr. Cory Pfeifer

I was working at a large children’s hospital last year when it occurred to me over the holidays that the institution did not have a single pediatric radiology fellow in place for the 2018 appointment year.

This was somewhat puzzling, as the program typically had three pediatric radiology fellows per year, and the hospital system was large enough to host one of the largest pediatrics residencies in the U.S. I asked one of my friends at a similarly sized children’s hospital across the country, and not only did they not have a fellow, they didn’t even have an applicant.



As I looked into the issue, I discovered that the number of pediatric radiology fellows had been declining, and survey data of chief residents in radiology suggested that this trend would worsen. The number of fellows in accredited programs has declined for the third consecutive year. Children’s hospitals will soon feel the brunt of this shortage of pediatric radiologists if they haven’t already.

Radiology experienced a job crisis from 2011 through 2015. The consolidation of practices, decreased rate of retirement following the recession and oversupply of training positions led to a drop in the number of available jobs to the point where radiology graduates entered fellowship at an accelerated pace to improve their personal marketability.

In search of reasons why so few radiologists choose pediatric radiology, I turned to some current residents for answers.

A resident from the Midwest explained that there were simply no radiology practices looking for pediatric radiologists in his home state, and doing a pediatric radiology fellowship would actually hurt his employment chances. Also contributing was the material itself. Constant exposure to child abuse and devastating pediatric cancer can be off-putting to early career radiologists, many of whom have young children. Another resident was warned that pediatric radiology is low in generating revenue, as pediatric radiologists spend much time doing fluoroscopic studies and reading plain radiographs, which is not nearly as lucrative as the adult imagers who read far more CTs and MRIs.

Pediatric radiologists are seemingly in business to be out of business, as pediatric imagers advocate for the use of less radiation in this sensitive population. Working in a large subspecialized practice alongside neuroradiologists and abdominal radiologists who can generate billable procedures at a must faster rate can create challenges. Those more interested in patient interaction are more apt to choose breast imaging, which does not require call.

A pediatric radiologist at a major children’s hospital told me that she left a private practice because she felt as though she was “dumped on” by her associates who required her to be on call endlessly for overnight emergency pediatric procedures, and none of the adult radiologists would touch a pediatric study to avoid the 18 years of liability associated with the exam. Such an experience can be alienating for the pediatric radiologist, and in her case, the move to the children’s hospital came with a significant decrease in compensation. Indeed, pediatric radiology is seen as a lesser paid career path which further deters radiologists from considering it.

With a shortage of pediatric radiologists looming, how can we right the ship?
Most large children’s hospitals either employ radiologists directly or contract with a university practice. Very few large children’s hospitals contract with private practice groups. Children’s hospitals must face the reality that they may need to increase compensation if they want to foster recruitment of certified pediatric radiologists. With more pediatric facilities implementing 24-hour staffing of radiologists, children’s hospitals are prioritizing coverage over productivity. This means that the value of having final interpretations available at all hours is important enough to staff radiologists at times when the workload is low. If children’s hospitals continue to place a high premium on having certified pediatric radiologists available, it is likely that they will need to increase pay during the daytime just as they have decided to offer incentive pay for nighttime coverage.

Hospitals have allowed the overutilization of radiology services because it results in billable procedures. However, this is in direct contradistinction to the mission of recent reforms in health care. Facilities may soon be penalized for low-quality practices such as these. Hospital administrators should consider employing pediatric radiologists as quality officers who can better regulate the appropriate ordering of imaging studies to reduce pediatric exposure to radiation and radiology-associated anesthesia. This would likely improve job satisfaction of pediatric radiologists while helping control radiology costs. Practicing medicine with the best interest of the patient in mind may come at the cost of fewer exams, but it is the ultimate form of following the Hippocratic oath.

Another practice which can help recruit pediatric radiologists is the expansion of research. The amount of health-related diagnostic data that radiologists possess is enormous, yet hospitals often choose to focus on clinical productivity over academic inquisition. This has resulted in a very small number of academically productive children’s hospitals, as the top three children’s hospitals ranked by U.S. News & World Report have been unchanged as long as the publication has ranked its honor roll designees. These rankings are often used in hospital marketing, and radiology departments can serve as hubs to drive the research output that can improve rankings. Children’s hospitals should incentivize academic radiology by decreasing clinical requirements for radiologists who acquire extramural support and publish liberally. This can serve as a recruitment tool by offering an improved lifestyle for prospective pediatric radiologists.

Children’s hospitals should be aware that the number of available pediatric radiologists is on the decline. It seems likely that those in need of certified pediatric radiologists will need to consider increasing compensation for pediatric radiology services if they wish to remain competitive as the radiology job market recovers. Pediatric radiologists are underutilized with respect to choosing the correct exam. By taking advantage of the data that radiology has to offer, children’s hospitals are poised to improve their reputations while offering more attractive jobs at the same time.

About the author: Dr. Cory Pfeifer is a pediatric radiologist and pediatric neuroradiologist in the Department of Radiology at the University of Texas Southwestern Medical Center in Dallas. Dr. Pfeifer has published extensively on the topics of radiology education and radiology policy over the past three years.