Also, I think there's a false dichotomy that is prevalent out there in the rads community: academic vs. private practice.
I think it's a false dichotomy, not because they are somehow similar, but the categories are no longer relevant. The real choice is between health system employee (often a university hospital) and private practice.
I'm cynical, but I don't think private practive can win this one (unfortunately), and the pointless rants that occur about lazy academics and glutting of the system with rads trainees... sure, sure... but private practice is not going to die from that. Private practice is going to die because the government is going to effectively make the playing field so lopsided in favor of massive health systems (mostly through economies of scale... are private practices ready to survive negotiating for bundled payments with large health systems that are looking to expand?). If we decrease the numbers of trainees by 10%, that will not change a thing in the long run since fewer radiologists in a bundled care system -- in which the bundles keep getting discounted lower and lower -- is not going to make them that much more valuable. The supply could go down, and demand could go up... but if the price is not allowed to adjust naturally to S&D (such as in a system where reimbursement is almost arbitrarily set downwards over time) then docs will end up chasing peanut shells around unless they have the leverage of a large health system to keep some of those peanuts in the bundle. This is eventually going to happen, because the government wants it to (e.g. MACRA) and radiology is no exception. As a health system employee, you will have little to no leverage and will basically become an employee like everyone else... that is "academics". PP will eventually become "academics" with less teaching responsibility, and "academics" will not be allowed to take time off from the volume without grant support. Similar to the possible problem with increasing number of U.S. med school grads not automatically getting a residency spot because of a fixed number of residency positions, this is likely going to translate upwards as well and getting a job out of fellowship will not be a given since the health system doesn't care how the work gets done... as long as it gets done cheaply. Like my earlier post, the metrics need to change at a U.S. health system level in order to recognize resident work, otherwise a more expensive department (more rads than residents) will look inefficient and get penalized. The idea that there are lazy academics abusing the poor residents is out of date. The health system margins will decrease over time and the weakest group (the residents) will get hit first and hardest, like any business. The salaries of employees in these systems will go down as well. Everyone's "losing."
So my personal take is that one can yammer on about trainee numbers, volume, academic culture, PP salaries... it's mostly missing the point. The world is changing, the sea is rising, and only the big ships are going to stay afloat (and buy out the little ships). This is the real issue. Once health care becomes an oligopoly, then it becomes all about having the lowest cost of production. Academic "culture" is going to diminish. What was once private practice will be as an employee within a satellite of the health system (a "portal" for the system). Residency will become a risky proposition, hierarchical, like getting a PhD. It's going to look like grad school in other fields. At the top of the pyramid will those who set the ratios and negotiate the bundles.
So what about the whole supply and demand thing? My assumption is that it's basically predicated on the idea that if there are fewer rads then there will be more jobs and one can negotiate more aggressively for jobs. So let's think about this. Say we slash residency slots by 50%. Half the number of rads are produced in 5 years. This will continue into the future, right? Because you're not so self-centered to think that everyone will slash residency training programs just so that just you can negotiate a great job for a while. Volume may increase or decrease. Reimbursements are unchanged or bundled. "Cost containment" will be the watchwords. Now what? Great, there are now temporarily tons of openings for jobs on the ACR website, but do you want these jobs? You have twice as much work to do per day. Your salary will not rise proportionately (or be very low if you choose low volume and/or are penalized for inefficiency). You're going to turn to residents or midlevels, or something or you're going to go insane. You could try to read a CT per minute... and then be penalized by not meeting quality metrics. Or get sued into oblivion. You're going to game the ratios... and to my mind, if money is exiting the pot at a macro level, and you do not have the choice to work less (i.e. you're an employee), then all the S&D manipulation is just spinning wheels. There's more work, less money, and you have little leverage as an employee. That's it. You can try to evade the health systems in rural areas for as long as you can, but if there's money there, the juggernauts are coming to deliver "high quality care" at lowest cost. If you think that's grim, pay more attention to politics.
So you say, don't slash residency spots. Just don't increase them. Great idea. But how many more is too many more? Volume is usually used to justify residency hires... in that if there's more volume, then there must be room for more workers in the future. It's more complicated than this, which some people don't want to see, but then how do you decide when there are too many? When avg salary declines then there are too many? Not a bad practical definition, but also a hugely impractical metric it's a lagging indicator and since money's exiting the system.
But this is too much thinking. People who complain are mostly complaining pointlessly that it's not PP of 15 years ago. Cry about all the spilled milk you want, it's a brave new world.
