It is undeniable that the radiologist shortage is here. While reimbursement is declining, free agents are few and far between, and compensation is exploding. Compensation per wRVU in the western region of the U.S. jumped nearly 16 percent from 2022 to 2023, according to MGMA. Job postings show salaries almost double what they were even five years ago, with signing bonuses, accelerated partnership tracks, and 12, 26, 34, or even 40 weeks of vacation. The truth is that there are simply no radiologists looking for a job who aren’t already overworked at their current positions.

Fourteen years ago, the Affordable Care Act was passed into law; since then, approximately 40 million people have been enrolled in health care. A pre-existing physician shortage, combined with the aging boomer generation already straining the health care system, exacerbated the problem. The answer to the overwhelming physician shortage was the acceleration of making NPs and PAs practice autonomously or nearly so across the country. Any radiologist can tell you that PAs and NPs order much more unnecessary imaging; a recent JACR study demonstrated that PAs ordered nearly ten times the amount of CTs as physicians. For physicians who are more overworked and have less time per patient, radiology becomes a convenient triaging tool.

These band-aids took a massive wave of newly insured patients and aging boomers, multiplied it, and sent it down the bottleneck of nearly every facet of modern health care: radiology. Hospitals, of course, encouraged all of this. The technical fees from radiology became their biggest cash cows. Why even bother hiring a physician when you can hire an NP who will order much more imaging and bring in more revenue?

And so, radiology utilization exploded. There are many proposed solutions to this problem: AI, ending fellowships, radiology NPs and PAs, etc. The truth is that this shortage will not end until there is a massive increase in radiology residency spots or the medicolegal liability landscape is radically changed. Since I do not see any workable solutions in the short to medium term, I’ll leave the solutions to this problem to others.

In the meantime, these forces have handed radiologists the best job market in medicine. Unfortunately, most of us are still living in the “before times.” What happens when you rapidly increase demand for services that are the lynchpin of large, extremely profitable businesses?

Across the country, radiologists are discovering this unheard-of leverage against hospitals. This can take many forms: massive subsidies with or without global billing, non-exclusive contracts that do not cover nights and weekends, or rejecting exclusive contracts and private practice entirely to become highly paid employees with little to no non-interpretive duties. Modern hospital systems have never dealt with the type of leverage that radiologists currently wield, and many have and will continue to deny its existence until it’s too late. Consider cardiology, neurosurgery, neuro IR, or trauma surgery. Hospitals cater to these specialties because hospitals know these physicians can threaten service lines or stroke/trauma certification. But hospitals also know that they have some leverage. A surgeon doesn’t want to move their family because their stipend was slightly cut or because the doctor’s lounge stopped stocking their favorite energy drink. Even then, you can run a hospital without a neurosurgeon for a day, a week, or even permanently if it gets too expensive. These specialties can threaten one or a few service lines, but hospitals know they have some wiggle room. There is an equilibrium between these entities that usually favors the physician.

On the other hand, hospitals quite literally cannot operate beyond a few hours without diagnostic radiology. We are the bottleneck for all inpatient care. All service lines run through us. Any radiologist can easily take one of the hundreds or thousands of teleradiology jobs, which offer less commute, less non-interpretive work, and often higher pay per hour. Hospital systems simply have no leverage against their radiologists except fear of the unknown.

What happens then when the specialty that was near the bottom of the totem pole finds itself at the top? For the sake of our sanity, we must come to terms with our current landscape:

• Radiology labor will soon become the most expensive labor in the inpatient setting.
• Hospital contracts, which used to be a golden ticket, are now a liability: you can pay me all you want, but if I can’t find radiologists to staff, what am I going to do with all that money?
• There is enough volume for every radiologist in the country.
• The only way radiologists lose is if we compete with one another for lower rates.

Old paradigms, where groups kept quiet about their contracts for fear of losing them, need to be abandoned because in many regions, there simply is no one else. Radiology groups in geographical regions need to share information about their deals and contracts with other groups if possible. Every group that gets a lucrative contract is a boon for every other radiologist.

The strongest position groups can take in this extraordinary job market is to walk away from partnership and exclusive contracts entirely, offering services as employees or independent contractors. Imagine the following scenario:

A group of radiologists is severely understaffed, reading far beyond what they normally would. Radiologists are overextended, and high-volume readers are threatening to quit unless something is done. The group is unable to afford hiring radiologists in the current market. Many other unsolvable issues, such as retirements, interpersonal issues, poor work ethic, interventional radiology (IR) vs. diagnostic radiology (DR) squabbles, and [plug in your practice’s problems here] plague the group. Negotiations with the hospital have yielded minimal results. What is a group to do? Take the money, or continue the negotiations?

Again, imagine all of the unsolvable problems this group may face: recruitment, billing issues, MIPS, exploding volumes during nights and weekends, older partners wanting to cut down or retire, cantankerous partners who are indispensable, ad infinitum. More money can’t solve all of these problems, because in this labor market, an exclusive contract is a massive liability. The group decides to turn these liabilities into leverage: They walk away from the contract and tell the hospital they can hire them as employees for base + productivity, or see you later.

The tables have immediately been turned. Suddenly, all of the issues that were unsolvable now become points of leverage. Can’t recruit? More leverage for us. Can’t staff weekends? More leverage for us. A couple of people retired? More leverage for those who stayed. Volume too high? I’m on productivity, or I’ll read slowly and take my base salary. Billing sucks? Not my problem. Overnight services increased their rates? Not my problem. Want to find another group? Good luck, there’s nobody else. We have three months of trailing AR to keep us fed until we get credentialed literally anywhere else.

Guess who wins?

These scenarios are not make-believe. They are happening across the country. Each time a hospital has a radiology meltdown, compensation balloons and is used to poach radiologists from nearby groups. A domino effect occurs, where these neighboring groups see what happened, lose radiologists to aggressive recruitment by the great deal down the street, and trigger another meltdown. To add insult to injury, hospitals that have already had a radiology meltdown before are more likely to have a second. Older, more hesitant radiologists quickly change their tune when they see what their leverage got them the first time around.

These changes leave significant questions about the future of radiology, and only time will tell how they reverberate outward:

• If, as we are seeing in many regions, radiologists are getting half or more of their salary directly from hospital stipends, what happens to outpatient radiology? These centers depend solely on reimbursement rates and may eventually be unable to compete with inpatient pay.
• Interventional radiology, which previously enjoyed higher salaries due to their leverage against their own partners (“you make the money, we keep the contract”), will get left in the cold by DR. They will have to prove their worth to hospitals on their own as they get booted from DR groups.

As for the rest of us, the only thing holding us back is fear—mostly due to a lack of knowledge in the market and antiquated thinking. I don’t blame any radiologists out there for failing to recognize this new moment. It’s hard to realize how irreplaceable you are when you’ve been treated as an afterthought for decades.

It is long past time for our specialty to stop taking on all of the liabilities of exclusive contracts for pennies on the dollar, shielding hospitals from the realities of the market as our volumes explode and our practices disintegrate.

The author is an anonymous physician.