It’s crunch time for radiologists. The New York Times reported that an osteopathic radiology residency in the Bronx was abruptly terminated (the decision was later reversed for this year), casting its 12 residents adrift. The article focused on the hospital’s plan to cash in on the primary care mini-boom that is allegedly taking place.

The article says the demand for radiologists is sharply down due to “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.”

A few years ago, the demand for radiologists was high, and the supply was limited by the 1997 Medicare cap on expansion of residency programs. This led to the establishment of services that offered remote radiology interpretation, known as “nighthawks,” for many hospitals that lacked enough local radiologists. Images were sent to groups of US or offshore radiologists who efficiently read them while maintaining quality.

What the article didn’t mention was that even hospitals with adequate in-house radiology coverage started using the nighthawks when the hospital-based radiologists decided they didn’t want to take calls at night or on weekends.

Now hospitals are apparently realizing that, with a few exceptions like interventional radiology, they don’t need the more expensive local radiologists at all. Another factor in the Bronx hospital’s proposal to eliminate their radiology training program is that they wanted to completely outsource their radiology service. That would have made it impossible to train residents unless they moved to India or Australia.

So this is what happened when radiologists got a little too comfortable.

The next specialty on the chopping block may well be anesthesiology. Currently, 16 states allow nurse anesthetists to practice independently, with more states considering such changes. They come cheaper than doctors, and while you’ll get an argument from most anesthesiologists, CRNAs probably do just about as good a job as doctors. Oh sure, there will be some cases where patients may die for want of a fully trained anesthesiologist, but think of the money that will have been saved, even after the inevitable malpractice suits are settled.

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I once thought surgery was immune to such schemes, but now I’m not so sure. I am hearing rumblings of mid-level “providers” (I hate that term) being taught how to do more and more procedures.

Will they take over? It’s possible that a physician assistant can learn advanced surgical procedures. The problem is that the operation is not all there is to it.

As I’ve said before, deciding who needs surgery, when to do it, and what operation is best are important features of what we do. This takes time to learn. Some fellowship directors are saying that 5 years of general surgery residency may not even be enough time. General surgery may be safe for now.

We keep hearing about nurse practitioners replacing primary care physicians, too. That Bronx hospital might be jumping on the bandwagon a little too late.

And maybe that projected shortage of doctors is really a mirage.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5,700 followers on Twitter.