Radiology as a Clinical Specialty

(For a printable version without graphics, please click here)

Lesson #1

Learning Objective - To develop a more accurate and comprehensive understanding of the specialty of Radiology.


The clinical specialty of Radiology is based on the technology of making medical images using some form of radiant energy. This activity began with the discovery of x-ray by Wilhelm Conrad Roentgen in 1895. Immediately after that, medical practitioners began offering different forms of x-ray diagnostic techniques and x-ray therapy. Currently in the United States, approximately three hundred and fifty million radiographic procedures are performed annually at a cost of approximately thirty billion dollars. You might be surprised to learn that more than one half of these are done in the offices of private physicians and most of those are not interpreted by radiologists. This phenomenon has been studied and in an article by Bruce Hillman1 it was found that primary care (general Internal Medicine) practices which have their own x-ray machines used radiographic imaging four (4) times more frequently with seven (7) times greater cost than similar practices which referred their radiographic imaging to a consultant.


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Post-graduate training for Radiology is a four-year residency after Medical School. This must include one full year of clinical training and this year of clinical training is typically obtained prior to beginning the  Radiology portion of the residency. During Radiology training, residents are rotated through various service subdivisions on a quarterly (sometimes monthly) schedule. Subdivisions such as chest radiology, gastro-intestinal radiology, interventional radiology, body imaging, and nuclear medicine would be some of the common rotations of a radiology residency program. Following the general residency, the majority of residents would elect to take at least one fellowship year in some subspecialty area of Radiology. Currently, body imaging is a popular subspecialty area. Others, such as pediatric radiology, interventional radiology and nuclear medicine would also be available.


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Radiology is a relatively highly compensated specialty. Radiologists are usually ranked just below some of the surgical subspecialties in  income. The income relationships are given in the slides below.



Professional Liability

The slides below show the relative frequency of malpractice claims directed at radiologists and the mean professional liability insurance premiums paid by radiologists. Radiology is not one of the highest risk medical specialties for malpractice litigation but it is certainly not the lowest. Radiologists are frequently involved in malpractice lawsuits in which it is difficult to understand exactly how the radiologist became involved. Usually, this results from some unfavorable clinical outcome and, during the case preparation, the plaintiff's attorney discovers that there is some technical glitch in the radiologic part of the patient's management. It may be a late report or some discrepancy in dates of reports. Occasionally, requested studies are not done or not reported. Any of these technicalities can lead to the radiologist being included in the lawsuit. Sometimes, it seems this is done simply to extend the insurance coverage (find a deeper pocket) so that it might be possible to obtain a larger settlement or judgement.


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Practice Pattern

Radiology is somewhat different from most other clinical practices because there is a relatively weak connection to the individual patient. However, there are subspecialties of Radiology (such as GI Radiology, Interventional Radiology and Nuclear Medicine) which include a lot of patient interaction. The positive and negative aspects of radiology practice are summarized below.





Problems associated with radiology practice have been described many times. A well-known editorial by Richard Heilman2 describes two serious problems with the current pattern of radiology practice.  In that editorial, one of the major problems was thought to be the difficulty in planning the diagnostic work up. Currently, there are so many imaging choices that it is very difficult to make a decision about the most effective method of obtaining the needed diagnostic information. A second major problem was thought to be the way radiology reports are presented. Frequently, the reports are not well organized and are relatively imprecise. This makes it difficult for the clinician to obtain a definite opinion from the radiologist on which the clinician can base appropriate patient management.


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Two examples of confusing reports are given below:  The "comments" are from the insurer.


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Most Common Image

To end this summary of the specialty, a picture of the most frequent radiographic image produced in the United States is included. Can you predict what image (what body part?) it will be? What is the individual and population risk (ionizing radiation) from the frequent use of that image?

Most frequent radiographic image (Click here to see).


Even though more exotic imaging techniques such as CT and Magnetic Resonance have become very popular topics of conversation, the conventional chest radiograph is still, by far, the most common radiographic image produced in this country. The chest x-ray accounts for approximately one half of all medical images. There may not be a good medical reason for this frequency of use but the chest radiograph is a very traditional image which is included in the general diagnostic work-up of almost any patient.



1.  Is there a need for a separate specialty of Radiology or could organ system specialists do the medical imaging within their own area of anatomic interest?

2. What would be appropriate compensation for the effort required in Radiology relative to other medical practice specialties?

3. How could the practice of Radiology be made more clinically useful?

a) How could the diagnostic imaging work-up be simplified?

b) How should the report be structured to provide information most effectively?

4. DHEC assumes that licensed physicians understand the quantitative risk of exposure to ionizing radiation. Because of that, they will license the use of x-ray machines to physicians. Can you predict the risk (risk of exposure to ionizing radiation) produced by the one hundred fifty million chest radiographs made each year in the United States?


Reference Citations

1. Hillman BJ. Frequency and Costs of Diagnostic Imaging in Office Practice - A Comparison of Self-Referring and Radiologist-Referring Physicians. N Eng J Med 1990; 323:23,1604-1608.

2. Heilman RS. Sounding Board - What's Wrong With Radiology? N Eng J Med 306 (8):477-479.


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