ACR Bulletin

Covering topics relevant to the practice of radiology

Rural Repose

Small town radiology needs strong local alliances and thoughtful recruitment strategies.
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For all the radiologists who grew up in small towns but practice in dense, urban areas, the draw to go home could be a powerful thing.

—Eric B. Friedberg, MD, FACR
March 25, 2021

Radiologists disenchanted with the idea of practicing in a smaller, rural setting may not be seeing the potential upsides — including a more desirable work-life balance, a broader connection with the community, and the ability to have a larger influence on the care and business models of their practice.

For years, small hospitals and rural communities have struggled to recruit and retain specialists compared to their urban counterparts. To survive and thrive, rural radiology groups need to make the landscape more appealing. That means building strong local alliances to weather hard economic times and honing telehealth services to fill coverage gaps, according to Eric B. Friedberg, MD, FACR, vice chair of the ACR’s General, Small, Emergency, and/or Rural Practice (GSER) Commission and associate professor of radiology in the community division at Emory University in Atlanta.

“We’re talking about a whole lot of people in need of services,” Friedberg says. “Approximately 20% of the U.S. population lives in rural areas — that amounts to more than 60 million potential patients.”

The GSER Commission supports radiologists practicing general radiology within small communities and rural areas. “General” refers to fellowship-trained subspecialists who spend a significant portion of their time interpreting studies outside of their subspecialty. Veterans Affairs and military hospitals fall under the GSER’s purview — as do radiologists serving in a teleradiology capacity for rural communities. The growing demand for 24/7 radiology services, increasing clinical volumes, expectations for robust patient access in rural and critical access areas, and an emphasis on containing costs and boosting efficiency could be met by hiring general radiologists with particular skill sets.1


“There is more work to do now than ever in radiology — and from a recruitment angle we have fewer people competing for positions,” says Ivan M. DeQuesada, MD, chair of both the ACR’s Rural Practice and Critical Access Hospital Subcommittee and Radiology Associates of North Texas’ (RANT) recruitment committee. Job-seeking radiologists may not realize their best option might be difficult to spot on a map.

While rural locations are sometimes stereotyped as undesirable, all of that may be changing. “Smaller private practice groups in rural areas may end up having an easier time recruiting radiologists than their large, urban counterparts, especially if they are still entirely owned by their radiologists, which is increasingly rare in big cities,” DeQuesada says. “I run recruitment at RANT and see the benefits of joining rural community practices.”

“For some people, being too far away from a metropolitan area is a nonstarter when looking for a job,” DeQuesada says. Many rural practices and small emergency hospitals, however, have more control over how much they pay, what they invest in, and how much time off employees get, DeQuesada says. “The venture capital-backed groups with high overhead — because they have considerable debt or a lot of shareholders to pay who aren’t radiologists — may not be as well-positioned when it comes to recruitment,” he says.

Regardless of location, recruitment for all radiology groups is being stymied at the medical school level. “Radiology in medical school programs often takes a back seat to other specialties — and students definitely don’t hear good things about being boots-on-the-ground radiologists in rural areas serving small hospitals and private practices,” DeQuesada notes. “That makes it difficult to attract the best and brightest to smaller communities.”

“In my role in the GSER Commission, I interact with many private practice doctors, and I get to share and hear positive stories about what it’s like to be a doctor in a small practice,” Friedberg says. These stories can be very impactful for young career physicians, because many of them are not exposed to radiology as medical students, he says. “Even if they choose radiology, as residents they still are not getting commonly accurate, firsthand, positive accounts of what it is like to be in a rural practice.”

“It is great to see more medical students attending ACR’s annual meeting in the last few years,” Friedberg says. “It is a chance to see presentations on rural radiology and interact with others practicing in and/or supporting rural communities — which may help them learn things that might change their perception of living and practicing in smaller communities.”

One of the challenges in changing perceptions is a fear of corporatization and consolidation, Friedberg says. “Small, rural hospitals are failing at an unprecedented rate. The number of rural hospitals that we have lost since 2005 is ~179 and ~135 since 2010, and counting, according to the Cecil G. Sheps Center for research at UNC.”2 But that does not mean there are not opportunities for sustainability and success.


The size of radiology groups has morphed in recent years through consolidation and corporate activities. “Many rural practices are — and for a long time now, have been — in an economically constrained situation, with competitive forces coming their way,” Friedberg says. “Several decades ago, a 60-person group was big. Now you have groups with several thousand radiologists.”

As another challenge, Friedberg points to chronic government underfunding for anyone practicing in the rural space. “We can’t afford to wait for the federal government to do a better job at granting money and providing loan programs for rural America — specifically those that assist with healthcare infrastructure including radiology,” he says.

“People are always talking about lessons learned throughout the COVID-19 pandemic,” Friedberg says. “A big one would be for anyone who has not already cultivated a strong relationship with their local financial institutions, to do so.” Local lenders have a stake in helping during times of financial hardship. “Hospitals are often the largest employers in these small communities,” Friedberg notes. When a local bank has an opportunity to obtain the business of professionals who are the economic linchpins of the community, it makes good business sense, he says. “When a hospital goes down, patients lose access to care, people lose jobs, real estate values go down — there is a horrible domino effect, and that is not conjecture,” says Friedberg.

“Right after the first shutdown from COVID-19 in March 2020, we were talking to people from all parts of the country who practice in rural and critical access facilities,” DeQuesada says. “The folks who had good relationships with their local lenders were able to access emergency funding more readily than some urban groups who had relationships with large, national banks.”

“I heard stories from tiny groups — one in Wyoming — about getting access to funds that really saved them during that critical period,” DeQuesada says. “So, in spite of the fact that this slice of radiology has been suffering for years with narrowing hospital margins and imaging cuts in general, this particular group was able to weather that shutdown period surprisingly well.”

We’re talking about a whole lot of people in need of services, approximately 20% of the U.S. population lives in rural areas — that amounts to more than 60 million potential patients.

—Eric B. Friedberg, MD, FACR


Contracting with larger radiology groups can also be a lifeline. And working with private equity entities can bolster business for smaller rural groups and alleviate the burden of managing the business side of their private practice or hospital, while securing access to subspecialists.

“With the current norm of immediate 24/7 coverage, and with the complete reliability of other physicians on imaging assessments to treat their patients, no small or even medium-sized hospital could afford that kind of coverage,” says Catherine J. Everett, MD, MBA, FACR, president and managing partner of Coastal Radiology Associates, PLLC.

“We are now providing an integrated radiology network option that I think has proven very valuable for groups that exist in a rural space,” DeQuesada says. “We provide administrative support for groups operating with only a handful of radiologists in very remote parts of the state — and provide 24-hour coverage for services they cannot provide locally.”

“Several of the corporate models have at least some physician ownership and therefore partnership,” Everett notes. “Sometimes loss of autonomy is hard, but consistency of clinical guidelines, expertise in new regulations, skilled human resources people, and representation in national committees of subspecialty physicians for clinical value standards are very positive things.”

“I was so relieved that I had a corporate structure to deal with the pandemic,” Everett says. “I don’t think my partners and I could have functioned as financiers and an HR department, figured out the rules of engagement, and gotten all of our work done at the same time.” In normal times, too, she says, it is beneficial to have structured IT services and physician resources.


“Those groups who have invested in infrastructure — particularly in the telehealth space — will have more creative opportunities to develop strategic alliances,” Friedberg says. Those groups who demonstrated during the pandemic that they could support their own activities, while supporting others when they ran into difficulty, will start to emerge in rural areas. “We are starting to see some symbiotic relationships,” Friedberg says. “The investment in teleradiology capabilities is crucial when you consider efficiencies, economies, specialty support — the whole 24/7 and 365-day-a-year coverage.”

Teleradiology has afforded specialists employment in rural areas where only a generalist might normally be hired. “Many hospital administrators, unfortunately, are stuck in the ‘80s and want ‘their’ radiologists onsite,” Everett says. “They remember the era of films and the relative lack of after-hours radiology services. The pandemic has demonstrated to hospital administrators that we can easily do required work with minimal or no onsite time.” That allows for consolidation of services and better specialty coverage for patients, she says.

“The ACR and the Society of Interventional Radiology have formed a task force to look at ways to improve IR services, and therefore radiology services, in rural hospitals,” Everett says. “IR and diagnostic radiology are going to have to work together to provide innovative models to serve rural patients.”

“When we don’t have enough radiologists, we open ourselves to geographic labor gaps in coverage,” Friedberg says. “If we don’t have boots on the ground and depth on the bench, we will see those gaps, particularly as it relates to needle- and catheter-procedural-based work. We must show medical students, residents, and fellows the value of small and medium-sized hospitals and the opportunities rural private practice may afford them.”

“Our goal now should be to find radiologists who will provide the highest quality of care — and to do that thoughtfully with eyes to the future,” Friedberg says. “When younger physicians predominantly desire to live in a metropolitan area, it feeds the rural labor challenges. For all the radiologists who grew up in small towns but practice in dense, urban areas, the draw to go home could be a powerful thing.”