Our study based on 131 primarily community-based radiologists from three geographic regions in the United States found that slightly more than half of radiologists who interpret screening mammograms enjoy this work. In particular, women radiologists, those who spend at least 20% of their time in breast imaging, those who have a primary academic affiliation, those who read more than 2,000 mammograms per year, and those who receive a salary were more likely to report enjoying interpreting screening mammography. Not surprisingly, those radiologists who feel like withdrawing from interpreting mammograms at least monthly because of malpractice concerns, those who reported mammography tedious, and those who have an overall high level of uncertainty in medical decision making when interpreting mammography examinations were significantly less likely to report enjoying interpreting screening mammography. Despite these differences, enjoyment was not significantly associated with interpretive performance for both screening and diagnostic mammography after adjusting for patient and radiologist characteristics.
In contrast to our current study that found 56% of radiologists in general community practice enjoy interpreting screening mammograms, Lewis et al. [8
] found a 93% professional satisfaction rate among breast imaging specialists, comparable to a separate report of job satisfaction among radiologists in general [7
]. We suspect that the lower rate of satisfaction noted in our study is related to differences in the study populations; primarily, most of the radiologists in our study were generalists who included mammographic interpretation in their clinical practice and were specifically queried about this part of their practice. Our study did show a 100% rate of satisfaction among academic radiologists. The study by Lewis et al. included only radiologists who specialize in breast imaging. The difference may also be due to asking slightly different survey questions. Our study asked, “Do you enjoy interpreting screening mammograms?” whereas the study by Lewis et al. asked about satisfaction with breast imaging overall.
According to the 2006 American College of Radiology survey, 10% of radiologists consider themselves specialists in breast imaging, although only 21% of the 10% are fellowship-trained [8
]. These breast imaging specialists interpret about one third of all mammograms each year, consistent with the Institute of Medicine report [18
], “Improving Breast Imaging Quality Standards,” which thoroughly reviews workforce issues about providing high-quality breast imaging services. There is no standard definition of a breast imaging specialist; therefore, Lewis et al. [8
] reported results by several different definitions, including percent effort in breast imaging. Radiologists who spend 30% or greater effort in breast imaging reported a high level of professional satisfaction.
Although percent effort categories in our study were different from those in the Lewis et al. [8
] study, we noted similar findings. The radiologists in our study who reported working in breast imaging less than 20% of their time were significantly less likely to enjoy interpreting screening mammograms than radiologists who spend > 40% of their time in breast imaging. Lewis et al. found that 82% of breast imaging specialists surveyed read > 2,000 mammograms per year compared with only 34% of radiologists in our study who read more that 2,000 mammograms per year. Our study's various measures that could define a breast imaging specialist—that is, percentage of time spent in breast imaging and high volume of mammograms—were both significantly associated with enjoyment of interpreting screening mammograms.
Overall, radiologists who enjoy interpreting screening mammograms do not perform better than those who do not enjoy interpreting mammograms, although suggestive trends were noted. Radiologists who enjoy interpreting screening mammograms have slightly lower abnormal interpretation rates and higher sensitivity of screening mammography without a reduction in cancer detection rates when adjusting for patient characteristics.
For diagnostic mammography, radiologists who enjoy mammography had statistically higher sensitivity while maintaining equal specificity as those who do not enjoy mammography. Thus, they missed fewer cancers without biopsying more women without cancer. These results were no longer significant after adjusting for other radiologist characteristics, but we do not know the direction of the causal relationship. We cannot tell what the causal association is or whether it is the enjoyment or the other radiologist characteristics that are the best indicators of performance because they are associated with each other. We do not know whether radiologists have improved performance because they enjoy interpreting screening mammography or that they enjoy it because they are good at their job.
Even though enjoyment was not significantly related to performance after adjusting for radiologists' characteristics, we can speculate how enjoyment may influence whether radiologists start and continue to interpret mammograms. Given the concern that there may not be an adequate workforce in the future to meet the increasing demands for mammography [1
], it is important to understand why new residents are not choosing breast imaging as a specialty. In our study, younger radiologists reported less enjoyment in interpreting mammograms compared with older radiologists. The difference was not statistically significant but may help explain why new residents are not joining the mammography field. Alternatively, the satisfaction seen among the older radiologists is because these are who remain after those who do not enjoy mammography have left the field. Therefore, this question may be a predictor of retention.
In the recent past, low reimbursement and increased malpractice litigation were two of the main reasons cited by radiology residents for not pursuing a career in breast imaging, and these were also related to enjoyment in our study. The primary reason given by radiology residents for not going into the field of breast imaging is that breast imaging was “not an interesting field” and limited in its application of advanced technology compared with other imaging subspecialties [2
]. However, circumstances are now changing with the rapid incorporation of digital mammography, including advanced platforms such as future tomosynthesis, and breast MRI into routine clinical practice and the increasing volume of imagingguided breast biopsy with subsequent patient interaction [6
]. These circumstances may change radiologists' attitudes toward mammography over time and warrant further study.
There are several strengths and limitations to our study. Although we surveyed radiologists from only three geographic locations, they represent very different regions of the United States (northeast, northwest, and central) and are primarily community-based, with only 6% of respondents working in academic centers. A previously published study using the same radiologists' survey data reported that the demographics of our radiologists and the radiologists in a study in which they were randomly selected were similar [20
]. Therefore, we believe that these findings are generalizable to mammographers in other parts of the country, most of whom are generalists and account for nearly two thirds of all mammographic interpretations in the United States [8
]. We asked detailed questions and were able to link the survey responses to their actual mammography data to measure interpretive accuracy of both screening and diagnostic examinations.
Because of the nature of our research question, we are unable to discern from our data the specific cause and effect of the associations reported. It may be that if one is proficient in the interpretation of screening mammography, one is more likely to enjoy the benefits of successful outcomes. Alternatively, the simple lack of aversion experienced by some radiologists to interpreting screening examinations may be more conducive to higher reading volumes and subsequent improved skills. Furthermore, those who may have performed poorly or were exceedingly unhappy either were no longer reading mammograms or might have refused to respond to the survey.
As the population of women over 40 increases over the next 10 years, the need for additional mammography will also rise [21
]. This trend is occurring because the supply of radiologists willing to interpret mammograms is declining and suggests a precarious situation [1
]. On average, 44% of mammography facilities reported staffing shortages in 2005, a problem that becomes even more severe in not-for-profit facilities [22
]. These findings emphasize the alarming discrepancy between the increasing demand for mammographic services and the decline of radiologists willing to provide these services.
Our study shows that almost half of radiologists who interpret mammograms do not enjoy interpreting screening mammography, although enjoyment does not appear to affect performance. It is reassuring that radiologists who do not enjoy interpreting mammography are as good as those who do because it is likely not an option for them not to do it given that many general radiologists work in small or rural practices where mammography must be part of their workload.