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The AFIP and the Tragedy of the Commons
David B. Larson, MD, MBA
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The views that the author expresses in this article are strictly their own and should not be attributed to the American College of Radiology.
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Reprinted with permission from JACR
Volume 4, Issue 1, Pages 8-10 (January 2007)
The AFIP and the Tragedy of the Commons
David B. Larson, MD, MBA
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In 1944, the US Coast Guard placed 29 reindeer on St. Matthew Island, a
small island in the Bering Sea. With no predators on the island, the
reindeer population had grown to 6,000 by 1963. During the winter of
1963 to 1964, all but 42 of the animals died of starvation.
There was plenty of vegetation to support a large herd of reindeer. Why
the catastrophic decline? Because by doing what was necessary to
survive, individual animals consumed and trampled the winter foraging
grounds to the point that the vegetation could not regenerate for the
next season. This is a classic example of what economists have termed
"the tragedy of the commons," referring to the conflict between
individual interests and the common good when individuals compete for a
shared resource.
This story might be applied in a variety of ways to the current state of
radiology. Many have argued that by neglecting academic radiology, we
are placing the future of the entire profession at risk [1]. Truly, as a
specialty, we must not be so shortsighted as to neglect our vital
research and education infrastructure.
At the recent annual meeting of the Association of University
Radiologists, as well as at a special summit convened by the ACR, a
handful of radiology leaders called for ending the 6-week Radiology
Pathology (RadPath) training course conducted by the Armed Forces
Institute of Pathology (AFIP) (G. Galdino, personal communication,
September 2006). Some of these individuals feel that the RadPath course
places too large a burden on residency programs, that the lectures are
not adequately attended, and that the course could be replaced by online
learning modules. If the RadPath course were to be eliminated, the
sacrifice of such a lasting benefit for such a small short-term gain
would be unparalleled in the history of our profession.
The future of the AFIP was a major topic among members of the ACR
Resident and Fellow Section at the College’s annual meeting this past
spring, with more than 150 residents representing 43 states contributing
to the discussion. An overwhelming majority of the residents endorsed
the following position: the members of the Resident and Fellow Section
of the ACR firmly support the preservation of the AFIP and the RadPath
course in its present state. This opinion piece reflects the consensus
of that meeting and is written on behalf of the Executive Council of the
RFS, with its blessing.
BENEFITS OF THE AFIP
The RadPath course of the AFIP is the crown jewel of radiology
education. There are few, if any, other specialties in which nearly
every practitioner has been brought together early in their careers to
focus on learning from some of the most vibrant teachers in the field.
This concentrated learning experience is more indispensable than ever as
the amount of material to be mastered expands (though the training
period does not). Many of our counterparts in other specialties are
envious, and for good reason. It is a resource that should be emulated
rather than abolished.
Because of its efficiencies of scale, the RadPath course offers a great
deal for the money. Hundreds of residents gather under one roof to hear
a presentation given by one lecturer that can be repeated numerous
times. Were the RadPath course to be abolished, the cost of filling that
void would shift back to individual programs. If one multiplies the
number of hours required to prepare each presentation by the hourly
salary of an attending physician, the cost of each lecture quickly
reaches thousands of dollars. For individual programs to replicate such
lectures at their own institutions, it would cost considerably more than
what the programs currently pay.
The AFIP is especially beneficial to programs with fewer resources and
faculty members. Perhaps some of the larger academic programs feel that
they rival the AFIP in their ability to provide highquality lectures
covering most radiology topics, complete with a comprehensive review of
the pertinent pathology and histology. Even if this were possible at
some sites, it would remain out of reach for the majority of programs.
Just as the educational aspect is vital to the health of an academic
radiology department, the Rad- Path course supports other missions of
this historic institution. The AFIP acts as a repository for a vast
amount of collective radiologic and pathologic knowledge. Particularly
difficult cases are often sent to the AFIP for definitive evaluation.
And the constant stream of publications produced by the AFIP is enjoyed
by radiologists at all career stages.
SPECIFIC CRITICISMS OF THE RADPATH COURSE
Of course, the RadPath course is not perfect. Despite the fact that the
course directors continually seek feedback and make changes, it
assuredly can be made even better. However, some individuals have used
the possible elimination of the AFIP as a starting point for discussing
how to improve the course. Discussions on whether to eliminate the
course and how to improve it cannot be made, in good faith,
simultaneously.
That being said, there are specific complaints about the AFIP that
deserve to be addressed.
- Residents treat the time given for RadPath as a vacation or, in
extreme circumstances, a moonlighting opportunity. There is no adequate
enforcement mechanism to ensure that residents are in class all day,
every day.
There is no question that residents attending the RadPath course should
be in class. Sadly, it is true that a minority of residents take
inappropriate advantage of the course by not attending some classes.
This can easily be traced by the sign-in sheets posted each course day,
which are shared with the program directors on request. Program
directors are encouraged to verify attendance and deal with those who do
not attend regularly in an appropriate manner. If they do not feel that
sign-in sheets are accurate enough to verify attendance, then
departments should use the same means that they use to verify the
attendance of faculty members at their conferences.
- The AFIP causes an undue financial burden to individual programs.
Residents are sent to the RadPath course while they are being paid but
providing no financial benefit to their institutions. In fact, at some
institutions, Medicare compensation is withheld during this time.
As residents and fellows, we are painfully aware of and extremely
sympathetic to the financial challenges facing our institutions. During
such times, all opportunities to cut costs are explored. It is
understandable how a course that removes third-year residents from
service for 6 weeks can become a tempting target for administrators
desperate to make ends meet. However, let us recognize that the real
problem is not the AFIP but one that residents and attending physicians
share alike: academic radiology’s crisis of finances and manpower. Even
if the AFIP were to disappear altogether, the burden lifted from
academic institutions would be negligible, and department chairs would
still be forced to continue their struggle for financial survival.
Although some programs help pay for tuition or travel, most residents
also pay a substantial portion. Given the disparity between the incomes
of residents and their programs, participation in the AFIP generally
constitutes a much greater hardship for residents than for their
programs (not to mention the intangible costs, such as time away from
home and family). Yet residents make this sacrifice with little
complaint, knowing that the return is worth the investment.
Some leaders in academic radiology may feel that they should not support
this financial burden when it does not benefit them directly. This is
exactly how some practicing radiologists seem to feel about academic
radiology. Academic radiologists who (justifiably) warn the private
community that we are shortsightedly neglecting our future by not
supporting them fall into the same trap when they are unwilling to
support their residents in a similar manner. Although we should
certainly explore ways to help ease the burden of academic institutions
(eg, some programs rely on their alumni to fund their AFIP residents’
expenses), program directors must not lose sight of their primary
mission.
- The lecture format of the RadPath course is a form of ineffective,
"passive" learning. The course should be replaced by a series of
interactive online modules that could be completed at the home
institution.
The RadPath course is very interactive. The lecturers are among the most
dynamic presenters in the field. Residents continuously discuss the
material with the AFIP faculty members and, even more important, with
one another. The unknown case presentations at the end of the day
reinforce what the residents have learned.
More important, the interaction that occurs during the RadPath course
offers residents valuable perspectives and insights. Friendships formed
at the AFIP with radiologists from all over the country are continued
well beyond residency. In fact, the futures of major radiology societies
such as the Radiological Society of North America, the ACR, the American
Roentgen Ray Society, the Association of University Radiologists, and so
on, all depend on the types of relationships fostered at the AFIP. Just
as being a radiologist involves more than sitting in a dark room
producing dictations, becoming a radiologist involves more than just
sitting at a computer going over cases.
Aside from the human interaction, the concept that an online module
could educate residents as well as the RadPath course is merely
speculative. RadPath has a proven track record of many years; its
electronic replacement remains but a notion. Furthermore, putting the
course online would likely drive away many of the outstanding faculty
members the AFIP has attracted over the years, because it would take
away the rewarding aspect of direct teacher-student interactions.
If the course were replaced with online modules, residents would almost
certainly be expected to complete them after work and call
responsibilities, eliminating the protected time for learning. That
alone would doom it to failure. Perhaps proponents of such a reformation
should try it out by attending their next national meetings online from
their home institutions, after fulfilling their clinical and academic
duties for the day.
Nevertheless, the presence of the AFIP prevents no one from developing
online resources. In fact, the residents strongly endorse such efforts.
Done well, an electronic component could nicely complement the lectures
by reinforcing what residents learn each day. However, the online
component should reinforce and not replace the on-site course;
otherwise, many program directors would likely opt for the cheaper (and
less valuable) alternative, spelling the beginning of the end of the
AFIP. Furthermore, although the residents have full confidence that the
AFIP faculty members would do it admirably, the burden of developing a
complementary online component might just as well be shared by other
academic or private practice radiologists.
CONCLUSION
Currently, all radiology residency programs in the country, save only
one, send residents to the RadPath course, even though no program is
required to do so (A. Levy, personal communication, September 2006).
Truly, there can be no stronger testament to the program’s singular
success. Nevertheless, if a program feels that its residents are not
adequately using their time, that the course is too expensive, or that
residents could be better served by an online module, there is a simple
alternative: do not send your residents to the AFIP. Choosing to not
participate in the RadPath course has the same effect on any given
residency program as abolishing the entire course; thus, no program
director or chairman should feel the need to prevent residents of other
programs from being able to reap the benefits of the course. It is hard
to fathom why any individual would feel compelled to try to dismantle a
course in which participation is voluntary.
Some individuals may feel that the residents are arguing for the
continuation of the RadPath course for disingenuous reasons (ie, we want
our 6 weeks away from service). I would point out that this author and
all of the members of the Executive Committee of the Resident and Fellow
Section have already completed the course: we are speaking on behalf of
future residents, not in our own interest. Having recently completed the
course, we found that it added so much to our education that the idea of
abandoning it astonishes and saddens us.
There are many, many other radiologists at all career stages who feel
just as strongly in favor of the RadPath course. Before the caretakers
of the AFIP consider making any significant changes, the residents would
ask that they seek out and consider the opinions of all of the
stakeholders, not just the vocal minority. Hopefully, they will also
carefully consider how to preserve the important, but less tangible,
benefits of the AFIP as they enhance the educational experience through
adjunct programs such as online modules.
No single reindeer on St. Matthews Island can be blamed for doing what
it had to do to try to survive in such harsh circumstances; namely, eat
the vegetation that would otherwise regenerate for the difficult winters
to come. But by preserving themselves individually in the short run, the
reindeer sealed their collective doom. As Garrett Hardin [2] stated,
"therein is the tragedy." Fortunately, though, with some foresight and
cooperation, such a tragedy can be avoided. Like their predecessors have
done, the residents hope that our current radiology leaders will fortify
the future of our specialty rather than consume it in a moment of
hunger.[1,2]
REFERENCES
-
Dodd G, Fletcher T, Thorwarth W, Jr. The crisis in academic
radiology: will we help ourselves? J Am Coll Radiol 2006;3:243-7.
- Hardin G. The tragedy of the commons. Science 1968;162:1243-8.
David B. Larson, MD, MBA
University of Colorado Health Sciences Center,
Department of Radiology, A-030,
4200 E Ninth Avenue
Denver, CO 80262
e-mail: david.larson@uchsc.edu.
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