The Radiologist’s Image

What’s the reputation of radiologists? “We have very little image, therefore it’s a blank slate to paint,” said Lawrence Muroff, MD, CEO and president of Imaging Consultants Inc. in Tampa, Fla.

Thinking about a profession’s reputation involves more than just one view. There are actually three views to consider, each with different implications. When thinking about radiologists’ collective reputation, consider what the patient thinks, what the referring physician thinks and what the hospital thinks, said Teri Yates, founder and principal consultant for Accountable Radiology Advisors in Columbus, Ohio.

Reputation with Patients
A small study presented at the 2012 RSNA meeting showed that only 53.5 percent of patients who underwent a CT scan knew that the radiologists reading their scans were physicians. Almost 28 percent thought they weren’t. And lest you think that the population queried was uneducated, half of those polled had at least a college degree. Regardless of the radiologist’s medical background, 64 percent of those polled had little to no idea what radiologists actually do.

There’s no better lens through which to view radiologists’ public image than how they’re portrayed on television. “You can’t show me a TV medical show where the radiologist makes a meaningful contribution,” said Muroff. “The public develops its perception of medicine through the media. We’ve done a poor job at having the media appreciate our relevance.”

When the television show House was broadcast, Muroff said he’d ask people what the role of radiologists was, and they’d say there was no role. “That’s not true,” he said. “Radiology played a central role. Every week someone got an MRI, CT scan or image-guided biopsy. But they were all done by House’s fellows. There wasn’t a radiologist around.” It’s important to make the public aware of what radiologists do.

And actual patients are often unaware who reads their imaging studies, let alone their qualifications, said Yates, since the radiologist isn’t typically visible to them. That’s often a function of the workflow. “I think that’s the more challenging area, establishing a reputation for yourself with patients and the public,” she said. “Breast imagers have done this very nicely. They have an opportunity to be more interactive with the patient. I think patients do choose a breast imager based on the radiologist and their reputation. One of the reasons is that they have contact, and the other is that they specialize.”

For those in different imaging fields, Yates recommends raising their profile with patients by highlighting their expertise. The group can increase the level of specialization within how the cases are read. “Play to the strength of individuals and their expertise,” she said.

There are other ways to connect with patients, said Geraldine McGinty, MD assistant professor of radiology, assistant director at Weill Cornell Medical College, and chair of the American College of Radiology’s (ACR) Commission on Economics. Introduce yourself during the imaging exam. Make reports, images and consultations available to patients, optimize your patient portal. “Think about your patient experience and small ways you can connect,” she said.[[{"type":"media","view_mode":"media_crop","fid":"27076","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5775968925078","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2599","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 166px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Reputation with Physicians
Referring physicians look to radiologists for their expertise, not just in reading studies, but in advising about the patient’s treatment. Emory University School of Medicine surveyed referring physicians to find out what these doctors wanted from their radiology colleagues. The results? They want greater interactions with the radiologists, including recommendations for next steps for treatment in their reports. Half of respondents indicated that the limited contact between the radiologists and referring physicians hindered best patient care.

How has the image of radiologists changed over the years? The radiologist’s image has been changing given the progress in technology. McGinty explained it as Imaging 1.0, 2.0 and 3.0. “Imaging 1.0 is essentially the discovery of X-ray and radiology as a subspecialty,” she said. “They were retiring as I was starting my training. The reading room was a place where (all physicians would) gather to ask questions about patients.”

The next generation, Imaging 2.0 was the explosion of technology, with voice dictation and cases read remotely. “All these things greatly enhance our productivity,” she said, however “we weren’t seeing our colleagues in the reading room anymore.” This technology, while valuable, made radiologists invisible. It led to commoditization. “Hospitals have looked at bringing in teleradiology groups to replace us.” While everyone understands the value of imaging, the radiologist’s value is less apparent.

And now Imaging 3.0, “we have a huge amount [of reports] to deliver, but we need to put ourselves out there,” McGinty said. The solution is to try harder to communicate, to be engaged with the physicians, said Yates. Communication opportunities present when ensuring that imaging exams are appropriate or when there’s an unexpected finding. While many radiologists just call the referring physician if there’s a life threatening finding, Yates suggests reaching out to the referring physician in a consultant manner, which improves visibility and reputation with colleagues at the hospital.

Taking the mystery out of how the radiology department works is another way to improve reputation, said Yates. “Some of the radiologists who seem to enjoy the best relationships with members of the medical staff of a hospital are the radiologists that open up the reading room and invite others in to see what happens.”

If a surgeon questions the accuracy of an image interpretation, the radiologist might react in two ways. The radiologist can get defensive, which won’t help build a strong relationship. “The radiologist is not being collegial in their approach,” Yates said. An alternative approach is to ask the referring physician to stop by the reading room to review the images together. “When they look at the case together and the radiologist shows the surgeon the findings and rationale, it can become a conversation. Instead of it being a detente, it’s an opportunity for learning for the physician, and an opportunity to reinforce that positive relationship,” she said. “Or if the radiologist did in fact make an error, their willingness to sit down and discuss the case can smooth over any hard feelings about the case.” Learning how to master discussions about interpretation errors is an essential competency for a radiologist, she said.

Another way to teach referring physicians about radiology capabilities is to hold educational programs, said Muroff. “Many referring physicians, particularly in smaller towns, their education ended when their residency ended. They often don’t know what we can do,” given the rapid changes in radiology technology.  

Reputation in Hospitals
When Radiology, Inc. of Indiana wanted to show their Elkhart General Hospital administration what value the radiologists provided, they started tracking all activities outside of study interpretation, including committee work, teaching, research and conferences. They tracked 3,000 value-added hours in one year, and presented this to the administration, who could now more fully understand the value of the radiologists’ services.

The radiologist’s reputation in hospitals is critical, because there’s a lot at stake. “The more valued you are in your community, the harder it is to commoditize you,” said McGinty. Commoditization leads to local groups getting replaced with other groups or with national teleradiology company contracts. “Groups that are intimately integrated into not only medical, but the social and political fabric of the hospital and community rarely get displaced,” said Muroff.

In terms of getting involved at the hospital, McGinty said there should be a radiologist on every committee. This is difficult because radiology productivity is rewarded by the health care payment policy system and individual groups, and is necessary for paying the bills. The big culture changes are in evaluating how you can do things differently, rather than just working harder.

The ACR Imaging 3.0 initiative aims to help radiologist’s reputations by encouraging the notion that radiologists provide added value, and understanding that you have to be an active participant, said Muroff. “You have to get out of the mindset of just cranking out volume.”

Radiologists don’t tend to be the first physicians volunteering, because of the productivity focus, said Yates, however those are ways to demonstrate engagement to the hospital, and it puts them in a position of collaborating with customers, referring physicians.

Involvement directly helps the group’s interests at the hospital as well. Yates gave one instance when serving on a committee would have made a difference for a radiology group. The credentialing committee was putting a physician performance assessment system in place. The committee implemented a review instrument that wasn’t applicable to the radiologists, mandating evaluations for physicians having a small number of cases with adverse events within a certain time period. That might be appropriate for a surgeon with fewer cases, but with a high radiology volume, that didn’t make sense. A hospital might use a one-size-fits-all approach because that’s all they have to use, and they don’t realize how it would affect radiologists.

Radiologists can add value to a committee at a hospital, because they have a unique perspective in that they interface with every other specialty across the health system, said McGinty. Radiologists have been using technology to move data around and for electronic health records for years, and have a lot of wisdom to offer in technology use.

In addition to participation in hospital committees, it’s vital to develop nonclinical skills as well, focusing on leadership, negotiation, human resources and basic finance. “These are all very important for being successful in times ahead,” Muroff said. The health care field is changing, and whenever there are changes, there are opportunities. However, those who do well will do so at the expense of their less innovative and less progressive colleagues, he said.

If you’re just providing interpretations, you’re no different than any other provider, said Muroff, and you’re more vulnerable to replacement. Radiologists are facing increasingly aggressive competition from national entrepreneurial companies. If you’re not readily available for consultations, going to conferences and serving on committees, you’re seen as anonymous and replaceable. “Be significant to the patient and referring physician,” he said. “If we don’t make ourselves visible, we’ll be fungible, replaced by other radiology practices, companies or even be replaced by nonradiologists,” he said.