Commoditization situates specialty at crossroads

Radiology is at a crossroads, according to three prominent radiologists who have followed the specialty's digital revolution and evolution of practice. Their message was characterized by the RSNA as "a warning and a challenge."

The transformative impact of technology was at the heart of opening session presentations by RSNA president Dr. R. Gilbert Jost, former American College of Radiology Board of Chancellors president Dr. James P. Borgstede, and University of Chicago professor Dr. Paul Chang.

The future can be bright if radiology embraces the best aspects of technological change and uses them to adapt to a challenging future. But the speakers warned that the prognosis for the specialty is poor if current technology trends, including teleradiology, are allowed to turn image interpretation into another low-priced commodity.

Probably the most unsettling comments came from Borgstede, who said a host of factors, fed by technology but involving business and economics, are pressing radiology practice toward commoditization.

Borgstede argued that a full radiology service should properly include four components: pre-exam evaluation of necessity and appropriateness, exam monitoring for quality performance, the interpretation itself, and a postexam consultation with the referring physician or patient.

He outlined many situations in which one or more of these elements has disappeared. The result is that radiology service purchasers have begun to treat interpretations as an assembly line commodity that they can buy from the lowest cost provider. Borgstede faulted utilization management companies that have brokered radiology interpretations to lower cost providers and pocketed the profits along with a reimbursement system that permits separate billing for professional and technical components.

Other villains include hospitals that angle for lower prices by contracting out interpretations via teleradiology and radiologists who, in giving up night call, have found new comfort but have lost contact with referring clinicians.

"The short-term perspective is to have someone take night call so I can sleep," Borgstede said. "The long-term perspective is to have a secure practice so I can sleep at night for the next 20 years."

Radiologists have unwisely resisted cooperation with their peers, worried about nearby radiologists who are competitors and might take their practices, Borgstede said.

"It's not the person in the next town you need to worry about. It's the regional and national and international publicly traded corporations that have the potential to commoditize radiology for interpretations only and take the practices," he said.

Steps to protect radiology against commoditization include more cooperation locally and regionally, better public understanding of what radiologists do, bans on arbitrage of professional fees, and refusal by radiologists to be employed by nonradiologists, according to Borgstede.

"Without radiologists, the venture capitalists, entrepreneurs, Wall Street traders, and hospitals will have no product to offer. Radiologists must strive to be peers and not pawns," he said.

Chang first recognized the risks that PACS and digital technology posed nine years ago when a referring clinician, after seeing that he could view images independently from radiologists, sent Chang a note: "Thank you for inventing this. Now we don't need you damn radiologists any more."

What radiologists need to do is recapture one of the elements of the days of film, when radiologists and clinicians discussed imaging findings in the reading room, Chang said. Too often, PACS has permitted radiologists to become isolated.

It isn't the technology to blame, however, but rather how it is used, he said. Technology can isolate, but it can also allow radiologists to become "value innovators" in improving the imaging experience for patients and outcomes for clinicians.

Areas where radiologists can provide improved value include imaging services offered, exam ordering and scheduling, patient comfort and convenience, report turnaround time, interpretation quality, report product, and price.

Jost suggested other changes that will need to take place if radiology is to survive. General radiologists will go the way of general practitioners and give way to "superspecialists," he said. Refinements in practice such as electronic medical records will require radiologists to use them as part of their diagnosis and to have a broader knowledge of medicine. Radiologists will need to learn emerging areas of knowledge, such as molecular imaging and bioinformatics. Image interpretation will move from gross pathology to cellular imaging.