- Email: [email protected]
Keeping Professionalism Alive in Radiology's New Age: A Choice; Our Future
Keeping Professionalism Alive in Radiology’s New Age: A Choice; Our Future Gregory J. Butler, MD
Professionalism in radiology is often talked about but seldom defined or formally instituted. Awareness of its value and adoption of its principles will be our best defense against the perils that lie ahead in radiology’s new age. Key Words: Professionalism, future, commoditization J Am Coll Radiol 2009;6:100-102. Copyright © 2009 American College of Radiology
A friend once suggested that a good measure of the impact of your life is to imagine your own funeral. In visualizing the eulogies and comments, you might better judge the wisdom of the directions you have chosen and choose yet again every day. All would want to be remembered for the love and devotion they have shown to family and friends, and as radiologists, most of us would want to be remembered as being good at what we did. But as I reflect on the radiologists and other physician teachers and mentors of my past whose funerals I would want to attend, I imagine that much more could and would be said about them. They will not be remembered for the money they made, the barriers they set up to restrict access to their minds and hearts, the self-importance they conveyed in their professional interactions, or the indifference they showed for their patients, colleagues, and students and for radiology as a whole. The reason they will be remembered as radiologists for more than an hour after the attendees leave their funerals is that they made a difference. They did so by being professional. PROFESSIONALISM Over 15,000,000 hits on the Internet for the word “professionalism” are currently identified. It is clear from examining the list that everyone agrees that professionalism (or “high levels of professionalism”) is a quality to be desired, but seldom is a description or definition found.
Department of Radiology, Valley Regional Hospital, Kentville, Nova Scotia, Canada. Corresponding author and reprints: Gregory J. Butler, Valley Regional Hospital, Department of Radiology, 150 Exhibition Street, Kentville, NS B4N 5E3, Canada; e-mail: [email protected].
100
To some, it may mean being courteous or kind, to others knowledgeable, and yet to others perhaps clean and well groomed. But to us, and our profession, it means all of these things and more. A professional is someone who professes to have a skill set and adheres to a code of conduct that leads those who seek that person’s help to be trustful of the intent. In our case, this comes from a tacit understanding that our actions are always in the interests of our patients, not ourselves. This “contract of trust” between ourselves and our patients, and even payers and governments, has been passed to us by countless members of our profession who have gone before. It is stated clearly in the Hippocratic oath and has allowed us to maintain our relative autonomy and self-regulation [1] (Normand Laberge, personal communication, 2004). In recognition of the emerging importance of self-awareness of professionalism, the Radiological Society of North America (RSNA) formed the Committee on Professionalism in 2005, which embarked on a professionalism project that lead to the “Charter of Professionalism,” a collaborative document with international members of the broader medical community [2]. Professionalism was the topic of the opening session of the RSNA’s annual meeting in 2006 and has been made into an ACR self-assessment educational module [3]. There is a statement on professionalism on the RSNA Web site [4]. The resulting charter lists 3 fundamental “principles” and 10 “commitments” to which a physician desiring to behave in a professional manner should adhere [2]. These call on the attributes of professionalism described by others. Another author has described the pursuit of quality as a key component to professionalism, and arguably, quality encompasses all of a professional’s attributes [5]. © 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2008.09.009
Butler/Keeping Professionalism Alive 101
In essence, it seems that all descriptors of professionalism in medicine attempt to verbalize what we believe to be the highest callings of our profession, namely, putting patients’ and society’s interests above our own and maintaining a focus on competence, respect, compassion, and integrity in all that we do. NEW-AGE DANGERS AND THE IMPERATIVES TO PROFESSIONALISM The plethora of Internet hits, as well as the recent articles emphasizing its importance, speak to increasing evidence that professionalism is seen as an emerging issue of importance, perhaps at the core of all debate on the future of radiology, not simply because it is the right way to see our role and conduct our affairs but also because the evolving nature of our practice environment points toward professionalism as the only behavior that is likely to save us from extinction. It is a given that our practices are more demanding than at any other time in our history. There is more opportunity for us to fall into the trap that greater expectation for timely reports creates, causing us to see ourselves as we are nothing more than “film readers” (a pejorative term I once heard a surgeon call radiologists). This is the commoditization of radiology; the conversion of radiology to “diagnostic imaging,” no longer a profession but rather a service. Serum PSA results come out of one machine, and a magnetic resonance imaging report out of another. The “new age” of radiology is upon us. Images have left the x-ray department; and if we have nothing more to offer than a report, referring clinicians can develop less interest in speaking with us or visiting our departments; a report will do, and where it comes from becomes less pivotal. Boiler room reading centers in India or computer-aided detection and diagnosis reports from a computer may suffice. And other disciplines are now recognizing that our new imaging tools are essential to practice and are fairly well remunerated, making imaging an attractive target for turf incursion. This, along with the alarming tendency for self-referral in the United States (not yet as much of a problem in Canada), has made nonradiologistperformed imaging one of the most rapidly growing cost centers in all of medicine, potentially at a cost of efficacy and even safety and attracting unwarranted attention to the entire universe of imaging as a “problem.” Teleradiology offers a huge technical solution to human resource distribution issues by allowing our eyes and minds to travel to the patients in underserviced areas and across time zones for late-night coverage without the consumption of gasoline or kerosene and, in the case of night reads, without stressful wear and tear on sleeping radiologists. At the same time, without watchfulness, this
tool can become a means for the less informed to seek low-cost, unprofessional image interpretation and potentially create an imperative for us to provide such service, just to keep the business. Price wars, the trading of reporting services, low-quality offshore solutions, and turf incursion on one another’s practices can be the ugly result. Organized radiology has endeavored to foresee and prevent these trends through standards and policy statements [6]. Our reputations with our colleagues in other disciplines can suffer when professionalism is not the primary mandate of our practices. We have never endeavored to measure the degree of respect or disdain we enjoy from our medical colleagues, but it is obvious that this will likely vary with the degree of professionalism we bring to bear in our interactions with them. Respect, courtesy, and a genuine desire to help their patients and to provide the best care required endears us to our colleagues, earns their respect, and even inspires them to greater degrees of professionalism themselves. Likewise, professional behavior mandates us to interact with our own radiology colleagues and support staff members with respect and helpfulness. Professionals edify one another. Radiology leadership in recent years has recognized the need to emphasize the value that radiologists add to the imaging process. In a recent exercise by the ACR Board of Chancellors in mapping the major future threats to our profession, it was felt that of all threats, radiologist apathy is perhaps the greatest [7]. Apathy is the antithesis of professionalism because it is the natural tendency inherent within us all to “leave well enough alone” and develop habits that are easiest and often in our best personal interests. In this case, the “well enough” may be a tacit permission from the system that meeting the minimum requirements of maintenance of certification is sufficient. Meeting minimum requirements is hard enough to be sure but will probably not be enough for the survival of radiologists in this new age. Professionalism, and this alone, will earn us the privilege of leadership and indispensability. It will be the professionals who will be called on by legislators, payers, and the public to help shape the future. DAY-TO-DAY PROFESSIONALISM Professionalism comes from our sense of what is right, but it is a learned skill set that requires motivation, organization, evaluation, and alertness. It cannot in most circumstances be legislated, because it exceeds the minimum requirements recognized by licensing and credentialing processes. The attitudes that lead to professionalism probably can be best started in childhood by teaching that each one’s behavior affects us all and that most
102 Journal of the American College of Radiology/ Vol. 6 No. 2 February 2009
interactions in life must be seen in the context of what is best for us all, not just “all about me.” Incorporation of the principles of professionalism in one’s day-to-day practice is perhaps easy to acheive but more difficult to formalize. This has been attempted in one department by the introduction of a booklet that puts in print the department’s mission to be professional, including prescribed “dos and don’ts” of physician and departmental staff behavior [8]. This outlines in practical terms how professional behavior can be intentionally committed and recognized in everyday practice. In such a department, a culture of respect for patients and one another and a passion for service and excellence can be a rich environment for optimal patient care, radiology resident training, research, and generally a better practice experience by knowing that one’s practice is a “good” one [9]. And undoubtedly, such a department will be seen as a high water mark in the hospital, elevating the stature of radiologists and technologists alike and making undesired turf incursions much less likely. THE FUTURE It is obvious that our profession is changing more quickly than at any time since Roentgen. The future of radiology as a unified specialty is uncertain, despite the overwhelming importance imaging will continue to play in medicine. Our mandate, should we wish to accept it, is to lead the process of change in a direction that our special knowledge and integrity tell us is for the good of our
patients and society. And as has often been said, what is good for our patients will ultimately be good for us. We will retain this leadership role and the undying gratitude, admiration, and respect of those we serve, only with proactive efforts to embrace professionalism and keep it alive. REFERENCES 1. Hattery RR. Strengthening professionalism. RadioGraphics 2008;28: 7-11. 2. 2005 RSNA Professionalism Committee. Medical professionalism in the new millennium: a physician’s charter. Radiology 2006;238:383-6. 3. American College of Radiology. Self-assessment module (SAM) online: professionalism. Available at: http://campus.acr.org/acr/sam_professionalism.aspx. Accessed December 19, 2008. 4. Radiological Society of North America. RSNA statement on professionalism. Available at: http://www.rsna.org/About/professionalism.cfm. Accessed December 19, 2008. 5. Lau LS. A continuum of quality in radiology. J Am Coll Radiol 2006;3: 233-9. 6. American College of Radiology. White paper on teleradiology and standard on teleradiology. Available at: http://www.acr.org/Secondary MainMenuCategories/BusinessPracticeIssues/Teleradiology/Reportofthe ACRTaskForce/onInternationalTeleradiologyDoc3.aspx?css⫽print 7. Berlin L. Apathy: the threat within. J Am Coll Radiol 2007;7:433-6. 8. Donnelly LF, Strife JL. Establishing a program to promote professionalism and effective communication in radiology. Radiology 2006;238: 773-9. 9. Gunderman RB. Promoting good work. J Am Coll Radiol 2004;1:343-5.
Professionalism in radiology is often talked about but seldom defined or formally instituted. Awareness of its value and adoption of its principles will be our best defense against the perils that lie ahead in radiology’s new age. Key Words: Professionalism, future, commoditization J Am Coll Radiol 2009;6:100-102. Copyright © 2009 American College of Radiology
A friend once suggested that a good measure of the impact of your life is to imagine your own funeral. In visualizing the eulogies and comments, you might better judge the wisdom of the directions you have chosen and choose yet again every day. All would want to be remembered for the love and devotion they have shown to family and friends, and as radiologists, most of us would want to be remembered as being good at what we did. But as I reflect on the radiologists and other physician teachers and mentors of my past whose funerals I would want to attend, I imagine that much more could and would be said about them. They will not be remembered for the money they made, the barriers they set up to restrict access to their minds and hearts, the self-importance they conveyed in their professional interactions, or the indifference they showed for their patients, colleagues, and students and for radiology as a whole. The reason they will be remembered as radiologists for more than an hour after the attendees leave their funerals is that they made a difference. They did so by being professional. PROFESSIONALISM Over 15,000,000 hits on the Internet for the word “professionalism” are currently identified. It is clear from examining the list that everyone agrees that professionalism (or “high levels of professionalism”) is a quality to be desired, but seldom is a description or definition found.
Department of Radiology, Valley Regional Hospital, Kentville, Nova Scotia, Canada. Corresponding author and reprints: Gregory J. Butler, Valley Regional Hospital, Department of Radiology, 150 Exhibition Street, Kentville, NS B4N 5E3, Canada; e-mail: [email protected].
100
To some, it may mean being courteous or kind, to others knowledgeable, and yet to others perhaps clean and well groomed. But to us, and our profession, it means all of these things and more. A professional is someone who professes to have a skill set and adheres to a code of conduct that leads those who seek that person’s help to be trustful of the intent. In our case, this comes from a tacit understanding that our actions are always in the interests of our patients, not ourselves. This “contract of trust” between ourselves and our patients, and even payers and governments, has been passed to us by countless members of our profession who have gone before. It is stated clearly in the Hippocratic oath and has allowed us to maintain our relative autonomy and self-regulation [1] (Normand Laberge, personal communication, 2004). In recognition of the emerging importance of self-awareness of professionalism, the Radiological Society of North America (RSNA) formed the Committee on Professionalism in 2005, which embarked on a professionalism project that lead to the “Charter of Professionalism,” a collaborative document with international members of the broader medical community [2]. Professionalism was the topic of the opening session of the RSNA’s annual meeting in 2006 and has been made into an ACR self-assessment educational module [3]. There is a statement on professionalism on the RSNA Web site [4]. The resulting charter lists 3 fundamental “principles” and 10 “commitments” to which a physician desiring to behave in a professional manner should adhere [2]. These call on the attributes of professionalism described by others. Another author has described the pursuit of quality as a key component to professionalism, and arguably, quality encompasses all of a professional’s attributes [5]. © 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2008.09.009
Butler/Keeping Professionalism Alive 101
In essence, it seems that all descriptors of professionalism in medicine attempt to verbalize what we believe to be the highest callings of our profession, namely, putting patients’ and society’s interests above our own and maintaining a focus on competence, respect, compassion, and integrity in all that we do. NEW-AGE DANGERS AND THE IMPERATIVES TO PROFESSIONALISM The plethora of Internet hits, as well as the recent articles emphasizing its importance, speak to increasing evidence that professionalism is seen as an emerging issue of importance, perhaps at the core of all debate on the future of radiology, not simply because it is the right way to see our role and conduct our affairs but also because the evolving nature of our practice environment points toward professionalism as the only behavior that is likely to save us from extinction. It is a given that our practices are more demanding than at any other time in our history. There is more opportunity for us to fall into the trap that greater expectation for timely reports creates, causing us to see ourselves as we are nothing more than “film readers” (a pejorative term I once heard a surgeon call radiologists). This is the commoditization of radiology; the conversion of radiology to “diagnostic imaging,” no longer a profession but rather a service. Serum PSA results come out of one machine, and a magnetic resonance imaging report out of another. The “new age” of radiology is upon us. Images have left the x-ray department; and if we have nothing more to offer than a report, referring clinicians can develop less interest in speaking with us or visiting our departments; a report will do, and where it comes from becomes less pivotal. Boiler room reading centers in India or computer-aided detection and diagnosis reports from a computer may suffice. And other disciplines are now recognizing that our new imaging tools are essential to practice and are fairly well remunerated, making imaging an attractive target for turf incursion. This, along with the alarming tendency for self-referral in the United States (not yet as much of a problem in Canada), has made nonradiologistperformed imaging one of the most rapidly growing cost centers in all of medicine, potentially at a cost of efficacy and even safety and attracting unwarranted attention to the entire universe of imaging as a “problem.” Teleradiology offers a huge technical solution to human resource distribution issues by allowing our eyes and minds to travel to the patients in underserviced areas and across time zones for late-night coverage without the consumption of gasoline or kerosene and, in the case of night reads, without stressful wear and tear on sleeping radiologists. At the same time, without watchfulness, this
tool can become a means for the less informed to seek low-cost, unprofessional image interpretation and potentially create an imperative for us to provide such service, just to keep the business. Price wars, the trading of reporting services, low-quality offshore solutions, and turf incursion on one another’s practices can be the ugly result. Organized radiology has endeavored to foresee and prevent these trends through standards and policy statements [6]. Our reputations with our colleagues in other disciplines can suffer when professionalism is not the primary mandate of our practices. We have never endeavored to measure the degree of respect or disdain we enjoy from our medical colleagues, but it is obvious that this will likely vary with the degree of professionalism we bring to bear in our interactions with them. Respect, courtesy, and a genuine desire to help their patients and to provide the best care required endears us to our colleagues, earns their respect, and even inspires them to greater degrees of professionalism themselves. Likewise, professional behavior mandates us to interact with our own radiology colleagues and support staff members with respect and helpfulness. Professionals edify one another. Radiology leadership in recent years has recognized the need to emphasize the value that radiologists add to the imaging process. In a recent exercise by the ACR Board of Chancellors in mapping the major future threats to our profession, it was felt that of all threats, radiologist apathy is perhaps the greatest [7]. Apathy is the antithesis of professionalism because it is the natural tendency inherent within us all to “leave well enough alone” and develop habits that are easiest and often in our best personal interests. In this case, the “well enough” may be a tacit permission from the system that meeting the minimum requirements of maintenance of certification is sufficient. Meeting minimum requirements is hard enough to be sure but will probably not be enough for the survival of radiologists in this new age. Professionalism, and this alone, will earn us the privilege of leadership and indispensability. It will be the professionals who will be called on by legislators, payers, and the public to help shape the future. DAY-TO-DAY PROFESSIONALISM Professionalism comes from our sense of what is right, but it is a learned skill set that requires motivation, organization, evaluation, and alertness. It cannot in most circumstances be legislated, because it exceeds the minimum requirements recognized by licensing and credentialing processes. The attitudes that lead to professionalism probably can be best started in childhood by teaching that each one’s behavior affects us all and that most
102 Journal of the American College of Radiology/ Vol. 6 No. 2 February 2009
interactions in life must be seen in the context of what is best for us all, not just “all about me.” Incorporation of the principles of professionalism in one’s day-to-day practice is perhaps easy to acheive but more difficult to formalize. This has been attempted in one department by the introduction of a booklet that puts in print the department’s mission to be professional, including prescribed “dos and don’ts” of physician and departmental staff behavior [8]. This outlines in practical terms how professional behavior can be intentionally committed and recognized in everyday practice. In such a department, a culture of respect for patients and one another and a passion for service and excellence can be a rich environment for optimal patient care, radiology resident training, research, and generally a better practice experience by knowing that one’s practice is a “good” one [9]. And undoubtedly, such a department will be seen as a high water mark in the hospital, elevating the stature of radiologists and technologists alike and making undesired turf incursions much less likely. THE FUTURE It is obvious that our profession is changing more quickly than at any time since Roentgen. The future of radiology as a unified specialty is uncertain, despite the overwhelming importance imaging will continue to play in medicine. Our mandate, should we wish to accept it, is to lead the process of change in a direction that our special knowledge and integrity tell us is for the good of our
patients and society. And as has often been said, what is good for our patients will ultimately be good for us. We will retain this leadership role and the undying gratitude, admiration, and respect of those we serve, only with proactive efforts to embrace professionalism and keep it alive. REFERENCES 1. Hattery RR. Strengthening professionalism. RadioGraphics 2008;28: 7-11. 2. 2005 RSNA Professionalism Committee. Medical professionalism in the new millennium: a physician’s charter. Radiology 2006;238:383-6. 3. American College of Radiology. Self-assessment module (SAM) online: professionalism. Available at: http://campus.acr.org/acr/sam_professionalism.aspx. Accessed December 19, 2008. 4. Radiological Society of North America. RSNA statement on professionalism. Available at: http://www.rsna.org/About/professionalism.cfm. Accessed December 19, 2008. 5. Lau LS. A continuum of quality in radiology. J Am Coll Radiol 2006;3: 233-9. 6. American College of Radiology. White paper on teleradiology and standard on teleradiology. Available at: http://www.acr.org/Secondary MainMenuCategories/BusinessPracticeIssues/Teleradiology/Reportofthe ACRTaskForce/onInternationalTeleradiologyDoc3.aspx?css⫽print 7. Berlin L. Apathy: the threat within. J Am Coll Radiol 2007;7:433-6. 8. Donnelly LF, Strife JL. Establishing a program to promote professionalism and effective communication in radiology. Radiology 2006;238: 773-9. 9. Gunderman RB. Promoting good work. J Am Coll Radiol 2004;1:343-5.