- Email: [email protected]
Medical imaging in the 21st century
THE LANCET
Issues in imaging
Medical imaging in the 21st century Bruce J Hillman Imaging has been one of the success stories of 20th century medicine but is now under pressure from tight health-care budgets and from professional competition. The 21st century will need a very different type of radiologist, one trained not just in imaging but also in more basic disciplines and in informatics. Research in radiology will need more attention than hitherto, and the imager of tomorrow will have to defend his or her specialty against the charge of “expensive high technology” and adapt, by taking a more market-oriented approach to the added value that the specialty provides. “If we want things to stay as they are, things will have to change” (Giuseppe di Lampedusa, The Leopard)
Medical imaging began as an adjunct to the work of established medical specialties, but since the 1950s separate departments of radiology have become the rule even for small hospitals. With advances in imaging technology (including innovations based on a range of radiofrequency waveforms, such as ultrasound, computed tomography, and magnetic resonance imaging), the specialty of radiology and its practitioners have prospered, both intellectually and financially. Advances in information technology processing offer the prospect of a further acceleration in what imaging has to offer to health care. The potential might seem limitless but there are many non-technical factors that will influence the future of radiology. Among the more important are: ● How changes in medicine will impact on the traditional scope of radiology. ● Changes in what constitutes new knowledge in imaging (and thus the role of imaging research). ● Pressures on budgets for health care. ● The changing nature of medical practice. ● The interest in imaging being shown by other medical specialties. These are powerful forces. Radiology in the future will be different—indeed in some scenarios the very existence of the specialty may be threatened. I will discuss here the way these forces will affect radiology and how the specialty might change if it is to continue to contribute to improvements in health.
Scope of radiology The origins of radiology are in gross anatomy and pathology and these remain the primary foci of the specialty even today. However, further advances in medicine that will significantly improve health are likely to require innovations that detect and treat disease at the level of early functional changes, perhaps even before any microscopic morphological alterations. Research in molecular genetics, cellular engineering, pharmacokinetics, and information technology is facilitating the transition of medicine from the macroscopic to the microscopic or even molecular level, by identifying genes that appear to control the likelihood of disease, by Lancet 1997; 350: 731–33 Department of Radiology, University of Virginia School of Medicine and Health Sciences Center, Charlottesville, VA 22908, USA (Prof B J Hillman MD)
Vol 350 • September 6, 1997
discovering new intrinsic transmitters of biological information and their sites of action, and by developing new drugs to take advantage of this information. However, the training of radiologists—still focused on gross anatomy and pathology—is a poor preparation for the new way these specialists will need to think early in the 21st century. Training must satisfy current clinical demands, but a look to future needs is essential too. Tomorrow’s radiologists need to exchange some of the rote learning of the imaging of gross anatomy and pathology for a better understanding of a range of basic and applied sciences and knowledge of how to use technology to get access to and interpret knowledge. The computerised integration of patient information with expert advice will remove the onus of remembering minutiae and place a premium on understanding the processes underlying disease so that image-derived information can be interpreted. In short, training programmes in radiology need revision with a broader emphasis than hitherto so that tomorrow’s radiologists can work as colleagues with both the molecularly oriented and traditional physicians from other specialties.
Research in radiology Few radiology programmes place much emphasis on research as an important part of training.1,2 However, as the emphasis switches from interpreting images to analysing chemical, genetic, and functional information derived from interrogating the body with various radiofrequency waveforms (often with no intermediary image) the radiologist is going to have to play an important part in imaging-related research. The historical dearth of welltrained radiology researchers and the poor research infrastructure in most academic radiology departments3,4 mean that focused “subspecialty” training in research will have to be incorporated into the postgraduate education of many new radiologists. These young researchers could work in the laboratories of traditionally more researchoriented specialties where they would learn the critical skills they need; in exchange, they would spread the word about what imaging technologies can contribute. These people would then return to radiology better equipped to participate in the interdisciplinary research model that has proved so successful in medicine; they would also be better able to fulfil their role in bringing the products of research to clinical service. Participation in the research enterprise will not be cheap, and it is unfortunate that this call for more radiology research comes at a time when funding for clinical services 731
THE LANCET
leaves little that can be shifted to research and development. Academic radiology departments will need to do some rethinking. First, research needs to be placed on the same business footing as clinical service. Cost and profit centres need to be identified and departmental resources allocated to research need to be considered investments made with the idea of a financial as well as an academic return. For academic medicine to provide research as a service—working with commercial agencies and governments to support product development, marketing, and regulatory functions—is not the traditional view of research but participation in these activities will both facilitate the introduction of clinically valuable innovations and create revenue streams to support more traditional, investigator-initiated studies. The scarcity of qualified radiology researchers has led to an unrealistic market for the services of the few who do qualify. However, it is unusual for radiology researchers to achieve in grants and contracts revenues equivalent to those derived from clinical services, and there will have to be compromises— namely, lower salary expectations in exchange for the funding, space, and other support their departments provide in helping them to pursue a research career. The broader community of radiology needs to recognise research and the small number of excellent research departments there are today as valuable resources for the specialty. All radiologists benefit by the translation of new knowledge into clinical application. Radiology organisations are just beginning to set aside greater resources for research development and researcher recognition.
Health-care budgets Much has been made politically of accelerating health-care costs in the United States but every developed country is experiencing similar pressures. A major factor is the increasing use of more and more complex technology. Policy analysts have questioned whether this investment in technology returns sufficient benefits in improved health.5 Since radiology is a high-technology specialty, this view has affected radiology more adversely than many other specialties. But is it true that modern imaging methods are not worth the price? Part of the problem is that benefits are measured so coarsely, largely as deaths or severe morbidity, while imaging will often affect the quality more than the length of life, by reducing pain and anxiety, shortening hospital stays, and reducing the time to full functional recovery.6 Little of radiological practice is evidence-based, and publications tend to be founded on uncontrolled observations.7 Since few training programmes emphasise critical thinking, the practice of clinical radiology has been inappropriately influenced by positively biased reports so that technology has been implemented with little scientific basis.8 Furthermore “indication creep” (“if it’s good for one thing, it also must work on this other thing, which is sort of like it”), and even financially motivated abuse have resulted in unnecessary duplication and testing and inappropriate treatment.8 Managed-care methods of paying for services give incentives for providers to use only those technologies that demonstrably contribute to improving health or lower health costs overall. Even where less draconian systems than the US managed-care approach are in place, providers are expected to have evidence that their services enhance the overall value of care. The waste so often experienced 732
What radiology needs to do to survive in the 21st century Develop a more intellectual, broader, interdisciplinary appoach to training Participate in and, where possible, lead the process of new discovery Be proactive in scientifically assessing imaging practices Adopt a “customer focus”, based on a more business-like approach Be creative in developing new, valuable, marketable clinical, educational, and research services Lead in implementing integrated information technologies that enhance the quality and reduce the cost of care Build alliances with non-radiologist physicians and health-service administrators
with the introduction of imaging technologies has led to an adversarial relationship between radiology and those responsible for allocating resources. To reduce the impact of this antagonism, radiologists from now on will need to be more active in demonstrating the benefits of their technologies and using them more efficiently. Tomorrow’s radiologists will need to be critical thinkers, learning how to read books and journals and to listen to “experts” more sceptically. This means that their training will need to include biostatistics, epidemiology, clinical research design, health economics, and related healthevaluation sciences—and the specialty as a whole will have to invest in health-services research. Also the specialty will need to recognise that compelling evidence for the efficacy of imaging technology requires radiologists to cooperate across institutions and with other disciplines in research projects on sufficiently sized and generalisable patient populations.6
Future radiological practice Market control of medical expenditure in some form is here to stay, and the trend towards corporatisation of health care that has characterised the late 20th century will continue. Corporate medicine usurps the traditional autonomy of clinicians but its infrastructure allows for quicker access to technological innovation, so long as the innovation is perceived to be beneficial. Information technology allows organisations to concentrate the most appropriate skills where they are needed. In the future, information systems and those who manage them will be able to combine patient information with information about the most recent diagnostic and therapeutic possibilities, referring patients to the most appropriate and least expensive provider, often without regard to geographical location. In medical imaging, the technology is more or less available already. Some radiologists have been trying to put up barriers to organisational restructuring, hoping to avoid losing clinical autonomy and the financial advantages of local competition. They may be successful short-term but the organisational changes will happen one day—and those who resist now will not be among the beneficiaries when they do. The integration of imaging information into comprehensive on-line medical services and the ability to project imaging services over distances (teleradiology), will exert new pressures on radiologists and may even affect radiologist manpower. Medical and surgical specialists seeking greater value from imaging will have, through multimedia communications, a much broader choice and
Vol 350 • September 6, 1997
THE LANCET
may demand a greater level of organ subspecialty still from the radiologist, or decide to do their imaging themselves. Many physicians and surgeons will want to participate more fully in imaging diagnosis and image-guided intervention, so further blurring previous definitions of specialisation. Tomorrow’s radiologist will need to seek accommodations on “turf” and compete with other practice alliances on quality and cost. With organisational and technological change will come new opportunities for radiologists to diversify. As older applications of medical imaging are discarded or taken on by other specialties, the new opportunities provide the entrepreneurial radiologist with the means to ensure the continued growth of the specialty.
most cost-effective options for solving imaging problems; monitoring of the appropriateness of referral; establishing imaging protocols and algorithms; report generation, archival, and improved results management; management of capital and operational resources; setting standards for quality and cost, then measuring performance against those standards and seeking improvement; equipment maintenance, certification, and repair; radiation safety and protection; and education about imaging for other practitioners. Greater appreciation of this infrastructure by non-radiologist physicians and by health service administrators (and a reminder of the costs of duplicating it) is a potent incentive for comprehensive radiology departments.
Interests of other medical specialties
Radiology in the 21st century
Radiology is a referral specialty. With few exceptions, the radiologist depends on other physicians for requests for imaging examinations. This historical mode of practice is under threat. Increasingly, physicians are asked to manage not only the health of their patients but also the money it takes to care for them. There is an excess of physicians in some specialties,9,10 governments are reducing the rate of growth of money available to physicians, and nonradiologist physicians have become more familiar with the imaging techniques most frequently employed in their practices. Also academic careers are frequently based on controlling the latest new technology. All this adds up to potent incentives for non-radiologists to take on imaging technologies and “self-refer” for imaging procedures rather than sending their patients to a radiologist. Even though self-referral means more investigations and greater costs, with no benefit,11–14 governments find it difficult to curb the practice. In the USA, about half the clinical imaging “work” is done by non-radiologists.15 Radiologists could weaken these incentives by altering the way they themselves work and by adopting a more business-like strategy. Radiologists could formally identify and then aim at their “market”, analysing and then directing efforts towards reinforcing their position in the value chain of their health-care market. They could adopt more of a “customer focus” approach to attracting and retaining “clients” (referring physicians and patients). Referring physicians are not only suppliers (of patients) but also customers, to whom the radiologist says, “Anything, anytime”. This approach means more aggressive management of the complete imaging environment and redefining what constitutes marketable “quality”. Traditional radiology’s concept of quality has focused on how well images are exposed and interpreted and how well image-guided procedures are done. If radiologist referral is to remain attractive the radiologist will need to share the interests of the specialist by becoming as expert in the function of organ systems and by understanding the referring physicians’ needs. Physicians (let alone patients) may have difficulty in distinguishing differences in professional quality among radiologists. Increasingly, they will look for timeliness and access, and the continued success of an integrated, comprehensive practice of radiology will depend on a “365 by 24” (all day, every day) service that can be made both more visible to and more valued by referring physicians. The infrastructure of such a service should include continued assessment, accreditation and quality assurance for professional and technical staff; consultation on the
Even though the changes discussed will occur step by step radiology will soon have to respond positively if it is to be as successful in the 21st century as it was in the 20th. The new radiology will need to be much more collaborative. The concept of collaboration is a frightening one—it means taking risks and, often, giving up something to get something. Collaboration means bringing something to the relationship that is valued by the collaborator, so that there is symmetry to the partnership. The needed metamorphosis does seem to have begun. The requirements are summarised in the panel.
Vol 350 • September 6, 1997
I thank Robert M Carey, Laurie L Fajardo, Diane G Hillman, Donald R Kirks, and C Douglas Maynard, for their advice.
References 1
2
3 4
5 6 7 8
9 10
11
12
13 14
15
Hillman BJ, Putman CE. Fostering research by radiologists: recommendations of the 1991 summit meeting. Radiology 1992; 182: 315–18. Hillman BJ, Fajardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti JV. Factors influencing radiologists to choose research careers. Invest Radiol 1989; 24; 842–48. Virapongse C, Emerson S, Li KCP, Martineau BS, Staab EB. Research resources in academic radiology. Radiology 1990; 175: 247–51. Hillman BJ, Witzke DB, Fajardo LL, Fulginiti JV. Research and research training in academic radiology departments: a survey of department chairmen. Invest Radiol 1990; 25: 587–90. Newhouse JP. An iconoclastic view of health care cost containment. Health Aff 1993; 12 (suppl): 152–71. Hillman BJ. Outcomes research and cost-effectiveness analysis for diagnostic imaging. Radiology 1994; 193: 307–10. Holman BL. The research that radiologists do: perspective based on a survey of the literature. Radiology 1990; 176: 329–32. Hillman BJ. Physicians’ acquisition and use of new technology in an era of economic constraints. In: Gelijns C, ed. Technology and health care in an era of limits. Washington, DC: National Academy Press, 1992: 133–53. Tarlov AR. Estimating physician workforce requirements: the devil is in the assumptions. JAMA 1995; 274: 1558–60. Goodman DC, Fisher ES, Bubolz TA, Mohr JE, Poage JF, Wennberg JE. Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA 1996; 276: 1811–17. Hillman BJ, Joseph CA, Mabry MR, Sunshine JK, Kennedy SD, Noether M. Frequency and cost of diagnostic imaging in office practice: comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990; 323: 1604–08. Hillman Bj, Olson GT, Griffith PE, et al. Physicians’ utilization and charges for outpatient diagnostic imaging in a medicare population. JAMA 1992; 268: 2050–54. Mitchell JM, Scott E. New evidence of the prevalence and scope of physician joint ventures. JAMA 1992; 268: 80–84. Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers compensation system as a result of self-referral by physicians. N Engl J Med 1992; 327: 1502–06. Sunshine JH, Bansal S, Evens RG. Radiology performed by nonradiologists in the United States: who does what? AJR 1993; 161: 419–23.
733
Issues in imaging
Medical imaging in the 21st century Bruce J Hillman Imaging has been one of the success stories of 20th century medicine but is now under pressure from tight health-care budgets and from professional competition. The 21st century will need a very different type of radiologist, one trained not just in imaging but also in more basic disciplines and in informatics. Research in radiology will need more attention than hitherto, and the imager of tomorrow will have to defend his or her specialty against the charge of “expensive high technology” and adapt, by taking a more market-oriented approach to the added value that the specialty provides. “If we want things to stay as they are, things will have to change” (Giuseppe di Lampedusa, The Leopard)
Medical imaging began as an adjunct to the work of established medical specialties, but since the 1950s separate departments of radiology have become the rule even for small hospitals. With advances in imaging technology (including innovations based on a range of radiofrequency waveforms, such as ultrasound, computed tomography, and magnetic resonance imaging), the specialty of radiology and its practitioners have prospered, both intellectually and financially. Advances in information technology processing offer the prospect of a further acceleration in what imaging has to offer to health care. The potential might seem limitless but there are many non-technical factors that will influence the future of radiology. Among the more important are: ● How changes in medicine will impact on the traditional scope of radiology. ● Changes in what constitutes new knowledge in imaging (and thus the role of imaging research). ● Pressures on budgets for health care. ● The changing nature of medical practice. ● The interest in imaging being shown by other medical specialties. These are powerful forces. Radiology in the future will be different—indeed in some scenarios the very existence of the specialty may be threatened. I will discuss here the way these forces will affect radiology and how the specialty might change if it is to continue to contribute to improvements in health.
Scope of radiology The origins of radiology are in gross anatomy and pathology and these remain the primary foci of the specialty even today. However, further advances in medicine that will significantly improve health are likely to require innovations that detect and treat disease at the level of early functional changes, perhaps even before any microscopic morphological alterations. Research in molecular genetics, cellular engineering, pharmacokinetics, and information technology is facilitating the transition of medicine from the macroscopic to the microscopic or even molecular level, by identifying genes that appear to control the likelihood of disease, by Lancet 1997; 350: 731–33 Department of Radiology, University of Virginia School of Medicine and Health Sciences Center, Charlottesville, VA 22908, USA (Prof B J Hillman MD)
Vol 350 • September 6, 1997
discovering new intrinsic transmitters of biological information and their sites of action, and by developing new drugs to take advantage of this information. However, the training of radiologists—still focused on gross anatomy and pathology—is a poor preparation for the new way these specialists will need to think early in the 21st century. Training must satisfy current clinical demands, but a look to future needs is essential too. Tomorrow’s radiologists need to exchange some of the rote learning of the imaging of gross anatomy and pathology for a better understanding of a range of basic and applied sciences and knowledge of how to use technology to get access to and interpret knowledge. The computerised integration of patient information with expert advice will remove the onus of remembering minutiae and place a premium on understanding the processes underlying disease so that image-derived information can be interpreted. In short, training programmes in radiology need revision with a broader emphasis than hitherto so that tomorrow’s radiologists can work as colleagues with both the molecularly oriented and traditional physicians from other specialties.
Research in radiology Few radiology programmes place much emphasis on research as an important part of training.1,2 However, as the emphasis switches from interpreting images to analysing chemical, genetic, and functional information derived from interrogating the body with various radiofrequency waveforms (often with no intermediary image) the radiologist is going to have to play an important part in imaging-related research. The historical dearth of welltrained radiology researchers and the poor research infrastructure in most academic radiology departments3,4 mean that focused “subspecialty” training in research will have to be incorporated into the postgraduate education of many new radiologists. These young researchers could work in the laboratories of traditionally more researchoriented specialties where they would learn the critical skills they need; in exchange, they would spread the word about what imaging technologies can contribute. These people would then return to radiology better equipped to participate in the interdisciplinary research model that has proved so successful in medicine; they would also be better able to fulfil their role in bringing the products of research to clinical service. Participation in the research enterprise will not be cheap, and it is unfortunate that this call for more radiology research comes at a time when funding for clinical services 731
THE LANCET
leaves little that can be shifted to research and development. Academic radiology departments will need to do some rethinking. First, research needs to be placed on the same business footing as clinical service. Cost and profit centres need to be identified and departmental resources allocated to research need to be considered investments made with the idea of a financial as well as an academic return. For academic medicine to provide research as a service—working with commercial agencies and governments to support product development, marketing, and regulatory functions—is not the traditional view of research but participation in these activities will both facilitate the introduction of clinically valuable innovations and create revenue streams to support more traditional, investigator-initiated studies. The scarcity of qualified radiology researchers has led to an unrealistic market for the services of the few who do qualify. However, it is unusual for radiology researchers to achieve in grants and contracts revenues equivalent to those derived from clinical services, and there will have to be compromises— namely, lower salary expectations in exchange for the funding, space, and other support their departments provide in helping them to pursue a research career. The broader community of radiology needs to recognise research and the small number of excellent research departments there are today as valuable resources for the specialty. All radiologists benefit by the translation of new knowledge into clinical application. Radiology organisations are just beginning to set aside greater resources for research development and researcher recognition.
Health-care budgets Much has been made politically of accelerating health-care costs in the United States but every developed country is experiencing similar pressures. A major factor is the increasing use of more and more complex technology. Policy analysts have questioned whether this investment in technology returns sufficient benefits in improved health.5 Since radiology is a high-technology specialty, this view has affected radiology more adversely than many other specialties. But is it true that modern imaging methods are not worth the price? Part of the problem is that benefits are measured so coarsely, largely as deaths or severe morbidity, while imaging will often affect the quality more than the length of life, by reducing pain and anxiety, shortening hospital stays, and reducing the time to full functional recovery.6 Little of radiological practice is evidence-based, and publications tend to be founded on uncontrolled observations.7 Since few training programmes emphasise critical thinking, the practice of clinical radiology has been inappropriately influenced by positively biased reports so that technology has been implemented with little scientific basis.8 Furthermore “indication creep” (“if it’s good for one thing, it also must work on this other thing, which is sort of like it”), and even financially motivated abuse have resulted in unnecessary duplication and testing and inappropriate treatment.8 Managed-care methods of paying for services give incentives for providers to use only those technologies that demonstrably contribute to improving health or lower health costs overall. Even where less draconian systems than the US managed-care approach are in place, providers are expected to have evidence that their services enhance the overall value of care. The waste so often experienced 732
What radiology needs to do to survive in the 21st century Develop a more intellectual, broader, interdisciplinary appoach to training Participate in and, where possible, lead the process of new discovery Be proactive in scientifically assessing imaging practices Adopt a “customer focus”, based on a more business-like approach Be creative in developing new, valuable, marketable clinical, educational, and research services Lead in implementing integrated information technologies that enhance the quality and reduce the cost of care Build alliances with non-radiologist physicians and health-service administrators
with the introduction of imaging technologies has led to an adversarial relationship between radiology and those responsible for allocating resources. To reduce the impact of this antagonism, radiologists from now on will need to be more active in demonstrating the benefits of their technologies and using them more efficiently. Tomorrow’s radiologists will need to be critical thinkers, learning how to read books and journals and to listen to “experts” more sceptically. This means that their training will need to include biostatistics, epidemiology, clinical research design, health economics, and related healthevaluation sciences—and the specialty as a whole will have to invest in health-services research. Also the specialty will need to recognise that compelling evidence for the efficacy of imaging technology requires radiologists to cooperate across institutions and with other disciplines in research projects on sufficiently sized and generalisable patient populations.6
Future radiological practice Market control of medical expenditure in some form is here to stay, and the trend towards corporatisation of health care that has characterised the late 20th century will continue. Corporate medicine usurps the traditional autonomy of clinicians but its infrastructure allows for quicker access to technological innovation, so long as the innovation is perceived to be beneficial. Information technology allows organisations to concentrate the most appropriate skills where they are needed. In the future, information systems and those who manage them will be able to combine patient information with information about the most recent diagnostic and therapeutic possibilities, referring patients to the most appropriate and least expensive provider, often without regard to geographical location. In medical imaging, the technology is more or less available already. Some radiologists have been trying to put up barriers to organisational restructuring, hoping to avoid losing clinical autonomy and the financial advantages of local competition. They may be successful short-term but the organisational changes will happen one day—and those who resist now will not be among the beneficiaries when they do. The integration of imaging information into comprehensive on-line medical services and the ability to project imaging services over distances (teleradiology), will exert new pressures on radiologists and may even affect radiologist manpower. Medical and surgical specialists seeking greater value from imaging will have, through multimedia communications, a much broader choice and
Vol 350 • September 6, 1997
THE LANCET
may demand a greater level of organ subspecialty still from the radiologist, or decide to do their imaging themselves. Many physicians and surgeons will want to participate more fully in imaging diagnosis and image-guided intervention, so further blurring previous definitions of specialisation. Tomorrow’s radiologist will need to seek accommodations on “turf” and compete with other practice alliances on quality and cost. With organisational and technological change will come new opportunities for radiologists to diversify. As older applications of medical imaging are discarded or taken on by other specialties, the new opportunities provide the entrepreneurial radiologist with the means to ensure the continued growth of the specialty.
most cost-effective options for solving imaging problems; monitoring of the appropriateness of referral; establishing imaging protocols and algorithms; report generation, archival, and improved results management; management of capital and operational resources; setting standards for quality and cost, then measuring performance against those standards and seeking improvement; equipment maintenance, certification, and repair; radiation safety and protection; and education about imaging for other practitioners. Greater appreciation of this infrastructure by non-radiologist physicians and by health service administrators (and a reminder of the costs of duplicating it) is a potent incentive for comprehensive radiology departments.
Interests of other medical specialties
Radiology in the 21st century
Radiology is a referral specialty. With few exceptions, the radiologist depends on other physicians for requests for imaging examinations. This historical mode of practice is under threat. Increasingly, physicians are asked to manage not only the health of their patients but also the money it takes to care for them. There is an excess of physicians in some specialties,9,10 governments are reducing the rate of growth of money available to physicians, and nonradiologist physicians have become more familiar with the imaging techniques most frequently employed in their practices. Also academic careers are frequently based on controlling the latest new technology. All this adds up to potent incentives for non-radiologists to take on imaging technologies and “self-refer” for imaging procedures rather than sending their patients to a radiologist. Even though self-referral means more investigations and greater costs, with no benefit,11–14 governments find it difficult to curb the practice. In the USA, about half the clinical imaging “work” is done by non-radiologists.15 Radiologists could weaken these incentives by altering the way they themselves work and by adopting a more business-like strategy. Radiologists could formally identify and then aim at their “market”, analysing and then directing efforts towards reinforcing their position in the value chain of their health-care market. They could adopt more of a “customer focus” approach to attracting and retaining “clients” (referring physicians and patients). Referring physicians are not only suppliers (of patients) but also customers, to whom the radiologist says, “Anything, anytime”. This approach means more aggressive management of the complete imaging environment and redefining what constitutes marketable “quality”. Traditional radiology’s concept of quality has focused on how well images are exposed and interpreted and how well image-guided procedures are done. If radiologist referral is to remain attractive the radiologist will need to share the interests of the specialist by becoming as expert in the function of organ systems and by understanding the referring physicians’ needs. Physicians (let alone patients) may have difficulty in distinguishing differences in professional quality among radiologists. Increasingly, they will look for timeliness and access, and the continued success of an integrated, comprehensive practice of radiology will depend on a “365 by 24” (all day, every day) service that can be made both more visible to and more valued by referring physicians. The infrastructure of such a service should include continued assessment, accreditation and quality assurance for professional and technical staff; consultation on the
Even though the changes discussed will occur step by step radiology will soon have to respond positively if it is to be as successful in the 21st century as it was in the 20th. The new radiology will need to be much more collaborative. The concept of collaboration is a frightening one—it means taking risks and, often, giving up something to get something. Collaboration means bringing something to the relationship that is valued by the collaborator, so that there is symmetry to the partnership. The needed metamorphosis does seem to have begun. The requirements are summarised in the panel.
Vol 350 • September 6, 1997
I thank Robert M Carey, Laurie L Fajardo, Diane G Hillman, Donald R Kirks, and C Douglas Maynard, for their advice.
References 1
2
3 4
5 6 7 8
9 10
11
12
13 14
15
Hillman BJ, Putman CE. Fostering research by radiologists: recommendations of the 1991 summit meeting. Radiology 1992; 182: 315–18. Hillman BJ, Fajardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti JV. Factors influencing radiologists to choose research careers. Invest Radiol 1989; 24; 842–48. Virapongse C, Emerson S, Li KCP, Martineau BS, Staab EB. Research resources in academic radiology. Radiology 1990; 175: 247–51. Hillman BJ, Witzke DB, Fajardo LL, Fulginiti JV. Research and research training in academic radiology departments: a survey of department chairmen. Invest Radiol 1990; 25: 587–90. Newhouse JP. An iconoclastic view of health care cost containment. Health Aff 1993; 12 (suppl): 152–71. Hillman BJ. Outcomes research and cost-effectiveness analysis for diagnostic imaging. Radiology 1994; 193: 307–10. Holman BL. The research that radiologists do: perspective based on a survey of the literature. Radiology 1990; 176: 329–32. Hillman BJ. Physicians’ acquisition and use of new technology in an era of economic constraints. In: Gelijns C, ed. Technology and health care in an era of limits. Washington, DC: National Academy Press, 1992: 133–53. Tarlov AR. Estimating physician workforce requirements: the devil is in the assumptions. JAMA 1995; 274: 1558–60. Goodman DC, Fisher ES, Bubolz TA, Mohr JE, Poage JF, Wennberg JE. Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA 1996; 276: 1811–17. Hillman BJ, Joseph CA, Mabry MR, Sunshine JK, Kennedy SD, Noether M. Frequency and cost of diagnostic imaging in office practice: comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990; 323: 1604–08. Hillman Bj, Olson GT, Griffith PE, et al. Physicians’ utilization and charges for outpatient diagnostic imaging in a medicare population. JAMA 1992; 268: 2050–54. Mitchell JM, Scott E. New evidence of the prevalence and scope of physician joint ventures. JAMA 1992; 268: 80–84. Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers compensation system as a result of self-referral by physicians. N Engl J Med 1992; 327: 1502–06. Sunshine JH, Bansal S, Evens RG. Radiology performed by nonradiologists in the United States: who does what? AJR 1993; 161: 419–23.
733