- Email: [email protected]
The Radiology World Is Flat: Problems or Solutions for Radiologists?
OPINION
The Radiology World Is Flat: Problems or Solutions for Radiologists? Giles W. L. Boland, MD Thomas Friedman [1], in his recent book The World Is Flat: A Brief History of the Twenty-First Century, wrote, “Thank goodness I’m a journalist and not an accountant or a radiologist. There will be no outsourcing for me.” His book discusses in detail how the Internet revolution and globalization might threaten the survival of our profession, as we now know it. I was highly skeptical when I first read this, even dismissive, partly because I could not envision radiologists being put into the same “pot” as accountants and telephone sales personnel. Surely our profession is a different breed, requiring far more skill and training than these other commoditized professions. Furthermore, our customers (patients, referring physicians, and to a lesser extent administrators) need us to be close at hand. Good patient care, we think, often requires a physical presence with our professional colleagues so we can readily discuss problem cases and advise on particular examinations that might benefit specific patients. Indeed, much of medicine is practiced in this way, because few patients, if any, present with exactly the same clinical and radiologic findings for a given diagnosis. Our referring physician colleagues (and for that matter ourselves) therefore find value in discussing the radiologic findings of their patients: it helps them synthesize these and other, sometimes confounding, factors toward a unique diagnosis in a given patient. How then could Mr Friedman glibly seem to state that radiologists had “better be aware”? 754
The reason, simply, is because radiologic images (being inherently digital) can be transmitted anywhere at any time, fortunately or unfortunately for radiologists. As Mr Friedman explains, a massive worldwide outlay of high-bandwidth fiber optics during the late 1990s has provided the infrastructure for any digital material to be transmitted faithfully and expeditiously anywhere in the world. He had been to India and had witnessed computed tomographic scans transmitted from the United States being displayed almost instantaneously with the same fidelity as if viewing them at the scanner console. Perhaps Mr Friedman does not fully understand how medicine works and his prediction will prove naive, but I have come to think that he may not be far off the mark. After all, a radiologist’s principal product is the report, so if this can be performed better elsewhere, maybe our customers will seek it elsewhere. Indeed, we, as radiologists, had better be aware. Not only are we witnessing a fundamental shift in the way radiology is practiced, we may actually be facilitating the process. Already, many radiology groups outsource their after-hours radiology to a variety of providers across the globe, not just within states or even across state lines [2]. Indeed, Mr Friedman’s prediction has already been fulfilled to some degree. Images are now beamed to Australia, Israel, Switzerland, and India, among other countries, for afterhours interpretation. It is difficult to know how many hospitals are
outsourcing their after-hours radiology, but some teleradiology providers believe it could be as high as 40% and rising (Keith Dreyer, MD, personal communication, 2007). Because most of this outsourcing is limited to after-hours radiology (which is generally seen as undesirable by most radiology groups), many radiologists have not yet realized that a widespread redistribution of daytime radiology is also possible. To be sure, there are regulatory, medico-legal, and fiscal hurdles that continue to hinder the outsourcing of daytime radiology [2,3]. However, capitalism, being what it is, makes some individuals and companies highly creative. Who would have thought that it makes sense for individual radiologists to be licensed in all 50 states? There are teleradiology companies and providers who have indeed found it more than worthwhile to have radiologists licensed in multiple states, despite the bureaucratic hurdles and expense that this entails. In fact, some teleradiology companies have dedicated staff members facilitating the licensing process for their radiologists, who can then become licensed in most states within a matter of months. And these teleradiology companies are highly successful, signing up new contracts weekly as radiology groups decide that they no longer wish to provide after-hours radiology coverage to their organizations. Obviously, this is precisely why teleradiology companies are flourishing. Together with ubiquitous fiber-optic bandwidth and an infra-
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.04.012
Opinion 755
structure to license their radiologists in multiple states, they have now made it easily possible for radiology groups to outsource their less palatable after-hours responsibilities [2]. Furthermore, it is now de rigueur to do so. Radiology groups can now point out to their administrators and referring physician colleagues that this is standard in the industry, and so they should likewise be permitted to do so. Some have even managed to convince their hospitals to pay for this service (even though most radiologists can bill for these cases by providing final signatures the next morning). Furthermore, many radiologists in residencies and fellowships are naturally more attracted to those groups in which there are minimal after-hours responsibilities. Teleradiology companies clearly know that their businesses will survive only if they provide superior customer service and radiologic interpretations of excellent quality [4]. This must be the case; otherwise, the thousands of hospitals that are now covered at night by these companies would soon withdraw their business. Any delay by these companies in nighttime interpretations would soon frustrate emergency room physicians. Neither would they tolerate consistently inferior interpretations for very long. In fact, many emergency room doctors (who request most of the radiologic studies after hours) now frequently state that these teleradiology companies provide superior service compared with their existing radiology groups, members of whom often grumble about having to be woken up in the middle of the night for what they deem may be inappropriate radiology requests. Referring physicians have also been impressed with the quality of interpretations, and although
some mistakes are made, they are generally within the expected error range or even less; the teleradiology companies (to stay competitive) have implemented sophisticated and rigorous quality control and quality assurance programs [2,4]. This state of affairs may at first seem highly desirable to most radiologists, because they can sleep at night while emergency room doctors obtain timely, accurate reports, without the slightest bit of attitude, from reporting radiologists. However, there has been a shift of thinking by these and other referring physicians. The word has been getting out to other referring physicians that they too can obtain timely, accurate, succinct reports, delivered with a smile, so to speak, from these teleradiology companies. They are therefore beginning to ask why they too cannot have the same service for regular, nonurgent, daytime radiologic interpretations. Radiologists may inadvertently be encouraging referring physicians to think in this way, often stating they are overworked because of the wellrecognized staff shortages and significant increase in radiology volume over the past decade [5-8]. Also, because of the sophistication of contemporary cross-sectional imaging, referring physicians are increasingly demanding greater specificity of reports, which requires subspecialty radiologists. Most radiology groups in medium-sized and smaller hospitals may not be able to provide the degree of subspecialization that their referring physicians would ideally wish for. Naturally, some teleradiology companies have recognized this new opportunity in the market and have either employed cadres of subspecialty radiologists themselves or teamed up with larger radiology groups, perhaps with teaching hospitals, to offer this extended service.
Because they have already overcome the technologic and licensing hurdles, they are poised to take advantage of this market and indeed are already doing so. After all, it was only perhaps 4 to 5 years ago that outsourced nighttime teleradiology was in its infancy, and now it is widespread. As referring physicians are demanding radiology readings of higher specificity, some are already either sending their patients out of network to competing facilities (if they exist) or are placing significant pressure on their own radiology groups to deliver more subspecialization. As a result, some radiology groups are beginning to turn to teleradiology companies to fill this gap rather than replace it with locum tenens radiologists. Locum tenens radiologists are often perceived as less than ideal because they may not offer subspecialized interpretations and are often left to do the “general work.” Additionally, it is hard for locum tenens radiologists to easily fit into the culture of organizations, particularly because they are by definition itinerant. Radiology groups may have no choice therefore but to outsource readings to teleradiology companies to meet their stakeholders’ expectations [8]. Although this state of affairs is far from ideal for radiology groups, many referring physicians might see it otherwise. Who could deny that timely, accurate, subspecialty radiology reports are a good thing? Anything that increases the value of the report enhances the value of the product, whether delivered by the existing radiology group or by a teleradiology company [8,9]. It is because there has been such a success with after-hours teleradiology that referring doctors now have enough confidence to ask (or even demand) that their radiology groups offer the
756 Opinion
same service, lest they need to outsource some of their existing work. It is therefore only a hop, skip, and a jump before daytime readings could take a similar hold in the radiology market, in the same way that after-hours readings have. Some may argue that there are not enough board-certified and licensed radiologists within the United States or abroad to meet this potential demand, and as of this moment, that statement is probably correct. However, there are hundreds, perhaps thousands, of licensed and board-certified radiologists across the United States who may be willing to enter this market, to make more money, or perhaps to have more flexible lifestyles (working out of the home, for instance). Some foreign nationals may use this as an opportunity to relocate to their home countries, even if for part of the year, to perform radiologic interpretations there (where the cost of living may be much lower). However, there will continue to be fiscal and regulatory hurdles (as there were initially with after-hours teleradiology) to overcome if this is to become widespread [3]. Currently, it is not possible to submit a bill to the Centers for Medicare and Medicaid Services if the radiology interpretation is performed outside of the country. However, that has not stopped radiologists signing off on preliminary interpretations (for after-hours teleradiology interpretations) with final signatures the next morning at the institutions at which patients were scanned. Although it is obviously the responsibility of the radiologist who records the final signature to diligently analyze the examination before signing this preliminary report, this process is probably faster than performing the primary interpretation de novo. At present, there is very little (if any) information on how this process is performed (including
the quality control procedures), and it is unknown how long this process generally takes. Therefore, despite the fiscal and medico-legal hurdles, it is quite conceivable that radiologists will still be encouraged (either by themselves or by referring physicians) to outsource their routine examinations, similar to the after-hours examinations. The existing provider models for daytime teleradiology range from local in-state providers (maybe local teaching hospitals) to offshore groups in India, where labor costs are low, that are offering $15 to $20 computed tomographic interpretations. To some, this latter model may seem highly unlikely to succeed, but it is already being offered to hospitals in the United Kingdom, where there is a chronic shortage of radiologists (David Roberts, chief executive, University Hospitals, Coventry and Warwickshire National Health Service Trust, personal communication, 2007). These providers are proposing a model whereby Indian radiologists (who may or may not be board certified in the United States) provide preliminary radiologic interpretations that can be final signed by board-certified and licensed radiologists and billed to the Centers for Medicare and Medicaid Services or to third-party payers. So what might the radiology landscape look like in 5 years? It is quite conceivable that large volumes of routine daytime radiologic examinations will be outsourced for interpretation, because the reports will be provided either more quickly or more accurately, or both. Most would probably be outsourced to radiologists physically located within the United Sates, but as the business becomes widespread, board-certified radiologists may be encouraged to work from overseas (for reasons of lifestyle or a
desire to return to their countries of origin). Radiology groups and hospitals may then choose to outsource professional interpretations to providers who offer the lowest price (as long as they could guarantee quality). In other words, the professional interpretation of radiologic images will become commoditized, something that has effectively already happened for outsourced nighttime teleradiology. Perhaps even third-party payers will take advantage of this commoditization and seek out the lowest bidders. What can radiologists do to prevent this, and should they prevent it? It may be that the “horse has already bolted,” and it will inevitably happen anyway. However, radiology groups can help address the demands of their stakeholders (patients, referring physicians, and administrators) by at all times striving to provide the highest quality service, with timely, accurate, ideally subspecialized reporting. Furthermore, radiology groups should actively promote new, state-of-the-art radiology technology and clinical protocols and help hospitals increase their revenue streams. Under these circumstances, there may be little need for organizations to desire or demand that any image interpretation be outsourced. On the other hand, as radiology volume continues to grow and the staffing shortages persist, or get worse (as the baby boomers retire), radiologists may have no choice but to outsource an increasing proportion of their examinations for professional interpretation. Perhaps all we can do as radiologists is insist that teleradiology companies maintain high-quality and ethical standards to ensure that our patients are well served. So maybe Tom Friedman has more than just a point. The radiol-
Opinion 757
ogy world is flat, and we had better be prepared. REFERENCES 1. Friedman TL. The world is flat: a brief history of the twenty-first century. New York: Farrar, Straus; 2006. 2. Bradley WG. Offshore teleradiology. J Am Coll Radiol 2004;1:244-8. 3. West RW, Sipe CY, Bentley TJ. Teleradiology: a legal perspective. J Am Coll Radiol 2004;1:242-3.
4. Wong WS, Roubal I, Jackson DB, Paik WN, Wong VKJ. Outsourced teleradiology imaging services: an analysis of discordant interpretation in 124,870 cases. J Am Coll Radiol 2005;2:478-84. 5. Maitino AJ, Levin DC, Parker L, Rao VM, Sunshine JH. Nationwide trends in rates of utilization of noninvasive diagnostic imaging among the Medicare population between 1993 and 1999. Radiology 2003;228: 795-802. 6. Maitino AJ, Levin DC, Rao VM, Parker L, Sunshine J. Growth in utilization of noninva-
sive diagnostic imaging (NDI) among radiologists and nonradiologist physicians between 1999 and 2002. RSNA Annu Sci Meeting 2004;231(D):365. 7. Moser J. Getting at the facts on imaging utilization rates. J Am Coll Radiol. 2005;2: 720-4. 8. Boland GWL. Stakeholder expectations for radiologists: obstacles or opportunities? J Am Coll Radiol 2006;3:156-63. 9. Boland GWL. Patient-focused radiology: the value of customer service? J Am Coll Radiol 2007;4:88-9.
Giles W. L. Boland, MD, Massachusetts General Hospital, Department of Radiology, White Building 270C, 55 Fruit Street, Boston, MA 02114; e-mail: [email protected].
The Radiology World Is Flat: Problems or Solutions for Radiologists? Giles W. L. Boland, MD Thomas Friedman [1], in his recent book The World Is Flat: A Brief History of the Twenty-First Century, wrote, “Thank goodness I’m a journalist and not an accountant or a radiologist. There will be no outsourcing for me.” His book discusses in detail how the Internet revolution and globalization might threaten the survival of our profession, as we now know it. I was highly skeptical when I first read this, even dismissive, partly because I could not envision radiologists being put into the same “pot” as accountants and telephone sales personnel. Surely our profession is a different breed, requiring far more skill and training than these other commoditized professions. Furthermore, our customers (patients, referring physicians, and to a lesser extent administrators) need us to be close at hand. Good patient care, we think, often requires a physical presence with our professional colleagues so we can readily discuss problem cases and advise on particular examinations that might benefit specific patients. Indeed, much of medicine is practiced in this way, because few patients, if any, present with exactly the same clinical and radiologic findings for a given diagnosis. Our referring physician colleagues (and for that matter ourselves) therefore find value in discussing the radiologic findings of their patients: it helps them synthesize these and other, sometimes confounding, factors toward a unique diagnosis in a given patient. How then could Mr Friedman glibly seem to state that radiologists had “better be aware”? 754
The reason, simply, is because radiologic images (being inherently digital) can be transmitted anywhere at any time, fortunately or unfortunately for radiologists. As Mr Friedman explains, a massive worldwide outlay of high-bandwidth fiber optics during the late 1990s has provided the infrastructure for any digital material to be transmitted faithfully and expeditiously anywhere in the world. He had been to India and had witnessed computed tomographic scans transmitted from the United States being displayed almost instantaneously with the same fidelity as if viewing them at the scanner console. Perhaps Mr Friedman does not fully understand how medicine works and his prediction will prove naive, but I have come to think that he may not be far off the mark. After all, a radiologist’s principal product is the report, so if this can be performed better elsewhere, maybe our customers will seek it elsewhere. Indeed, we, as radiologists, had better be aware. Not only are we witnessing a fundamental shift in the way radiology is practiced, we may actually be facilitating the process. Already, many radiology groups outsource their after-hours radiology to a variety of providers across the globe, not just within states or even across state lines [2]. Indeed, Mr Friedman’s prediction has already been fulfilled to some degree. Images are now beamed to Australia, Israel, Switzerland, and India, among other countries, for afterhours interpretation. It is difficult to know how many hospitals are
outsourcing their after-hours radiology, but some teleradiology providers believe it could be as high as 40% and rising (Keith Dreyer, MD, personal communication, 2007). Because most of this outsourcing is limited to after-hours radiology (which is generally seen as undesirable by most radiology groups), many radiologists have not yet realized that a widespread redistribution of daytime radiology is also possible. To be sure, there are regulatory, medico-legal, and fiscal hurdles that continue to hinder the outsourcing of daytime radiology [2,3]. However, capitalism, being what it is, makes some individuals and companies highly creative. Who would have thought that it makes sense for individual radiologists to be licensed in all 50 states? There are teleradiology companies and providers who have indeed found it more than worthwhile to have radiologists licensed in multiple states, despite the bureaucratic hurdles and expense that this entails. In fact, some teleradiology companies have dedicated staff members facilitating the licensing process for their radiologists, who can then become licensed in most states within a matter of months. And these teleradiology companies are highly successful, signing up new contracts weekly as radiology groups decide that they no longer wish to provide after-hours radiology coverage to their organizations. Obviously, this is precisely why teleradiology companies are flourishing. Together with ubiquitous fiber-optic bandwidth and an infra-
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.04.012
Opinion 755
structure to license their radiologists in multiple states, they have now made it easily possible for radiology groups to outsource their less palatable after-hours responsibilities [2]. Furthermore, it is now de rigueur to do so. Radiology groups can now point out to their administrators and referring physician colleagues that this is standard in the industry, and so they should likewise be permitted to do so. Some have even managed to convince their hospitals to pay for this service (even though most radiologists can bill for these cases by providing final signatures the next morning). Furthermore, many radiologists in residencies and fellowships are naturally more attracted to those groups in which there are minimal after-hours responsibilities. Teleradiology companies clearly know that their businesses will survive only if they provide superior customer service and radiologic interpretations of excellent quality [4]. This must be the case; otherwise, the thousands of hospitals that are now covered at night by these companies would soon withdraw their business. Any delay by these companies in nighttime interpretations would soon frustrate emergency room physicians. Neither would they tolerate consistently inferior interpretations for very long. In fact, many emergency room doctors (who request most of the radiologic studies after hours) now frequently state that these teleradiology companies provide superior service compared with their existing radiology groups, members of whom often grumble about having to be woken up in the middle of the night for what they deem may be inappropriate radiology requests. Referring physicians have also been impressed with the quality of interpretations, and although
some mistakes are made, they are generally within the expected error range or even less; the teleradiology companies (to stay competitive) have implemented sophisticated and rigorous quality control and quality assurance programs [2,4]. This state of affairs may at first seem highly desirable to most radiologists, because they can sleep at night while emergency room doctors obtain timely, accurate reports, without the slightest bit of attitude, from reporting radiologists. However, there has been a shift of thinking by these and other referring physicians. The word has been getting out to other referring physicians that they too can obtain timely, accurate, succinct reports, delivered with a smile, so to speak, from these teleradiology companies. They are therefore beginning to ask why they too cannot have the same service for regular, nonurgent, daytime radiologic interpretations. Radiologists may inadvertently be encouraging referring physicians to think in this way, often stating they are overworked because of the wellrecognized staff shortages and significant increase in radiology volume over the past decade [5-8]. Also, because of the sophistication of contemporary cross-sectional imaging, referring physicians are increasingly demanding greater specificity of reports, which requires subspecialty radiologists. Most radiology groups in medium-sized and smaller hospitals may not be able to provide the degree of subspecialization that their referring physicians would ideally wish for. Naturally, some teleradiology companies have recognized this new opportunity in the market and have either employed cadres of subspecialty radiologists themselves or teamed up with larger radiology groups, perhaps with teaching hospitals, to offer this extended service.
Because they have already overcome the technologic and licensing hurdles, they are poised to take advantage of this market and indeed are already doing so. After all, it was only perhaps 4 to 5 years ago that outsourced nighttime teleradiology was in its infancy, and now it is widespread. As referring physicians are demanding radiology readings of higher specificity, some are already either sending their patients out of network to competing facilities (if they exist) or are placing significant pressure on their own radiology groups to deliver more subspecialization. As a result, some radiology groups are beginning to turn to teleradiology companies to fill this gap rather than replace it with locum tenens radiologists. Locum tenens radiologists are often perceived as less than ideal because they may not offer subspecialized interpretations and are often left to do the “general work.” Additionally, it is hard for locum tenens radiologists to easily fit into the culture of organizations, particularly because they are by definition itinerant. Radiology groups may have no choice therefore but to outsource readings to teleradiology companies to meet their stakeholders’ expectations [8]. Although this state of affairs is far from ideal for radiology groups, many referring physicians might see it otherwise. Who could deny that timely, accurate, subspecialty radiology reports are a good thing? Anything that increases the value of the report enhances the value of the product, whether delivered by the existing radiology group or by a teleradiology company [8,9]. It is because there has been such a success with after-hours teleradiology that referring doctors now have enough confidence to ask (or even demand) that their radiology groups offer the
756 Opinion
same service, lest they need to outsource some of their existing work. It is therefore only a hop, skip, and a jump before daytime readings could take a similar hold in the radiology market, in the same way that after-hours readings have. Some may argue that there are not enough board-certified and licensed radiologists within the United States or abroad to meet this potential demand, and as of this moment, that statement is probably correct. However, there are hundreds, perhaps thousands, of licensed and board-certified radiologists across the United States who may be willing to enter this market, to make more money, or perhaps to have more flexible lifestyles (working out of the home, for instance). Some foreign nationals may use this as an opportunity to relocate to their home countries, even if for part of the year, to perform radiologic interpretations there (where the cost of living may be much lower). However, there will continue to be fiscal and regulatory hurdles (as there were initially with after-hours teleradiology) to overcome if this is to become widespread [3]. Currently, it is not possible to submit a bill to the Centers for Medicare and Medicaid Services if the radiology interpretation is performed outside of the country. However, that has not stopped radiologists signing off on preliminary interpretations (for after-hours teleradiology interpretations) with final signatures the next morning at the institutions at which patients were scanned. Although it is obviously the responsibility of the radiologist who records the final signature to diligently analyze the examination before signing this preliminary report, this process is probably faster than performing the primary interpretation de novo. At present, there is very little (if any) information on how this process is performed (including
the quality control procedures), and it is unknown how long this process generally takes. Therefore, despite the fiscal and medico-legal hurdles, it is quite conceivable that radiologists will still be encouraged (either by themselves or by referring physicians) to outsource their routine examinations, similar to the after-hours examinations. The existing provider models for daytime teleradiology range from local in-state providers (maybe local teaching hospitals) to offshore groups in India, where labor costs are low, that are offering $15 to $20 computed tomographic interpretations. To some, this latter model may seem highly unlikely to succeed, but it is already being offered to hospitals in the United Kingdom, where there is a chronic shortage of radiologists (David Roberts, chief executive, University Hospitals, Coventry and Warwickshire National Health Service Trust, personal communication, 2007). These providers are proposing a model whereby Indian radiologists (who may or may not be board certified in the United States) provide preliminary radiologic interpretations that can be final signed by board-certified and licensed radiologists and billed to the Centers for Medicare and Medicaid Services or to third-party payers. So what might the radiology landscape look like in 5 years? It is quite conceivable that large volumes of routine daytime radiologic examinations will be outsourced for interpretation, because the reports will be provided either more quickly or more accurately, or both. Most would probably be outsourced to radiologists physically located within the United Sates, but as the business becomes widespread, board-certified radiologists may be encouraged to work from overseas (for reasons of lifestyle or a
desire to return to their countries of origin). Radiology groups and hospitals may then choose to outsource professional interpretations to providers who offer the lowest price (as long as they could guarantee quality). In other words, the professional interpretation of radiologic images will become commoditized, something that has effectively already happened for outsourced nighttime teleradiology. Perhaps even third-party payers will take advantage of this commoditization and seek out the lowest bidders. What can radiologists do to prevent this, and should they prevent it? It may be that the “horse has already bolted,” and it will inevitably happen anyway. However, radiology groups can help address the demands of their stakeholders (patients, referring physicians, and administrators) by at all times striving to provide the highest quality service, with timely, accurate, ideally subspecialized reporting. Furthermore, radiology groups should actively promote new, state-of-the-art radiology technology and clinical protocols and help hospitals increase their revenue streams. Under these circumstances, there may be little need for organizations to desire or demand that any image interpretation be outsourced. On the other hand, as radiology volume continues to grow and the staffing shortages persist, or get worse (as the baby boomers retire), radiologists may have no choice but to outsource an increasing proportion of their examinations for professional interpretation. Perhaps all we can do as radiologists is insist that teleradiology companies maintain high-quality and ethical standards to ensure that our patients are well served. So maybe Tom Friedman has more than just a point. The radiol-
Opinion 757
ogy world is flat, and we had better be prepared. REFERENCES 1. Friedman TL. The world is flat: a brief history of the twenty-first century. New York: Farrar, Straus; 2006. 2. Bradley WG. Offshore teleradiology. J Am Coll Radiol 2004;1:244-8. 3. West RW, Sipe CY, Bentley TJ. Teleradiology: a legal perspective. J Am Coll Radiol 2004;1:242-3.
4. Wong WS, Roubal I, Jackson DB, Paik WN, Wong VKJ. Outsourced teleradiology imaging services: an analysis of discordant interpretation in 124,870 cases. J Am Coll Radiol 2005;2:478-84. 5. Maitino AJ, Levin DC, Parker L, Rao VM, Sunshine JH. Nationwide trends in rates of utilization of noninvasive diagnostic imaging among the Medicare population between 1993 and 1999. Radiology 2003;228: 795-802. 6. Maitino AJ, Levin DC, Rao VM, Parker L, Sunshine J. Growth in utilization of noninva-
sive diagnostic imaging (NDI) among radiologists and nonradiologist physicians between 1999 and 2002. RSNA Annu Sci Meeting 2004;231(D):365. 7. Moser J. Getting at the facts on imaging utilization rates. J Am Coll Radiol. 2005;2: 720-4. 8. Boland GWL. Stakeholder expectations for radiologists: obstacles or opportunities? J Am Coll Radiol 2006;3:156-63. 9. Boland GWL. Patient-focused radiology: the value of customer service? J Am Coll Radiol 2007;4:88-9.
Giles W. L. Boland, MD, Massachusetts General Hospital, Department of Radiology, White Building 270C, 55 Fruit Street, Boston, MA 02114; e-mail: [email protected].