Strategies for Radiology to Thrive in the Value Era

Introduction

It is an exciting time to be a radiologist. Medical imaging technology continues to advance. Tools used to view images are nothing short of astonishing. Images and our interpretive expertise have become an indispensable part of the diagnostic process, enabling effective and timely clinical care. The job market is strong and salaries remain healthy. Our educational efforts continue to expand in breadth, depth, and degree of innovation, and our training programs are as competitive as ever. The advent of artificial intelligence holds promise to continue the positive effect of medical imaging and image interpretation on patients’ lives.

However, the winds of change are blowing on a number of fronts. As technology becomes more sophisticated, it becomes more difficult to manage. Continued advances in technology and understanding of disease require increasing radiologist skill, which calls for increasing specialization. Radiology practices are continuing to increase in size and geographic coverage, which itself poses significant management challenges. The hospitals and health care delivery systems with which we partner also continue to increase in size and complexity while radiology becomes more deeply integrated into their clinical workflows and electronic systems. Similarly, our electronic systems are becoming increasingly complex and burdensome, consuming an increasing amount of our time and attention.

As technology and medical knowledge mature, they become more regimented and standardized. For example, in the United States, classification systems such as Liver Imaging Reporting and Data System (known as LI-RADS), Lung Reporting and Data System (known as LungRADS), and Prostate Imaging Reporting and Data System (known as PI-RADS) are building on the tradition of Breast Imaging Reporting and Data System (referred to as BI-RADS) (1–4). This increased uniformity in assessment improves our ability to characterize and treat disease, but adds to the burden of managing an increasingly complex and complicated system.

As our capability and complexity increase at an exponential rate, the costs of delivering our services continue to increase. Health care costs have become one of the major burdens on households and society alike, and are increasingly contributing to national political upheaval (5,6). Fairly or unfairly, medical imaging is often held up as the poster child for excessive health care costs. This is no longer a problem of the far-off future; payers are now actively implementing strategies to rein in costs.

Facing Change in Radiology

Many of these pressures are due to our sustained advancements and growth. In some ways, we are victims of our own success. While these may be good problems to have, they are problems nonetheless. How we respond will shape our careers as individuals and radiology groups and as a specialty as a whole for many years to come.

Medical imaging is a critical component of modern medicine. That is not likely to change any time soon. It is difficult to imagine a future in which medical imaging becomes irrelevant or is excluded from the care process. Radiology is here to stay, regardless of the challenges it faces.

The question is not whether radiology will survive, but rather what our role will be in the specialty and in the medical field going forward. Our current practices may be replaced or subsumed by other practices or practice models. Radiologists may lose power and positions of respect within their local medical communities and at the national and international level. Artificial intelligence threatens to replace radiologists. Loss of interpersonal professional relationships is already leading to degraded feedback and learning loops, undermining continuous improvement efforts at a time when they are most needed. Weakening of relationships and increasing productivity demands are leading to unprecedented rates of physician burnout, even while our salaries remain high. Our ability and willingness to participate in collective efforts to advance the specialty threaten to lead to marginalization of the profession as a whole.

Fortunately, change is nothing new to radiology. Perhaps the greatest strength of our profession has been our ability and willingness to change. Ours is still a young profession. The Radiological Society of North America only recently celebrated its 100-year anniversary. Our most senior radiologists have been in the profession for over a third of the entire existence of the specialty. Within most of our lifetimes, we have seen the emergence of CT, US, MRI, SPECT, and many other imaging techniques. We have participated in the transition from film to digital imaging and from geographic isolation to electronic omnipresence. What we do on a daily basis today barely resembles what a radiologist did 30 years ago. We have embraced these changes and have continued to build a thriving profession.

However, the challenges we are currently facing are different from those faced in the past. Historically, our challenge was to learn to master new technology and an ever increasing body of knowledge. Then, with the advent of information technology, we had to deal with both the opportunities and the pressures of increased radiologist efficiency and productivity. Now we face a dizzying network of systems and processes in which skilled professionals have become increasingly isolated from each other, from their referring physicians, and from their patients. In the past, our problem was one of mastering the clinical and technical challenges. Now we must also master the organizational challenges.

The Concept of Value in Radiology

Regardless of what challenges come our way, we as individuals, as radiology practices, and as a profession will continue to thrive as long as we learn to work collaboratively to continuously do two things: more deeply understand the varied needs of those whom we serve and better meet the needs of those whom we serve (7).

These two elements are the foundation of the concept of value. Embracing the concept of value means that we know whom we serve, what they need, and how we can meet those needs. This includes all of their needs related to the service that we provide them, not just image acquisition and reporting. It also means that we work productively with each other and with our partners to provide a seamless experience for those we serve. It means that we take ownership of the entire process rather than only those elements that we consider to be under our control. To do this in an ever-changing world, we must become what Peter Senge has called a “learning organization” (8). It means that we must continue to learn and improve our performance as individuals, as teams, and as teams of teams, forging learning relationships with members of other teams.

Barriers to Embracing a Focus on Value

What is preventing radiology practices from fully embracing a focus on value? There are many factors, but a handful seems to stand out.

We Are Used to Working as Independent Contractors Rather than as Cohesive and Integrated Teams and Organizations

Our processes, systems, organizational design, and culture have evolved around the paradigm of independent radiologists overseeing image acquisition and generating individual reports. Whereas we may be masters of image interpretation, we often are less expert at organizing ourselves as effective teams, especially when it comes to integrating efficient and reliable processes and systems. We are increasingly being judged by our performance as organizations, not as individuals. Fragmentation and balkanization will not survive an increasingly interconnected world.

Focusing on Value Is Difficult to Conceptualize and to Execute

The concept of value is difficult to articulate in the context of health care, but it is especially challenging for a consultative specialty like diagnostic radiology. Because diagnostic radiologists do not directly manage care, measuring and improving the value we provide to patients is not straightforward. This calls for greater creativity in determining what is meant by value in the context of radiology and how a radiology practice can improve it.

We Do Not Know Who Our Customers Are

Radiologists have many stakeholders, including patients, referring clinicians, hospital administrators, payers, and the radiologists themselves, each of whom have different demands. With so many masters, it can be difficult to know whose perspective to prioritize.

We Seem to Have Forgotten That Our Specialty Is Based on Service

Like much of the health care system, many radiology practices have evolved more around the convenience of the radiologists than that of patients or referring clinicians. Explicitly stating that our primary purpose is to support the referring clinicians in the diagnostic process may feel like we are ceding power to another medical specialty. Moving to a value paradigm requires that we work around the needs and desires of patients and referring clinicians, rather than expecting them to work around ours.

We Do Not Have (or Necessarily Want) Control of the Entire Process

There are many opportunities for things to slip through the cracks in any care setting, but this is especially true in an information-intensive field like diagnostic radiology. Ensuring reliability requires a high level of performance from everyone in the value chain, including referring clinicians, scheduling personnel, technologists, nurses, radiologists, administrative staff and leaders, and information technology staff. Patients and referring clinicians experience the system as a whole and have little patience for breakdowns in transitions that are “nobody’s fault.”

Financial Incentives Are Not Aligned with All Value-added Activities

Radiology practices’ reimbursement has centered on image acquisition and interpretation, based on the number of reports generated. Other activities have generated little to no direct revenue to the radiologists, so it is not surprising that such activities often become targets for cost-saving measures.

Our Mindset of Performance Measurement Is Taking Us down the Wrong Path

The maxim “you cannot improve what you do not measure” has been falsely interpreted as “if you measure it, it will improve.” This has led to a proliferation of measures that do little more than place an increasing administrative burden on all of health care, including radiology practices. Similarly, there is little agreement on—and, therefore, no benchmarking of—so-called outcomes metrics that reflect the value that our diagnostic services add.

We Are Too Focused on Demonstrating Our Value Rather than Improving It

It is tempting to respond to the call to increase our focus on value with the assumption that we are already providing value and that we just need to better convince our stakeholders of this fact. This can feel to them a lot like arguing. Such an approach is a nonstarter because what our stakeholders most desire is to know that we are working in good faith to continuously improve our performance, not arguing with them about what we are already doing.

Value Work Will Add to the Existing Work Burden

In our contemporary workplace, radiologists are already mastering a heavy workload. From one perspective, the strategies that we recommend are likely to be additive, further challenging the effort. This can be balanced by getting rid of some low-value activities in order to embrace those that we recommend. Additionally, the expanding availability of effective informatics tools and greater development and future adoption of artificial intelligence and machine learning algorithms are expected to provide some solutions for our daily practice.

Strategies for Transitioning to a Value-based Practice

The call for a shift to a focus on value in radiology has been around for many years, beginning with the Imaging 3.0 campaign launched by the American College of Radiology in 2013 (9). Much has been written about the concept (10–13). Still, it can be hard for individual practices and individual radiologists to know what specific steps can be taken to increasingly shift to a value-based practice. Here are a few places to start.

We Need to Understand Who Our Customers Are and What They Need

In our case, the term customers refers to those whom we serve, or the recipients of our work (7,14–16). Value is rooted in satisfying a customer, but not all customers are the same or have the same needs. For the core work that we do, our direct customers are referring clinicians; patients generally are the indirect customers. Even then, different types of referring clinicians and patients have different needs. To understand their needs, we just need to ask. Radiology practices focused on value understand who are their major referring clinician groups and continuously inquire as to what aspects of performance they most desire to see improved. They then work to meet those desires in a measurable way. The concept of value boils down to this simple principle.

We Need to Be True Physicians

True physicians do more than provide episodic care. Radiologists should be the doctor's doctor and function as true consulting physicians (17,18). We are true physicians when we develop personal relationships with referring physicians and welcome interruptions from referring clinicians as a chance to connect around patient care. We participate on hospital boards and committees and conduct multidisciplinary rounds. We make ourselves available at inconvenient hours. We follow up on interpretations and recommendations. We provide and graciously accept feedback—even regarding mistakes. We observe the so-called three As of consultative work: availability, affability, and ability. To prevent commoditization of radiology, we must be visible members of the patient’s health care team (19,20).

We Need to Be Excellent Communicators

In diagnostic radiology, we create one thing: information. It is only through information and effective communication that we affect patients’ lives. We should take pride in our primary product: our reports. They should be clear, concise, precise, and actionable (21,22). It is no longer acceptable to use imprecise terms such as interval, short-term, non-urgent, or routine. Our recommendations should reflect national guidelines and other accepted practice standards. It is unacceptable to attach disclaimers excusing typographic and grammatical errors. Instead, we should systematically evaluate and improve the content and value of our reports. We should have a low threshold to pick up the phone and have a conversation with our referring colleagues, especially when we are tempted to use terms like recommend or correlate clinically. Effective verbal communication improves safety, allows for clarification and feedback, and reinforces relationships.

We Need to Work Effectively as Teams and as Teams of Teams

Modern medicine is a team sport. In radiology, as in all of medicine, the so-called cowboy model is an antiquated mindset; it is giving way to the pit crew model (23). As the complexity of modern medicine has advanced, excellent care is increasingly dependent on health care provider teams rather than individuals. In radiology, this includes technologists, nurses, administrators, and information technologists and other support staff. Radiologists who cannot work well in teams, including across authority gradients, place patients at risk.

Even as we learn as individuals to work effectively as teams, our teams must learn to work effectively with other teams (24). In large organizations, individuals tend to naturally form tribes because they identify more closely with members of their own profession, specialty, and role. Although loyalty to one’s colleagues is admirable, it can manifest itself as rivalry with those of other groups. For example, it is tempting for radiologists to see other specialists such as emergency physicians, cardiologists, and orthopedists as “others,” giving rise to petty rivalries and even hostility. This compromises the care and safety of patients, who depend on trusting relationships between professionals for their complex care. To be most effective, we must function as cohesive care delivery systems, with radiologists functioning as members of care provider teams. Our field should embrace or develop models of health care and health care financing that encourage rather than discourage teamwork.

We Need to Become Learning Organizations

A learning organization has been defined as one that is “skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insights” (25). Learning organizations deliberately use data and introspection to focus on continuously improving both individual and group performance. Ironically, our tools for collaborating and sharing our radiology knowledge with our colleagues remain primitive even while we exchange trivial details of our personal lives across the globe. Learning radiology practices have well-cultivated shared teaching files. Instead of trying to ferret out outliers through scoring-based peer review, individuals in learning radiology organizations invest in each other through peer feedback, learning, and improvement (26). Even this is not enough. If we truly desire to improve care by improving our performance, we must embrace peer coaching and ongoing prospective learning.

We Need to Use Our Resources Appropriately and Conscientiously

A major part of providing value is knowing what activities to avoid (27). The equivalent of the readmission rate for clinical patient care in radiology includes unnecessary repeat studies; inappropriate recommendations; nondiagnostic studies; procedure complications; negative customer experience; poor follow-up management; adverse safety events; delayed interpretations; and incorrect, vague, or changed interpretations. Each of these cause inefficiencies, unpredictability, waste, and poor care. We must systematically work to address these.

We also must partner with our referring clinicians to ensure that imaging is utilized appropriately. Appropriateness is not just implementation of a software tool. Our role as diagnostic radiologists is to answer questions (28). Inappropriate imaging utilization occurs when clinicians look to imaging for answers when they should not need to. Rather than simply telling them not to order studies, we should be partnering with our referring clinicians to collectively learn how to better answer their questions without imaging, where appropriate, so that they do not feel they need to ask the question in the first place. Regardless of the approach, ensuring appropriate utilization requires active engagement with our referring clinicians.

We Need to Be More Thoughtful in How We Measure and Improve Performance

In our experience (26), performance measurement does not typically lead to improvement. Rather, the converse tends to be true: those who engage in genuine improvement efforts usually develop good performance measures. Measurements consume time and resources; we need to be judicious in developing and applying performance measures. Such measures must reflect the outcomes and costs that we strive to affect.

Focusing on value is not the same as focusing on demonstrating our value. Rather, we should work to improve our value in tangible, demonstrable ways. To our customers, this feels more like genuine efforts to better serve them. While the difference between the two may seem subtle, in a service-based business, the difference between arguing with the customer and working to improve customer service is often the difference between having a customer and not having a customer. The only thing worse than having a demanding customer is not having a demanding customer.

We Need to Develop Processes and Systems That Make It Easy for Us to Do Great Work

Achieving consistent excellent outcomes depends on developing and using excellent processes, including enabling information technology platforms. This also requires that radiologists work with each other and with their clinical and administrative partners to develop standard guidelines and processes on the basis of the best available evidence, and then adhere to them. Medicine’s social contract with society grants physicians professional autonomy, which means that they are expected to work together as professionals to develop standards of practice and then to learn and operate within those standards (29). It does not mean that every physician gets to do as he or she pleases—it never did.

As the practice of radiology becomes increasingly dependent on electronic systems, we must work to ensure that those systems help us in our efforts to provide value. In his book The Digital Doctor, Robert Wachter, MD, laments the loss of interpersonal relationships caused by the advent of the picture archiving and communication system (30). Whereas he claims this was a side effect that nobody saw coming, many radiologists who lived through this transition foresaw this but were powerless to stop it. As our work becomes increasingly dependent on automated algorithms, we must fight to ensure that they are used to enhance rather than compromise critical but less tangible elements that bring value, such as interpersonal interactions, communication, relationships, feedback and learning, and collegiality.

Conclusion

The concept of value simply boils down to understanding the needs and desires of those whom an organization serves and continuously working to improve how well those needs and desires are met. The concept is not new to radiology; on the contrary, it is based on the founding principles of the profession. The difference is that we now work in a much larger, more complex, more integrated, and more technologically advanced environment. As organizations continue to grow in size and complexity, less tangible elements can be lost in the drive to increase efficiency and productivity.

However, we cannot merely revert back to simpler times. Often, debate about performance is framed as either/or. You can have either efficiency or quality, but not both. You can have either standard processes or customization for each patient. You can either be geographically dispersed or have strong interpersonal relationships. These are examples of false dichotomies. We should no longer think of performance as either/or. It would benefit us to change our mindset. We need to figure out how we can increase both efficiency and quality, both standardization and customization, and both wide geographic coverage and strong interpersonal relationships. That is an exciting challenge and a timely opportunity for us. We must learn how to increase both efficiency and quality. We must learn how to develop standard processes as well as customize for each patient as needed. We must learn to develop and use electronic systems that can both enable us to work in geographically disparate locations and enhance interpersonal professional relationships. This will be difficult but not impossible.

We should be clear about the stakes. The practice of radiology is not going away. Rather, the question is more about our roles in this evolving environment. Radiology practices that cannot meet these challenges are being—and will continue to be—replaced or subsumed by practices that can. The professional partner model is being replaced in many instances by the corporate employer model. As the power of referring clinicians and patients increases, organizations and models that truly understand and represent the interests of these groups will increasingly dominate whereas those that cannot will be phased out.

Perhaps more poignantly, individual radiologists who can effectively collaborate with each another and who can increase the value to referring clinicians and patients are increasingly recognized as assets to radiology practices, whereas radiologists who cannot work toward consensus with their colleagues, who treat technologists with condescension, who generate sloppy reports, who constantly complain about the demands of referring clinicians, and who cannot accept feedback and learn from mistakes are increasingly becoming a liability.

Although this may be seen as a threat, it is actually an opportunity. Because our profession is based in service, we are already well prepared to embrace this transition; in many cases, we just need to embed our natural individual efforts to connect with our patients, our referring clinicians, and our radiology colleagues into our organizational designs, our workflows, and our electronic systems. Strengthening our professional relationships and deepening our engagement also enhances our professional satisfaction and helps prevent burnout.

For those who are willing and able to accept these challenges as opportunities, this is an exciting time to be a radiologist.

Disclosures of Conflicts of Interest: J.B.K. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed money paid to author from Up-To-Date for writing. Other relationships: disclosed no relevant relationships. D.B.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed grants/grants pending to author’s institution from Siemens and Phillips for research support. Other relationships: disclosed no relevant relationships.