Radiology myths considered: 7 debunked, 1—commoditization— confirmed

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 - Benjamin W. Strong, MD (ABR, ABIM)
Benjamin W. Strong, MD (ABR, ABIM)

The time has come for the profession of radiology to embrace a label it has been furiously trying to beat back for years: commoditization. The battle against those who wield it as a pejorative is not just futile, it’s also counterproductive.

Step back and consider the label at a distance sufficiently removed from the agendas and aims that drive some to dismiss things they don’t like by labeling them commodities. Commoditization in real-world applications is, in fact, a very good thing for the consumer. The term connotes not only quality but also availability and cost savings.

Consider the matter from the perspective of people who produce true, honest-to-goodness commodities. The federal government regulates as commodities corn, beef and wheat. What these three examples all have in common is the requirement for food producers to meet standards of quality that are strict, objective and non-negotiable.

In the case of corn, the simplest of the three, FDA places demands on such invisible-to-the-consumer characteristics as moisture content—this cannot exceed 14%—and insect damage, which must be at least 95% absent. Wheat must meet similarly exacting criteria. Beef has so many categories, from prime to choice to commercial to canner, one practically needs an advanced degree to navigate the nuances of each.

So it is that I hereby wholeheartedly embrace the term commoditization as applied to radiology. That goes, with special emphasis, for its use around the branch of radiology near and dear to my heart: teleradiology.

I hope all who love our profession will join me.

Toward that end, I offer several popular myths underlying—and misinforming—the catcalls behind commoditization (as well as its frequent co-pilot in the intended-insult cockpit, “depersonalization”). If you agree that each of these myths is quite easily debunked by the facts, you are well on your way to not only embracing the commoditization of radiology, but also even smiling when you discuss it.

MYTH: Radiology quality can be defined in many different ways, many of which are difficult to quantify.

FACT: Quality in radiology comes down to one thing and one thing only: interpretive accuracy. Did the radiologist make the finding or miss it? This standard may be so plain and obvious that it’s easily overwhelmed by important but lesser concerns. Did you address the clinical question that was asked? Did you use clear and concise terminology? Did you orient your report for the expected target audience?

No one is saying these concerns are inconsequential. However, interpretive accuracy is the sine qua non of the radiologist’s responsibilities. Slip on that, and what difference does it make when you very clearly communicate “no evidence of appendicitis” alongside an image of an abdominal tumor?

MYTH: Most radiology practices have adequate quality-assurance (QA) oversight.

FACT: Most practices practice QA in name only. They tend to overread a minimal percentage of their volume. They tend to do it on modalities not actually prone to misinterpretation. And their overreads are rarely provided by an objective third party who doesn’t have some personal relationship with the radiologist they are overreading or, worse yet, some financial interest in that radiologist’s practice.

For comparison’s sake, and to show what’s possible with dedicated QA, consider vRad’s QA data from the past three years. Our error rate bounced between .3% and .35% for combined major and minor errors. That’s far lower than the standards in the most frequently cited studies, from Wilson Wong, MD, (1.09%) to D.J. Soffa, MD, (3.48%) to Leonard Berlin, MD, (various analyses; see accompanying Q&A article in this issue of Medical Imaging Review).

How did we do it? Over the course of those three years, our practice read approximately 13 million studies. These were overread to the tune of 70% by objective, paying clients who are highly motivated to find errors in our work. Meanwhile, we produce graphs every quarter so that every radiologist in our practice sees exactly where he or she ranks from a quality percentage standpoint. We then place the lowest ranked performers on an improvement plan that leverages our physicians’ best practices.

If more radiology practices followed this model of what I’m proud to call “commodity-level QA,” albeit adjusted to their own scale, more would welcome the charge of commoditization as warmly as I do.

MYTH: Teleradiologists are of lesser training and ability than onsite radiologists.

FACT: Teleradiologists frequently have better training, deeper experience and more finely honed subspecialty skills than onsite radiologists. In the case of vRad, our teleradiologists are all trained at reputable U.S. residencies, they have to pass our own rigorous testing—failure rate: 39%—and they are subjected to extensive background checks.

The latter is a must for teleradiology practices working across state lines, by the way, and I can draw from my own experience as an example. To get 50 state licenses, I had to give account of every step of my career from its start to the current day. One state licensing board flagged my file because it didn’t include contact information for my grade school. Another wanted to know where I was the day after my graduation from medical school. Someone there felt that omission constituted a gap. That’s what inter-state teleradiologists must go through to prove their competence. How many onsite radiologists face as thorough—make that as commoditized—an investigation? 

MYTH: Radiologists are valued, if not revered, by their clinical colleagues.

FACT: We diagnostic radiologists are still working our way out of clinicians’ perception of us as either underworked and overpaid prima donnas, anti-social troglodytes—or some strange brew of both. We have decades of cumulative reputational deficit to overcome, which surely helps explain why we’re so rarely sought out for input on clinical decision-making.

Stated more plainly, we’re only valued by our clinical colleagues to the extent that we consistently provide interpretive accuracy. Again, in light of reality over perception, commoditization is a hard-earned feather in our cap.

MYTH: Consultation between a radiologist and a clinician (or between radiologists) must be performed in physical proximity.

FACT: Even fulltime onsite radiologists do consults remotely, whether by phone or email or some mode of communication other than face-to-face. At vRad, as at most teleradiology practices, radiologists are readily reachable 24/7. We use phones, instant messaging, videoconferencing and whatever means of communication best match up with those of our clients. We’re there around the clock with up to 200 expert diagnosticians representing just about every subspecialty of the profession.

And, by the way, we’re so completely commoditized that our reporting of critical findings averages six minutes from initiation to completion.

MYTH: It is impossible to develop meaningful clinical relationships in a distributed practice model.

FACT: Relationships may take a little longer to develop when there isn’t a face to put to a name—but develop they do. Our clients often send in cases requesting a radiologist by name, and all they know about that radiologist is the spelling of his name, the sound of his voice and his established interpretation accuracy. This clearly speaks to the power of the distributed practice model to encourage professional relationships while also eliminating meaningless prejudices.

Meanwhile, a 2013 study published in Proceedings of the National Academy of Sciences showed that close to 35% of married couples got acquainted not face-to-face but online. Evidently distributed-model matchmaking has gotten happily commoditized too.

MYTH: Radiologists can establish their value through personal relationships with their hospital administrators and clinical colleagues.

FACT: No one worth reading for is going to assign a radiologist solely on the basis of friendship. As a radiologist, your ability to sustain your current relationships and contracts comes down to your ability to deliver on basic, objective service parameters—just as it does for the beef producer behind the carefully inspected steak on your plate.

In conclusion, commoditization really does mean availability, cost savings and quality. I hope you’ll start using the term as the compliment it truly is.

Benjamin W. Strong, MD (ABR, ABIM) is chief medical officer of vRad, Eden Prairie, Minneapolis.