The Coming Crisis in Radiologist - Hospital Relationships

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This is the time of year when visions of sugarplums are fresh in our heads from the RSNA, and we like to reminisce about days gone by when radiologists and hospitals were friends and worked together in harmony for the good of the patient and the well being of the radiologist. Now, that is not to say that somewhere in our fair land things are not copasetic and goals are not aligned. But I haven’t seen it lately.

Somewhere in the recent past and in many places in the country, the situation has changed: that relationship has turned antagonistic and the hospital/radiologist relationship is in jeopardy. As a resource, we are more often called upon to assist in changing this dynamic, to act as a reconciler of differences that run deep, so much so that hospitals are often on the verge of terminating contracts and radiologists are fed up with the way they have been treated and would just as soon walk away.

When I was a hospital administrator, a long time ago in a galaxy far, far away, we valued the contributions and relationships we had with our radiologists. They were the visionaries of where diagnostic medicine was heading, and we needed to pay attention. Radiology departments were the front door to our hospitals, and referrals often resulted in patient admissions, outpatient surgeries, and the like. We knew radiologists worked hard and created a valuable resource that the attending physicians and their patients needed. But that was before DRA, digital mammography, PET/CT, PACS, voice recognition, IDTF, Stark I, II, and III, locum tenens, nighthawk, multi-slice CT, and, of course, cardiologists.

From the radiologists’ perspective, they are overworked and underappreciated and in fact this is very true. Utilization has increased dramatically by as much as 200% over the past decade due to numerous factors and it’s getting worse. ED physicians have also increased their referrals to imaging departments to the point that unnecessary tests account for as much as a third of all ED referrals and is used as a triage tool rather than a necessary diagnostic tool. This increases the workload, often to a point of unsustainability. If some of this unnecessary utilization isn’t controlled, the payers will figure out how to control it for you. Needless to say, that with the radiologist shortage over the past decade, keeping up with the volume has been more than a full time job.

Root of the Problem
But why are they underappreciated? With pressure to meet turnaround times and volume doubling, there is no longer any time to meet with referring physicians to consult on difficult cases or add their diagnostic expertise. They rarely make calls to physicians who request stat reports, since so many reports seem to be stat these days. Radiologists are reluctant to perform interventional or minor procedures as these take them away from the lengthening work lists they must get through before they can leave for the day. They often close their doors to avoid interruptions, which is often perceived as anti-social or worse, malingering.

Hospitals bring out the best and worst in radiologists’ practices, as they should: the most challenging cases, the highest level of physician-patient interaction, the late nights, and the long days. With that come the administrative meetings, the lack of staff resources (or indifference), and capital shortages for this year’s equipment needs. Many patients are uninsured (and this number keeps growing), requiring an altruistic understanding of the patient care mission. Nighttime coverage now costs more than those reimbursements provide, and diminishing professional reimbursements that Medicare and third party payers are unconcerned about exacerbates the shortage.

Medical imaging is a series of complex collaborations to one purpose and that has not changed: Provide an accurate and timely diagnosis to improve a patient’s care. Hospital administrators hear the complaints of staff and physicians, with cardiologists and vascular surgeons leading the way, pleading to perform interventional and now, non-interventional CT and MR cases. They too are concerned that radiologists are overworked with not enough “warm bodies” in the department to meet the demands for daily, nightly, or weekend coverage. They hear that radiologists make more money and get more paid vacation than any other physician on staff and yet the Press-Ganey customer service scores for Radiology, their bread and butter lines, are sliding into oblivion.