‘Image factories’ or ‘clinical imaging services’: what does the future hold for radiology departments?

A recent article in the New England Journal of Medicine raises some very interesting questions about the future of imaging service provision. Who are we as radiologists, and where do we want to go? Are we running “imaging factories” or “clinical imaging services”? We would like to hear what you think in the comments section at the bottom of this article.

Are modern radiologists just cogs in an image production machine?

Dr. Saurabh Jha is a radiologist working in the Department of Radiology at the Hospital of the University of Pennsylvania, Philadelphia. Before that, he had a professional life as a surgical trainee on this side of the pond, in England. In a paper entitled From imaging gatekeeper to service provider – a transatlantic journey
(N Engl J Med 2013:369:5-7) he underlines the differences between the way he perceived radiologists when he worked in Europe as a surgeon and the way he practices radiology in the USA. English radiologists were gatekeepers: that is, they provided imaging studies only when they were really appropriate and necessary according to their clinical judgement. American radiologists are service providers; that is they perform and read the examinations requested according to the referring physicians’s clinical judgement.

“Evaluation of radiological services in the USA is based on the volume of examinations and turnaround time; the higher the number of studies, the better it is for the department.”

Dr. Jha explains that this difference is mostly related to the fact that imaging was a scarce commodity when he was working for the British National Health Service while, on the contrary, there is abundance of CT scanners, MRI machines, and technologists in the United States. Another explanation is that evaluation of radiological services in the USA is based on the volume of examinations and turnaround time. In such a case, the higher the number of studies, the better it is for the department.

Dr. Jha goes on to explain that there are “seismic” changes occurring within the American system. The overutilisation of imaging is being questioned due to economic reasons, radiation protection concerns, and undue anxiety from false-positive results. Preauthorisation of advanced imaging studies has become standard practice for insurance companies, and it usually involves decisions being made by people who are not directly involved in the clinical consultation.

“Radiologists are the people who are best suited to becoming the managers of imaging utilisation”

He believes that radiologists are the people who are best suited to becoming the managers of imaging utilisation, with a role quite similar to the gatekeepers he knew when in the UK. Radiologists can become the protagonists of this change if they position themselves at the centre of the clinical decision-making process, acting as imaging consultants, developing clinico-radiological conferences and conducting imaging rounds. A deep modification of their mindset is needed, shifting the emphasis from service provision, operations, and efficiency, to a new role, which has still to be clearly defined, but which will surely involve higher clinical responsibilities.

So, what do you think? What is the future shape of radiology service provision? Is Dr. Jha correct? Let us know in the comments section below.

Prof. Lorenzo Derchi is Chairman of the Radiology Department of the Hospital of the University of Genoa and the ESR Publications Committee.

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    14 Responses to : ‘Image factories’ or ‘clinical imaging services’: what does the future hold for radiology departments?

    1. APP says:

      I do not see any conflict in being a gate keeper and service provider, the question is just how you define “service”. If making sure your patient gets the most accuarte diagnosis and in the fastest and cheapest way, than that is what you should do. The issue between the US and Europe is more about defensive medicine.
      I think we are clinically oriented, but of course we do no have equal access to all patients. In my country (Norway) radiologists are definitely managers of radiology utilisation,as the final decision on whether an examination is done or not lies with the radiologist.

    2. Tim Leiner, MD PhD says:

      I fully agree that radiologists have an important role as gatekeeper. Unrestricted imaging is expensive and dangerous for patients. We should image when it’s needed, not because someone asks us to. Many times we don’t know the evidence to image. In those cases we should aim establish appropriateness criteria by doing adequately powered studies.

      • Rick van Rijn says:

        I totally agree with Tim Leiner. In paediatric radiology we are gatekeepers, especially when it comes to the use of fluoroscopy and CT, but also service providers. We perform a service to our patients, and their parents, by making sure that imaging studies which are being performed are indeed relevant and can help the treating physician to improve care.
        I strongly believe that a clinically involved radiologist has a strong added value to the care of patients.

    3. Emerald says:

      Yes, I agree with all of the above. As radiologists we have to take our responsibility to deliver high quality patient care at present and in the future. So we have to act as gatekeepers of imaging utilisation and follow the ALARA-principle. Furthermore, our attendance in multidisciplinary meetings is important to explain our imaging findings to the referring physicians and guide clinical decisions. With regard to the service provided to the patients, I expect that in the future more and more patients would want to discuss their imaging examinations directly with a radiologist, so we might have to consider to restructure our work flow at the department.

    4. Lorenzo Derchi says:

      I agree that the most important thing is how to define what a “service” is and to whom the service has to be provided.

      Patients are the “subjects” of our activities and the best service we can give them is to evaluate first if each requested study is indeed relevant and can help the referring physician to improve care; then, to perform it with the right technique, provide timely and correct interpretation and, in many cases, to discuss what we have found with referring clinicians.

      How hospital administrators evaluate radiology departments is of concern, however. Also in Europe, in fact, the number of examinations and turnaround time are often the only factors taken into account, and if these are considered our “products” we risk losing our role as clinicians.

      I think we should make all efforts to make administrators, politicians and citizens alike understand that radiologists do not “do examinations”; we make, or try hard to make, “diagnoses”. These are the result of complex work that starts before each examination is done and continues after it. Discussion and consultation with referring clinicians, and even directly with patients, are a quite important part of our work. This has to be recognised if we want to keep our role and cope with the high clinical responsibilities we have.

    5. Alberto Tagliafico says:

      Dark side of the Dark Room.
      I think that a Radiologists is a Medical Doctor who has to INTERACT with patients, clinicians, hospital managers, public, and even media. However, this part of the job, especially for some who chose Radiology to deal with images and not patients, is time consuming, tiring and difficult. It requires will to act and training. A Radiologists has to be an open mind clinician and not only a Super-tecnician able to see a even a small hypodense spot on a 1236-images CT scan but unable (or unwilling) to communicate with patients and colleagues. If Radiologists refuse the effort to drive medical imaging they will see an endless decline. Radiologists lost several “turf battles (cit…)” and have to collaborate to avoid losing the “war”.
      Sorry, I did’t meant to be pessimistic, I wanted only to encourage Radiologists to be “pro-active” in managing Medical Imaging in general.

    6. marian Macken says:

      As A pediatric Radiologist now retired I struggled to get Radiology residents to consider the clinical parameters before ordering a CT on a child or adolescent. The decision was often driven by a surgical collegue . It is all too easy to get a CT scan without thinking the clinical picture through. the training of radiology residents should include much more clinical training. A young resident in Canada can go through med school doing all his/her electives in radiology thus further diluting the clinical training. Do we in Radiology practise as physicians or technicians?

    7. Carolien says:

      Agree with Dr. Jha. Radiologistc are the people who are best suited to bevoming the managers of imaging utilisation, ergo, the gatekeepers. Radiologists should not hide in the backoffice but should take actively part in clinical decision making concerning imaging and should take the lead in multidisciplinary discussions/meetings. It is, therefore, their responsibility to fully equipped to this task and be low-key available for consultation by a clinician.

    8. Marion Smits says:

      I think the question is not whether we’re gatekeepers or service providers, but how we perceive our role in clinical management. We are doctors, and should act like ones, but from the perspective of our specific expertise.
      That means we need to help solve a clinical question with imaging. That doesn’t mean either gatekeeping or providing a service, it means providing the appropriate imaging to answer the clinical question. Whether that is posed to us in a request form, an email, a phone call, a multidisciplinary meeting, or directly by the patient…

    9. Sergey Morozov says:

      The question posed is a strategic one. In general, the answer depends on a specific type of healthcare system financing.

      Obviously, open radiology market with a competition for private patients’ money has a KPI of productivity. Regulator or authority modifies this indicator by introducing perfomance assessment criteria which can be used to control payments to radiology overutilizing practices. This is the way it happens now in the US.

      At the same time, centrally controlled radiology with an evidence-based approach for healthcare financing requires radiologists to act as gatekeepers, limiting the costs. Obviously, gatekeeper’s role is more advanced, interesting, and demanding. However this appears as a combination of GP and radiology specialization. We shall need more radiologist-generalists to answer this demand.

      I think that radiologist’s role now is to work closesly with clinicians by consulting them and participating in clinical boards. However, this role is going to be undermined soon by decision support systems development. Our role of gatekeepers is going to expand then to cover not only clinical utilization issues but also financial and asset management issues. This goes beyond clinical specialty of course.

      To sum up, I think that we shall see further transformation of radiology into 3 directions:
      1. Radiologist-generalist (front-line activity in primary care, close cooperation with GPs, participation in screening programs, reading routine images, etc.) – controlled by standards, performance and effectiveness criteria
      2. Radiologist-specialist (expert, working in tertiary care, direct contact with patients, strong memeber of clinical team) – controlled by performance and effectiveness criteria
      3. Radiology-managers (combining clinical understanding with business analytics, information managers, departmental and section chiefs) – controlled by costs, revenues and expenses

    10. Lorenzo Derchi says:

      Sergey Morozov suggests we need different people with different attitudes to cover different aspects of the same job. I agree, but they have to work together, in a team.

      We can compare a radiology department to an orchestra and its chairperson to the conductor. He/she, to be able to perform music, and any kind of it, has to create a team and first of all chooses the best virtuosos on each of the many musical instruments (violin, cello, double bass, trumpet, oboe, etc…). Then, he makes them play together. The better they are, the better the music. A department chairperson has to choose experts in chest, cardiac, GI, MSK, GU, etc … who, together, can provide all the services requested by the hospital. The better they are, the better the diagnoses.

      But this is not enough. Music is written on sheets of paper and the conductor has to “translate” them into harmony through his/her interpretation and guidance of the orchestra. This is achieved taking into account many different parameters, such as knowledge of the piece of music to be performed, as well as of its author, the capability and sensitivity of the conductor and of each of the components of the whole orchestra, and even consideration of the particular audience. Furthermore, it is his/her duty to identify among the many maestros those who can play the solo parts, since not everybody is able to play them.

      The same can be said about the radiological work within hospitals. The chairperson, in fact, has to coordinate many different people in order to “translate” the written requests for examinations into useful diagnoses and to make things run harmoniously. There is agreement that simply performing many examinations is not enough and that radiologists also have to work as consultants (towards referring physicians), communicators (towards both colleagues and patients) and administrators (of resources and revenues). Not everyone is able to discuss, communicate or provide administrative work, but there are many who can manage or learn how to do it. They have to be identified and empowered.

      If each component of the radiological team provides his/her contribution according to his/her capability and sensitivity it will be possible to cover all different aspects of our work with efficiency and effectiveness. This will help us to be considered by colleagues and patients as a clinical imaging service, and not as an image factory. Although there are wonderful pieces of music written for soloists, most of them are written for groups: duo, trio, quartets, camera or symphonic orchestras.

    11. Edwin van Beek says:

      Having worked as a Radiologist on both sides of the Atlantic (trained in the Netherlands, practiced in the US and now back in the UK), there is a vast difference between how radiologists are perceived and how they work.
      The workloads are equally high, but in the US there is a structure where there is more support on the ground with secretarial support and automation where possible. In the UK, there is an erosion of the consultant’s role from a doctor to a “get more done with fewer people”. In addition, there is the constant abuse of imaging requests, with insufficient clinical details to actually act on. This makes the gatekeeper role a very difficult one to maintain. Clearly, there is a lack of understanding on many fronts, as to what radiology can and cannot do. A lot of teaching is required from basic medical curriculum to managers to help them understand!

    12. Marc-André Weber says:

      In my opinion, as clinical radiologists we are both gatekeepers and service providers for our clinical partners and our patients. Of course, we have the expertise to tell our clinical partners which imaging modality is best for the patient presenting with a clinical problem and which is the best imaging algorithm and workflow. Also, we can advise our patients and recommend them the best imaging for their clinical issues and in addition we can offer imaging-guided interventions. Thus, I fully agree with Marion Smits that this means we have to provide the appropriate imaging to answer the clinical question and this of course means that we have high clinical responsibility.

    13. Athanasios Gouliamos says:

      A radiology department can be gradually transformed to a decision-making center where various subspecialists are discussing with clinicians their patients problems and provide appropriate answers