Sunday, March 09, 2008

The Decline and Fall of Radiology
(and How to Avoid It)
and a factor the authors missed

In a recent JACR, Richard B. Gunderman, MD, PhD, Andrew J. Koerber IV, BS, MS make some interesting comparisons between the decline and fall of radiology, and the historical downward spiral of the Roman Empire. They base their discussion on Edward Gibbon’s The History of the Decline and Fall of the Roman Empire.

Rome was the greatest empire that had been seen up until its time, and some would say it still holds this distinction. I'm not going to review all of its accomplishments, but they were legion. So what happened? Gibbon noted several factors. The reason most often cited is the pressure from outside, the Huns and Goths, and other shabby folks, who ultimately destroyed the city of Rome itself. The authors of the JACR article liken this to the external problems radiology faces such as uncooperative hospitals and turf battles with other docs. But Rome probably fell more because of internal decay than any other reason, and radiology as a specialty needs to see these parallels.

Gunderman and Koerber note that Rome progressed from a republican government, where the people had a say (and were honored to participate) to despotism, where the emperors took over all power, and became increasingly corrupt. They compare this to the pursuit of revenue amongst radiologists, giving the example of outpatient imaging centers being built where they will make the most money, not where they would do the most good.

Rome, it seems, also gave too much power to mercenaries, ruining the ideal of the citizen-soldier. Mercenaries sadly may eventually ignore or even turn against their employers, because, after all, they are just hired guns (or maybe hired swords in this era.) Radiology is doing something similar by turning its decision making processes over to consultants and lobbyists. Research is increasingly in the hands of the vendors, and not the universities. Radiology isn't even a required course in most medical schools. Of course, teleradiology might be the best example of how radiologists can hand off their responsibilities, although for the most part this is at least to other radiologists!

Luxuries lured Romans' attention away from where it should have been directed, and even today, after two thousand years of pillage of the sites, you can still see that a lot of time and money was spent on frivolities. Cash became the most important thing, and previously loyal folk would sell their support to the highest bidder. Corruption became widespread, and no one trusted the government. Sadly, radiology is falling prey to the same sort of thing, Making money becomes the end-all, instead of taking care of patients. To get said money, radiologists are making bad deals with hospitals and governments.

Gunderman and Koerber conclude that radiology has to avoid making income the primary motivation. It needs to promote invention and innovation, and work for the good of the patient. There must be collaboration with other specialties.

I couldn't agree more. However, I think Gunderman and Koerber left off a very important item, which is why this belongs on this blog. That is, of course, the scourge of self-referral, and the damage it is doing to radiology and to medicine in general. They do come close to mentioning this at several points, but I think it needs to be stated more explicitly in terms of the foregoing arguments.

Self-referral in many ways relates to every one of the factors that brought down Ancient Rome. I won't even try to discuss this in terms of the clinicians who participate; they are no better than the barbarians that invaded Rome. They are invading radiology and medicine quite nicely, and radiologists are holding the gates open for them. Why is this? Reread the discussion above. The primary factor is money, of course, be it the opportunity to zero in on the reads generated by the excess ordering of scans, or even the thought to preserve interpretive income when the clinician takes his paying patients away from the hospital to be scanned on his own machine. And as with the increasing corruption of Rome, radiologists are abdicating their moral responsibility to stand up and say something about this issue, for fear of disrupting their incomes. These radiologists are themselves becoming the mercenaries, being willing to work for clinicians that most would agree are not doing the right thing. From Gunderman and Koerber's article,
The word mercenary derives from the Latin merces, meaning “price,” and also the source of our words mercantile and merchandise. Mercenaries are guided by overarching concern with wealth and profit, as opposed to honor. They sell their services to the highest bidder and do what they are paid to do, often unencumbered by moral scruples. To expect loyalty or trustworthiness from a mercenary is to fail to understand what a mercenary is. They enter, exit, and reenter contractual relationships as needed to maximize their earnings. In the final analysis, they can be trusted to do but one thing: pursue their own self-interest.
Need I say more? Vēnī, vīdī, vīdere animus.....


Anonymous said...

Harold- I applaud your efforts. I am a radiologist and you wouldn't believe the quality of some of the imaging done at these 'self referral' centers. I think we need to educate the government (...and taxpayers) and insurance companies that they're the ones paying for all this unnecessary substandard imaging. Also patients need to know there is a difference b/w getting an imaging study at a quality facility vs. in their physicians office. I can't even count the number of times patients have come to our office for an MR Angiogram who were told they had a high grade stenosis on an ultrasound done at their doctor's office and end up not having ANY carotid disease. As radiologists we really have no control over how many patients are sent to us. Unfortunately, when imaging is available in the physicians office the lure to over image is really great. Why not? most imaging is safe and non-invasive...and it pays. Unfortunately, this issue isn't getting much publicity. The reason the cost of imaging goes up every year is b/c of self referral.

Keep up the good work. Hopefully the gov't and insurance companies will wake up and address this issue.

Princess said...