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.....

Talk To Congress!

AuntMinnie.com recently reviewed a speech given at the RBMA meeting in February, 2008 by Douglas Smith, founder and president of Barrington Lakes Group, a healthcare consulting firm in Barrington, IL. Mr. Smith made some suggestions that are right in line with what I've been saying myself.

Elected officials often don't differentiate between different imaging entities -- radiologist-, corporate-, or referring physician-owned -- but focus instead on imaging's spike in the percentage of total medical services, Smith said.

"The radiology profession is not well understood in the halls of Congress," Smith said. "Many Congress people don't realize that overutilization is something that is done to radiologists, not something they do."

Policy makers have moved to clamp down on costs with legislation such as the DRA, assuming that the increased volume of imaging exams performed compensates for federal reimbursement reductions.

It doesn't, of course. But unless radiologists and administrators begin to educate governmental representatives, medical imaging will get more of the same in coming years, Smith said.

What should the radiological community do about this?

The Association for Quality Imaging (AQI), the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), and the RBMA have been working to educate governmental representatives on the cost and practice of radiology. But more can be done, especially in light of the experience and resources of the American Hospital Association, the American College of Cardiology, and other advocacy groups. Radiology staff -- from physicians and imaging center operators to teleradiology companies, suppliers, and billing companies -- need to get active to gain a voice in Congress, Smith said.

The message I hear is that Congress (and by extension state legislatures and governors) doesn't have a clue about the imaging self-referral problem in particular, and about what it is that radiologists do in general. I'm sure the self-referrers would be glad to educate them if no one else wants to bother.