Getting Along in the Sandbox
Working together with colleagues and administrators will help the specialty succeed.
When people ask me what Imaging 3.0® is about, I gauge my response based on the time available and interest expressed by the questioner.
In the simplest terms, Imaging 3.0 is about integrating radiologists into the care delivery engine beyond being simply "report generators," to quote Bibb Allen Jr., MD, FACR.
Like many movements, individuals will interpret the charge and intended course of action differently. Recently, I was surprised to learn of a different interpretation of Imaging 3.0, as espoused by some who were trying to inspire emboldened and new behaviors in their constituents. In a fictionalized piece intended to inspire radiologists to inject themselves into the care delivery engine, an interventional radiologist was portrayed bargaining with a hospital administrator, trading the care of an individual patient with the assumption of primary responsibility for patients who present to interventional radiology.
Social justice movements are replete with challenges about ensuring that participants remain on point with regard to the intended message and desired actions. Dr. Martin Luther King Jr., struggled throughout his tenure in the Civil Rights Movement to keep protestors from turning bitter and violent. I never imagined that a similar challenge would be faced in Imaging 3.0, but the example above reminds me that bitterness and desperation among radiologists might inspire some to justify "civil disobedience" in the world of health care while using Imaging 3.0 as a call to action.
Watching the fruits of one's efforts to build a practice drift to practitioners in other specialties can be very demoralizing, particularly when one's innovation and passion have been leveraged to advance the specialty for patients' benefit. Hospital administrators face complex decisions on a daily basis and the outcomes of those decisions disfavor radiologists as often or more than they favor our profession. Out of desperation, radiologists sometimes will try to barter their way toward a favorable solution, sometimes losing sight of the need to keep the patient at the forefront of all discussions and considerations. James V. Rawson, MD, FACR, chair of the ACR Commission on Patient- and Family-Centered Care, is fond of saying, "It's hard to place the patient at the center of health care if you're standing there yourself."
This year marks my 20th year in administration. Over the years, I've come to appreciate the delicate world in which we live as members of hospital and health system communities. Like the "Circle of Life" in The Lion King, health system communities are fragile ecosystems where disruptions in practice patterns in certain areas have profound downstream consequences in others. Hospitals that allow interventional radiology to be performed by other disciplines during routine hours of operation risk losing a competent IR workforce to cover emergency services around the clock, owing to a reduction in case volume and subsequent loss of clinical skills. Conversely, interventional radiologists who demand complete responsibility for their patients risk lapses of clinical care if adequate inpatient call coverage has not been arranged. Moreover, such demands polarize radiology from hospital administrators and other clinical disciplines. Aggressive posturing and an "eye for an eye" approach often leads to escalation of ill will and to the loss of privileges and stature in the health ecosystem.
Moreover, the new financial realities that accompany MACRA compliance require interdisciplinary collaboration, particularly for success with advanced payment models (APMs). It is virtually impossible for radiologists alone to succeed in APMs. Close collaboration with our clinical colleagues in other specialties will likely be necessary to craft and comply with metrics for successful participation in APMs.
Another common source of strife between hospital administrators and practitioners relates to disputes about space. Practitioners, including radiologists, commonly view space allocations in legacy terms. Arguing that a given clinical or research footprint has been held historically by the radiology department will fall on deaf ears unless continuance of that space allocation is well justified and warranted. Early in my career as an administrator, I, like others before me, tried to argue that a certain footprint was "radiology space." The hospital's senior vice president admonished me, "No, that space is hospital space; you are merely a tenant." As radiologists must justify their place in the circle of life of the health ecosystem, radiologists must also justify the space and resources that they consume within the hospital and health system. To fall on historical precedent is a specious argument that will not serve us well.
What should radiologists do to play successfully in the sandbox of one's hospital or health system? We must continue to look for ways in which we can advance patient care uniquely and highlight those services through data-driven communications, multidisciplinary conferences, hospital committee meetings, and personal interactions. We must continue to innovate to ensure that we are contributing new practices and services that demonstrate our value, by enhancing the quality of care that is provided or reducing the cost of care or both.
Imaging 3.0 is about extending our reach beyond the classic wheelhouse of radiology: protocolling, supervising, and interpreting imaging examinations. It's about extending our scope to ensure integration with the entire care delivery engine. While desperate times may seem to call for desperate measures, we must remain patient and mindful of the challenges that our clinical colleagues and hospital administrators face. The grass is not always greener on the other side of the fence that separates us from other disciplines, and we must look for ways to integrate harmoniously into this circle of life, lest we fall prey to predators that share the medical landscape. In his guide for global leadership, Robert Fulghum says, "All I really needed to know about how to live and what to do and how to be I learned in kindergarten. Wisdom was not at the top of the graduate school mountain, but there in the sand pile at school." If we can all get along in the sandbox, our trajectory will be positive and our destiny more likely assured.
By James A. Brink, MD, FACR, Chair