Dreaming the Impossible

How can radiologists look past the current difficulties in their specialty?


In the musical play Man of La Mancha, the delusional idealist Don Quixote is asked why he does the ridiculous things he does. Before breaking into the iconic song “The Impossible Dream,” he responds simply, “I come in a world of iron … to make a world of gold.”1

It’s possible that today many radiologists feel like they are on their own quest to return their profession to the golden days when radiology reigned supreme. But like Quixote, today’s radiologists have been thrust into a world of iron, so to speak, where government regulation, bundled payments, and undermined reimbursements reflect a stark reality.

Given this reality, what can be done? How can radiologists turn their world of iron into one of gold? The answer is simply that the paradigm must be changed. Rather than futilely attack the giant, immovable windmills of reduced reimbursement and increased regulation, leaders throughout the specialty have admonished their peers to go around the obstacles in their path. In other words, radiologists must refocus on the value of their care instead of the volume of the reads or procedures that they complete on any given day.

None of this information should be surprising. Richard Duszak Jr., MD, FACR, vice chair for health policy and practice in the department of radiology and imaging sciences at the Emory University School of Medicine and also chief medical officer of the Harvey L. Neiman Health Policy Institute™, explained in a video posted on the JACR® website that radiologists are currently “in a system where we are being paid for performing procedures.” However, he says, over time this will change to a system “in which we are paid to take care of patients.” Eventually, he notes, radiologists may be moving to a system in which they will be taking care of large groups of patients over long periods of time.

So as payments based on volume decrease and those based on value increase, asks Duszak, how can we define value? “There are a lot of definitions out there,” he admits, “but essentially value equals quality over cost.” More quality is more valuable and less cost is more valuable, he notes, especially if quality goes up and cost goes down at the same time.

But what constitutes quality? According to Duszak, improving patient outcomes and providing better service while reducing the amount of waste equates to better quality. However, these factors only improve quality if the reason for care is deemed appropriate for the patient in the first place. Therefore, using tools such as ACR’s Appropriateness Criteria® and clinical decision support can increase the quality of care and the value of the radiologist.

Like Don Quixote, radiologists must look toward a golden ideal that lies not in the current reality of fee-for-service but in providing the absolute best value to patients with radiologists at the helm of health care. While the dream of such a world seems nearly impossible, radiologists have already moved towards that ideal through such initiatives as Imaging 3.0™.

View Duszak’s video defining the new role of radiologists here:


By Brett Hansen, senior managing editor, ACR Press

1. Wasserman, Dale. Man of La Mancha: A Musical Play. Random House. 1966.

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