AMA Journal of Ethics^®

Case

As part of a private practice radiology group in a small town, Dr. Adams had been reading the imaging studies from a local community hospital, Holmes Medical Center, for 15 years. A native of the town, Dr. Adams grew up learning about his community and embraced its culture. He lived in the same neighborhood as many of his patients and often saw them at the local coffee shop and diner. Through these informal interactions, Dr. Adams was able to observe the changing health of his patients over a period of years. He has also been an active member of the local medical community, meeting face-to-face with the referring physicians from the medical center weekly.

At a meeting with Holmes' administrators Dr. Adams heard for the first time about a proposed cost-cutting initiative. The hospital was considering whether to send imaging studies to specialists at a large academic medical center in a different state. The larger center had more radiologists and performed the services for less than Dr. Adams's group charged. After Dr. Adams described the disadvantages of the proposed initiative, a hospital administrator said, "Without the large source of images from us, your small group probably won't be able to support a practice anymore. I think your arguments are motivated primarily by concerns about your financial well-being."

Commentary

At stake in this case are competing visions of radiologists and their role in the care of patients. On one side is the view that radiologists are basically interpreters of images, who, in this era of electronic imaging and report transmission, can perform as well from another state (or even another country) as from the local hospital. On the other side is the view that radiologists have responsibilities that extend beyond image interpretation and include relationship building with patients, referring physicians, and the communities they serve.

The out-of-state academic practice may offer greater value than the local radiologists in several areas. If it is a large group, it may be able to deliver more specialized diagnostic expertise in areas such as neurological, musculoskeletal, and pediatric imaging than a small community practice. Again, because of its size, the larger practice may be able to offer superior after-hours service by providing interpretations within minutes of exam completion, a standard that is difficult for small community groups to match. Finally, an academic practice may confer extra prestige on the hospital, which can claim that its radiology services are provided by a nationally recognized faculty.

On the other hand, the local radiology group may offer advantages of its own. The local radiologist and his colleagues are likely to be better known to the patients and referring physicians, as well as to the community at large. In medicine, where trust is paramount, actually knowing the person to whom you are entrusting your life (or your patient's life) can be crucial. Moreover, local radiologists may be in a better position to improve working relationships between radiology and other departments and to ensure that imaging services best meet the needs of those who depend on them. Community radiologists are also able to serve more effectively as patient advocates because they understand the local health care environment.

The out-of-state academic practice claims that it can provide radiology services at a lower cost than the community group. At the very least, such a claim deserves careful scrutiny. Will the out-of-state services be comprehensive, including reading of fluoroscopic exams performed at the hospital by on-site radiologists, or will they handle only exams that do not require the physical presence of a radiologist, such as CT and MRI? It is worth noting that the reimbursement levels for CT and MRI are generally considerably higher than those for fluoroscopic exams.

More Than an Image Interpreter

Underlying all these practical issues is a still deeper question. What does it mean to be a radiologist? Is a radiologist analogous to a piece worker on an assembly line, taking in images and churning out diagnoses? Or is the radiologist a full-fledged physician, no less responsible to patients and professional colleagues than physicians in any other medical specialty? Do radiologists' responsibilities end at ensuring that no findings are missed or misinterpreted, or is the radiologist also responsible for ensuring that the specialty makes the optimal contribution to patient care with minimal risk and cost? Are radiologists highly skilled technicians or true consultant physicians?

The long-term health of the field requires that radiologists cease to think of themselves strictly as image interpreters and recognize that they have a vital role to play in building relationships. Radiologists should be at the forefront of efforts to educate health professionals about the appropriateness of alternative imaging examinations in different diagnostic contexts and must offer strategies for reducing unnecessary risks and costs. Likewise, radiologists should help educate patients and communities about the role imaging plays in their care. On-site radiologists are far more likely to fulfill such responsibilities effectively than radiologists operating from another state.

Community Considerations

Before a decision on outsourcing is made, stakeholders should also consider how often the members of an out-of-state teleradiology group will participate in the hospital's grand rounds program? How often will they join actively in the professional life of the hospital, through service on committees and elected offices? What types of relationships will these out-of-state physicians forge with those working directly with the patients? What will they contribute to the local community, not only in terms of monetary donations to worthy causes but also as volunteers through the hospital and local civic, religious, and educational organizations? Participation on local committees and in community events is one of the responsibilities and privileges of being a physician, and replacing local medicine with outsourced services is likely to undermine these pursuits.

Radiologists who think that they speak directly only to voice recognition software and who see every request for consultation as an interruption should not be surprised when their hospitals propose to replace them with nonlocal radiology services. If radiology is to remain a vital part of community health care, radiologists need to see themselves not only as image interpreters but also as relationship builders, whose on-site, face-to-face contributions to hospitals, referring physicians, patients, and communities are so substantial that it is difficult to imagine life without them.