LIVE FROM RSNA 2012: Where Is Radiology Practice Headed? A Conversation with Keith Dreyer, M.D.

Maybe I’m being mildly defensive as a physician. Here’s what I’ll say: I have a resistance to change across my whole life—don’t make me change to a Mac, etc. So there’s general resistance among all people to change. But in medicine, partly because of fear of litigation and everything else, you don’t want to be the first bird, nor the last; you want to be in the middle. There’s that comfort with being in the middle of the group. And the feds want to push change. And that’s what I think is happening here; no one’s scared to death to do this. People are just saying, tell me what I have to do. Because in the early stage of decision support, 2004, 2005, all you had to do was to talk to a physician who had used RBM who had been told ‘no,’ and all you had to do was to show them decision support, and they were there. Because with the RBM process, you’ve wasted a lot of time, and either you end up doing what you wanted to do in the first place, or you can’t now, and you can’t do what you wanted to do that you thought was best for the patient.

And here, with decision support, the doctors are really learning something. So it really is the perfect situation for how we want to practice. And the other thing I hear is, patients are getting so smart, and so specific. Patients will come in and say, I want an MR on my knee. And now with this, the physician will say, actually, according to national standards, that’s not called for. And you couldn’t do that with an RBM.

So more and more, physicians will be rationalized into and accept, parameters?

Yes, because payment will be put into parameters based on quality standards. It won’t be like the days of HMOs where they said, here’s $3,000, now work with that. And also, patients will be faced with a choice, and they could choose treatment outside your organization. So you really have to become patient-aware, consumer-aware. And if a patient has to sit there for three hours or has a bad experience with a doctor, they’ll move.

How will radiology practice in the next three years?

I gave a plenary oration here at RSNA, and I was talking about meaningful use, but in a broader context. And I said, we got ourselves in the state we’re in because of a fee-for-service payment model. So we’ve been driven by quantity. But it made us less relevant and less present in patient care; it all becomes about being revenue-conscious and maximizing volume. And if you squeeze fee-for-service down so much that you just can’t do it more and it becomes a commodity, I think the system will shift towards quality and being present for patients and patient-centered. And in terms of teleradiology, we didn’t give images to our peers nearby or to our patients; but it’s going to change so we’ll be incentivized to share with our colleagues and competitors, and with our patients, share images with all of them. And technology is changing all that. And so all of a sudden, I’m sharing images. And this technology-driven wave will force change.

So what I argue to radiologists is, we need to get ahead of this wave. And if I have to talk to referring physicians and to patients and that slows me down, then we should be compensated for that patient interaction and communication. So I argue, shouldn’t we be renegotiating our contracts? And some colleagues are figuring that out and some aren’t. and the pioneers will be reengaging radiologists on quality and service, instead of just cranking out interpretations. And these innovators are going to figure that out first.

Instead of becoming hamsters running faster and faster on wheels, right?

I say, imagine you’re talking to a major PACS vendor. And they ask the radiologists, what do you want to do if someone is an ordering physician, and they’re spending a long time looking at a diagnostic image—and for me, the radiologist, what would I want to have happen? What would we want for that ordering physician? If I was volume-based, I’d probably want them to order another exam; that would be how I would design the software. But instead, if I was motivated by outcomes, and I was getting a negative for the exams being ordered, first, I’d be putting decision support in front; and if I’m driven by outcomes, if that patient does well and lives longer, I’d facilitate the ordering physician being able to instant message me, to get additional consultation, as opposed to just ordering more exams. And thirdly, if I’m motivated to provide more patient access, wouldn’t I want the patient to see the images, too? To facilitate the patient viewing images and talking with me—both kinds of interaction. Patients talk to all other physicians, after all. We always hide behind this cloak of, well, they’re really the referring physicians’ patients, we shouldn’t step on those doctors’ toes. But honestly, the patients are fearful of what’s happening, they want to be reassured, and now we can do it in that new model. And the features of the technology will be driven by everybody’s incentives.