Am I Adding Value?

There is a great deal of paranoia among radiologists about being commodities.  This concern seems to surface repeatedly in journals and at open microphone sessions at the American College of Radiology annual meeting. Yet, the idea of a radiologist being a commodity is a fallacy due to a fundamental misunderstanding of the definition of a commodity.  A commodity is a fungible object that can be traded in a market with low transaction costs.  The two operative concepts in this definition are “fungible” and “low transaction costs”.

Our board certification process would have the appearance of making us fungible.  Is one board certified or CAQ’d radiologist the same as the next?  It depends on whom you ask.  A professional physician, nurse, or technologist knows this question is never true.  However I have first hand experience that schools teach hospital administrators that physicians are fungible.

A medical professional can quickly evaluate the manner in which a colleague cares for a patient and it is frequently unique.  However it take years to develop these perceptive skills.  For example, if you want to know who the best OB/GYN is in a town, ask the other physicians and nurses, you’ll probably find that they cluster with one or two choices.  A recent Harvard Business Review article entitled Why The Best Hospitals Are Managed by Doctors highlights the fact that medical professionals “know what ‘good’ looks like”.  The knowledge gap between experienced medical professionals and academically trained hospital administrators is tremendous.

A typical hospital administrator with no first hand knowledge of patient care and quality, frequently makes mistakes.  Administrators tend to rely on process metrics that only tell a part of the story and do not understand the concept of true quality. If we do switch into a management perspective and value radiologists along the operational priorities of costs, quality, flexibility, and timeliness; no two are alike.  For an administrator to think that one radiologist can be traded for another without a change in operations would be a grave mistake.

Commodities are traded for pennies; the trading of physicians is expensive and low transaction costs are not present in the marketplace.  Headhunter fees, moving costs, time spent on-boarding, credentialing, and decreased clinical productivity during the transition easily add up to over $100,000 for the typical physician.  Management must account for these costs when thinking of making a change.  However if an astute manager is threatening to replace a group or individual and is appropriately applying these concepts, then that incumbent needs to realize that they are not adding enough value and are in severe jeopardy.

Radiologists need to stop being concerned about being commodities and instead start to ask themselves about being expendable.  Every time a radiologist signs a report they need to ask, “Am I adding value?” If not and if done frequently, there are two possible outcomes. First that service may disappear entirely, which is why we have Appropriateness Criteria and computerized decision support. Alternatively for truly needed services, substitutions from other sources outside of radiology may be made.

There are many substitutions already present as well as new ones entering the marketplace.  Other specialists who want to read their own imaging exams are an example radiologists have continuously battled. The financially motivated behavior of self-referral is a negative economic force helping to keep this substitution in check.  Lately, artificial intelligence (AI) is another substitution that has received much attention.  In areas where radiologists are not adding value, AI is poised to replace that task.

A small amount of paranoia is healthy.  It forces individuals to survey their environment and make changes that improve survival.  Radiologists have never been commodities, but they do need to broaden their perception of the environment and marketplace.  If we do not want to end up like our former transcriptionists, radiologists need to perpetually ask, “Am I adding value?”

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