Advances in imaging modalities and technical infrastructure have occurred at a head-spinning pace over the last three decades. The bread and butter of the radiology business—CT, digital x-ray, PACS—were mere concepts for radiologists who started practicing in the 1970s. As baby boomers ponder retirement, millennials are just beginning to embark on their careers.

Health Imaging asked millenial radiologists, born in 1982 or later, about their futures, how they envision practicing radiology and how tomorrow’s radiologists will differ from today’s. A few findings include:

• Many display a pervasive sense of optimism and a comfort with the corporatization of medicine.
• Young physicians understand the pressing need to deliver value and service beyond image interpretation.
• Many are eager to communicate and collaborate with referring physicians and patients.
   

Farewell to a bygone era

The easy days are behind us, observes James H. Thrall, MD, radiologist-in-chief at Massachusetts General Hospital (MGH) in Boston. Imaging has entered a new era characterized by reimbursement cuts, the pending demise of the fee-for-service payment model, the advent of corporate structure and increased competition among radiologists and between radiologists and clinicians.

Young radiologists face additional challenges. The average medical student graduates with $160,000 in debt, according to the American Association of Medical Colleges. In addition to facing a nearly crippling debt burden, many trainees recognize that the practice of radiology will continue to undergo massive changes. “One of the hardest realizations is that the way we are going to practice radiology is not the way we are trained or mentored,” says C. Matthew Hawkins, MD, pediatric radiology fellow at Cincinnati Children’s Hospital Medical Center (CCHMC).

Despite these challenges, radiology has retained its appeal among residents. Consider, for example, Lisa M. Mabry MD, a first-year radiology resident at University of Alabama at Birmingham. “Once I started clinical rotations, I thought radiology was a great field. You aren’t limited to one area of the body or one disease, and because many other physicians look to radiology for consults, you can get involved in a lot of great cases.” In fact, greater involvement with physicians and patients will be a defining characteristic for future radiologists.

Hawkins foresees an increasingly collegial atmosphere, characterized by multidisciplinary teams and problem-solving. The basic duties of radiology—image interpretation and reporting—will remain essential functions but will not be radiologists’ only roles in healthcare delivery.

For starters, radiologists of the future will need to help clinical colleagues order studies and develop appropriate patient management and follow-up plans.

This change is partially fueled by the rise of chronic diseases rather than acute illnesses. Take, for example, diabetes. Radiologists can add value to the management of a patient with diabetes by including the sequalae from the disease, such as hypertension in the brain or parenchymal changes in the kidney in their interpretation, which could help inform appropriate follow-up studies, says Hawkins.

In other cases, a physician may order one imaging study when another may be more appropriate for the indication. “We have to take responsibility for the images we are viewing. It is in the patient’s best interest to ensure the physician has ordered the appropriate study,” says Mabry.

“A physician might order a high-resolution chest CT for suspected malignancy or metastasis where a CT with contrast would be more appropriate. On the other hand, a high-resolution chest CT would be more appropriate for evaluating interstitial lung disease,” she says. “It is the radiologist’s job to communicate with the ordering physician and understand the test indication, so that together they can decide the best, most appropriate test for the patient.”

Clinical and patient care needs also intersect with economic realities. “With rising costs, radiologists will increasingly direct smart use of imaging. We will have more responsibility in containing costs appropriately,” predicts Mark D. Mamlouk, MD, of the radiology department at the University of California, Irvine. “We need to provide what is best for the patient in a safe, cost-effective manner. That may not mean more studies, which is one of the hardest concepts for physicians to grasp.”

Thrall of MGH explains that the hospital can flow chart the entire potential process of care for specific patient populations such as a patient who presents with suspected stroke. At each step, the hospital can analyze resources, identify possible complications and try to reduce unnecessary use of resources while making the process more timely and efficient. “It will be vitally important to have radiologists participate in the process.”

Doing so requires some know-how about the business of medicine. Jonathan A. Flug, MD, MBA, from the radiology department at Winthrop-University Hospital in Mineola, N.Y., predicts more MD/MBA combinations among radiologists. The number of joint MD/MBA programs has swelled from five in the late 1990s to 65 in 2011, and approximately 500 physicians graduate from dual-degree programs each year.

Another trend is the number of physicians pursuing process improvement certifications like Lean Six Sigma, which helps providers understand healthcare at the macro level. Some young radiologists, like Mamlouk, are self-starters. Mamlouk has assigned himself additional homework focused on the increasing his knowledge of the business side of radiology.

The new radiology report

The primary output of a radiologist—the report—needs to catch up to technical capabilities and referring physicians’ needs. Image-based reporting is likely to emerge.  

“My generation prefers websites and pictures to reading long reports,” says Flug. “We like to have the important information right in front of us, which means more radiology reports with embedded imaging.”

Informatics may hold the key. CCHMC is experimenting with image-based reports viewable on tablets and phones. The goal, says Hawkins, is to provide physicians with easy access to reports and images and allow them some image manipulation capabilities. Although server-side rendered viewers offer similar functionality, they still require physicians to log into another system. “If they are in the EHR and we force users into another system, adoption may be slow or may not occur at all,” he observes.

The focus on anticipating and meeting clinicians’ needs could be somewhat self-serving, as radiologists endeavor to deliver value and compete with each other as well as other specialists.

As radiologists increasingly prioritize referring physicians’ needs, additional reporting gaps will become more apparent. “There are no conventions in radiology reporting right now with the exception of mammography. Radiology reporting needs more standardization. In addition, reports have to be more clinically oriented,” says Mamlouk. Structured reporting may offer a framework to address some of these needs.

In the September issue of Journal of American College of Radiology, Mamlouk advocated for clinical diagnostic reporting that:

• Seamlessly guides clinicians to their diagnoses;
• Avoids vague terminology and provides meaningful impressions;
• Gathers a separate history when needed; and
• Keeps referring clinicians and patients in mind.

Delivering clinician-friendly reports offers one way to better meet the needs of one primary customer group. The other group is patients. The expectation of increased interaction with patients is nearly universal among young radiologists. Most envision more face time between radiologists and patients. Radiologists can assist with efficiency across the healthcare delivery chain by delivering normal or unchanged results directly to patients, notes Hawkins. At the same time, imagers of the future recognize the need to liaise with referring physicians and solidify those relationships prior to communication with patients.
 

Radiology on Facebook?

Radiologists of the future will use social media to a far greater extent than current practitioners, predicts Marc D. Kohli, MD, of Indiana University School of Medicine (IU) in Indianapolis. He refers to thought leader Atul Gawande, MD, MPH, who says medicine will be practiced by more integrated, less autonomous teams. “The only way to accomplish this goal is through good communication. There are so many tools that are easily available at low cost. But we can’t use them because of security requirements.”

The grandaddy of security requirements—HIPAA—may have to accommodate 21st century clinical realities and make it easier to share patient information. “It is critical to the future of medicine,” says Kohli.

What does social media look like in clinical practice? Image-sharing systems might leverage Google or Facebook authentication and link patients’ images with their Google account, which would reduce barriers to image sharing.

At IU, Kohli and colleagues have attempted to identify opportunities to use social media to improve interactions with clinicians. For example, when a radiologist opens a study at the PACS workstation, the system might search LinkedIn to pull more information about the ordering physician and his or her practice. Enabling radiologists to access such information helps patients and referring physicians.

“It’s different to interpret a renal mass CT study for a urologist than it is for a primary care physician. I might tailor the report differently, integrating social media into the interpretation process. It’s a different way to provide clinical context.”

Nearly every social media user recognizes that it’s a double-edged sword, and healthcare is no exception. Social media has the potential to blur boundaries between institutions, which facilitates greater integration of patient care but also enables more patient mobility between healthcare systems. However, at least some young radiologists take competition in stride. “If you establish a good camaraderie with referring physicians and practice good medicine with the patient in mind, your efforts will be recognized,” offers Mamlouk.

Another platform that can help support inter-system communication and reduce unnecessary imaging is health information exchange (HIE), says Mabry. As patients seek care at a variety of different hospitals, imaging studies may be repeated multiple times. “This is an area where radiology needs to be involved,” says Mabry. Advocating for HIE and assisting with implementation of image sharing exemplify the value-added activities that will characterize radiology in the future.  

While social media use may be on the uptick, other technologies may fall by the wayside. The chain that binds physicians to their practices—the ubiquitous pager—is becoming less relevant. Kohli and colleagues use a group text messaging service for communication such as informing physicians when a procedure is about to begin. “A secure channel that allows sharing of patient data would be an improvement.” It could eliminate one gadget and optimize another to increase physicians’ efficiency.
 

The E-word

When a younger Flug pondered his career choices, his father, a practicing dentist, advised him that a career in medicine guaranteed two outcomes: self-employment and security. One decade later, neither outcome is certain.

As healthcare adopts an increasingly corporate structure, mega-sized healthcare systems and radiology employment contracting firms have emerged. Both have fueled the shift toward an employment model.

“Many in our generation are more attracted to shift work. We want work-life balance,” says Mabry. Avoiding overhead office costs also appeals to young physicians burdened with debt. Plus, as administrative levels and responsibilities associated with running a practice have multiplied, young radiologists recognize that they may not have the training needed to successfully manage a practice.

There are downsides to the employment model. On one hand, younger radiologists avow an interest in patient care and communication. However, the shift toward employment may begin to de-professionalize medicine, says Thrall. In a worst-case scenario, physicians will embrace a shift-work approach and punch the clock at the end of the day, regardless of patient implications. “We have to find a new golden mean between continuing to have a professional sense of responsibility for the patient while recognizing that too many physicians in the past have not looked after themselves as much as they should have,” opines Thrall.
 

Plugging the gaps

One common thread—leadership— links outcomes such as optimized social media, improved patient communication and clinical diagnostic reporting. Both RSNA and the American College of Radiology have developed formalized leadership development programs to prepare radiologists to navigate change. Perhaps, some good days are ahead.

Radiology 2020: What’s Out/What’s In
While the exact nature of the future is certainly uncertain, it’s possible to sketch a gestalt by comparing hallmarks of the past with those of the future.

What’s Out

• Small, local practices
• Private practice (extended hour work-weeks)
• Workstations/isolated image review
• Text-only reports
• Unchecked imaging volume
• Pagers
• Image review without patient history, prior exams

What’s In

• Subspecialized, regional or national businesses
• Employment (work-life balance)
• iPads/Tablets/collaboration
• Structured and/or image-based reports
• Appropriate use
• Secure social media
• HIE, clinical context