JACR: Planning for the unpredictable future of radiology

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The "cone of possibility." The scenarios are represented by broad cones whereas the prediction cone, by definition, is much narrower. Image Source: J Am Col Radiology 2010 8;3: 175-9.
During a time of tremendous uncertainty in healthcare and monotonously consistent inaccurate predictions about the system’s future and radiology’s role in it, scenario planning offers radiology chairs a complementary approach to improve readiness and maximize the department’s prospective problem solving capabilities, argued the authors of a March study published in the Journal of the American College of Radiology.

“Although the Oracle of Delphi has lost its influence, we, like the Greeks of 1,600 years ago, still have great curiosity to see into the future,” said Dieter R. Enzmann, MD, from the department of radiological sciences at the David Geffen School of Medicine, University of California, Los Angeles, and co-authors. “The monotonous consistency of prediction failures, however, has not dampened our enthusiasm.”

“Traditional strategic planning yields a single set of best responses to an imagined ‘most likely’ future,” explained Enzmann and colleagues. And yet, they argued that the future is highly dynamic, more so than humans tend to acknowledge. This significantly handicaps strategic planning, which is specific and rooted in probabilities, but has only weakly deterred executives of companies or chairs of radiology from making such predictions.

Enzmann and co-authors argued for an alternative approach, one independent of probabilities but offering highly detailed scenarios, serving as signposts to inform practitioners of the field’s trajectory and thereby offer a broader scope and greater preparedness for scores of different futures. Developed by Pierre Wack of Royal Dutch/Shell as an alternative to predictive planning, scenario planning gained credibility after helping the Dutch oil and gas company weather the oil crisis of 1973 and the recession of 1981.

Enzmann and co-authors described scenario planning as a method that generates a (potentially large) list of factors that affect a given institution’s decision making and includes forces that are likely to affect that entity’s future. The planners then select the most important and uncertain items from that list to define “axes of uncertainty.” Each axis of uncertainty, of which there will be about three for a given problem, consists of two poles with opposite characteristics. Referring to the cone pictured above, the aim of these dyadic axes would be to cover a larger portion of the future horizon, the cone’s opening.

Arising from the increasing struggle voiced by members of the Society of Chairs of Academic Radiology Departments (SCARD) in balancing departmental missions in the face of growing political, economic and social change, the authors were part of a project that included SCARD executives, clinical department chairs (from radiology and other specialties) and venture capitalists, aiming to tackle a related radiology scenario planning initiative.

In an extended brainstorming session of a segment of the group, 300 drivers and forces in radiology were identified across a timeline of 10 years into the future. These 300 high-impact, uncertain forces were copied onto sticky notes, placed on a whiteboard and classified into three groups, the scenario plan’s three axes: market focus; radiology’s business model; and technology and science. The respective poles of each of these axes consisted of centralized healthcare vs. a decentralized private market; a unified, single specialty vs. a splintered, disaggregated subspecialty; and technology enabling radiology vs. technology threatening to radiology.

Finally, of the eight possible interacting scenarios, the authors developed planning scenarios for three. The first, “entrepreneurialism,” consisted of a decentralized private market, a disaggregated radiology business model and technology that was threatening to the field. Providing only the executive summaries of these detail-laden scenarios, the narratives embedded numerous signposts by which radiologists could conceive of potential circumstances, advances and roadblocks to better prepare for the trajectory of the specialty under variegated conditions.

Under the first scenario, for example, a completely private market would deliver intensive competition and a fragmented specialty, under pressure from competing technology and highly autonomous radiologists. Moreover, without universal healthcare coverage, the public would be highly focused on costs, resulting in retail radiology and greater dependence on less specialized, nonradiologists.

The second scenario, “socialized medicine,” would involve a centralized market, a unified specialty and technology and science enabling to radiology. Under these circumstances, the authors envisioned highly regulated, top-quality care with longer waits for non-emergent services. With emphasis on universal care to cut costs, and tight quality conditions, radiologists would be in short supply and would turn increasing to extenders (radiologist assistants) to meet the margins. If technology centers were involved with comparative effectiveness in this scenario, industry would forge a government-medical-industrial complex.

In the final scenario, the authors portrayed what they called a “freefall,” involving a centralized market, a disaggregated radiology model and threatening technology and science. Comprising an era where radiology has “lost its compass,” freefall would see a service line-driven disarrangement of radiologists, facing competition from technology and nonradiologists. Ultimately, this model could lead to a peripheral role for radiologists.

Enzmann and co-authors stressed the preparative rather than predictive role of scenario planning. By illustrating detailed hypothetical futures, the scenario planning aims at pushing planners’ Weltanschauungs, or worldviews, under the notion that unpredictable futures demand flexible leaders.

The particularly dynamic stage of healthcare at present highlights this quality brightly, the authors contended: “‘[P]reparedness’ has little meaning if the insight gained from scenario planning does not influence or change the behavior of decision makers. That may in fact be the key psychological and organizational hurdle in the planning challenge.”