Radiology: Personalized service can combat commoditization

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In the interest of improved and personalized patient care and to stave off the increasing commoditization of the field, radiologists need to step forward from behind their screens and make their roles known to patients, argued the authors of a comment published in the January issue of Radiology.

With 80 to 90 percent of radiologists remaining invisible to their patients and approximately half of the public unaware of whether radiologists are physicians or technicians, the commoditization of radiology is becoming a pressing concern to many practitioners. "How did radiologists become so invisible to their patients?" and "What is the long-term effect of losing visibility to patients?" asked Gary M. Glazer, MD, and Julie A. Ruiz-Wibbelsmann, PhD, of the department of radiology at Stanford University School of Medicine in Palo Alto, Calif.

The roots of commoditization

As the turn of the 20th century saw the invention of the x-ray machine, radiologists asserted their roles as providers and interpreters of medical imaging, often without medical degrees, by communicating their findings directly to patients. But driven by emerging standards for qualification as a radiologist and the American Roentgen Ray Society's urging that radiologists communicate results to referring physicians, rather than patients, in order to gain the physicians' esteem as medical professionals, in the 1920s radiologists embarked on an enduring trend—moving behind the screens and out of the view of patients.

This invisibility was entrenched by radiologists usually being subsumed into surgery departments. Furthermore, with Blue Cross's designation of radiology in the 1930s as a "hospital service," not a "medical" one, radiologists were increasingly seen as ancillary, a perception solidified by hospitals' (as opposed to radiologists') unilateral control of radiology billing, according to Glazer and Ruiz-Wibbelsmann.

Radiology's autonomy was recaptured, the authors pointed out, with Medicare's 1965 designation of the field as a medical service (enabling radiologists to bill for their own services) and with the coming introduction of CT and MRI. Notwithstanding, increased volume and respect for radiologists in medicine did not bring them greater visibility among patients.

And while the advent of interventional radiology and gastrointestinal radiology brought many radiologists into direct contact with patients, teleradiology and PACS have recoiled in the opposite direction with comparable force. Glazer and Ruiz-Wibbelsmann contended that the spread of independent imaging centers, promulgated by the fee-for-service "reimbursement system creates a disincentive for direct interaction between radiologists and patients becoming the accepted standard of practice."

The authors elucidated their fear of radiology's commoditization and partial disintegration through the narrative of pathology: "[T]he commoditization of pathologic studies, particularly blood testing in clinical laboratories, has been one of the major factors diminishing the status of pathology. ... Because identical test results can be obtained no matter which laboratory processes them, the only factor differentiating clinical pathology tests is cost; this standardization has caused the commoditization of pathology.

"Many of the factors that led to the commoditization of pathology are also operating in radiology," the authors continued. And while radiologists' efforts to eliminate variations in image acquisition and interpretation have improved quality, the by-product has been a service that is increasingly distinguishable by price alone.

But commoditization is only a partial truth. "[C]ost is not the only factor differentiating imaging services, such as the prescribing of examinations and the interpretation of images. Unlike pathology tests, these services are not commodities because they vary according to the expertise of the radiologist who personalizes them by determining, on a case-by-case basis, the appropriate imaging test, the specifics of image acquisition, and the interpretation of images," Glazer and Ruiz-Wibbelsmann countered.

Patient communication and the de-commoditized model

The authors argued that commoditization is perpetuated by the invisibility of radiologists to their patients—a practice that can and should be reversed. "[W]e strongly agree with the American College of Radiology that direct communication of results to patients should be the overall, long-term goal