At a time when clinicians are looking for every excuse to take imaging out of the hospital and into their own offices, devaluing the role of in-house radiologists, we have provided them with one of their strongest arguments. The outsourcing of night call coverage to third parties, including offshore agents, is truly a dagger in the heart of radiology. To understand that statement, consider one definition for the “heart” of our specialty. Whereas the official diagnostic report of our procedures may represent the mind of radiology, it is the interactive, consultative role that radiologists play in the health care of almost every patient, particularly those ill enough to require a diagnostic study at night, which rests at the central, beating core of value-added services that in-house radiologists provide to clinicians, and especially ER physicians. That a significant number of hospital-based radiologists, including those in at least one academic center, have succumbed to the siren call for outsourcing night coverage speaks to the shortsighted vision of our collective future—perhaps our Achilles’ heel.

The term “dagger” is an appropriate one, being defined as a double-edged weapon, one that is symbolically ambiguous. To quote Wikipedia, an online resource for word definitions and etymology, the origins of the term dagger “… may be associated with cowardice and treachery, due to the ease of concealment and surprise [that] someone wielding one could inflict on an unexpecting victim …. “1 In addition to assassination, it can be a weapon of choice for suicide.

The seductive edge of this weapon is the ability to jettison the most demanding, and potentially litigious, aspect of radiology practice—one that saps our colleagues of their physical and mental strength, as well as one with negative financial impact on the practice. It may indeed save the lifestyle, if not the very life source, of radiologists, to outsource night call. Financial calculations in many entities where such outsourcing occurs indicate that under current reimbursement, the savings in full-time employees for a radiology group by providing outsourced night coverage more than compensates for the costs of such outsourcing. The key phrase in the last sentence is “under current reimbursement.” Yet, the very existence of such outsourcing undermines the reimbursement future of radiology. The reason, in my opinion, why such outsourcing is truly a lethal dagger is because it sends three basic messages.

The first is that radiologists are overpaid. After all, if they can afford to pay someone else (ie, subcontract) for their services and still have a comfortable margin, those services are not competitively priced. The second obvious message is that, unlike their clinical colleagues who must toil at night with patient care responsibilities, the radiologists are too lazy to continue their day job responsibilities into the night. A similar cultural message was one of the original criticisms leveled at radiologists from our early years, one that we have worked hard to overcome in our busy practices, with our clinically oriented interventional radiologists in particular, and the added value of our multiple clinical real-time interactions with our colleagues.

Finally, the most insidious message of all—the one that takes radiology from the realm of a profession (defined by sociologists as a service rooted in empirically validated subspecialized knowledge, governed by self-regulated oversight, and done for the greater good) to that of a commodity (defined as a mass-produced, unspecialized product, one that is subject to ready exchange or exploitation)—is the message that, after all is said and done, any radiologist (physician) anywhere is as good as we are and can perform radiology interpretation. It requires no specialization or knowledge of local practice patterns, and interpersonal interactive communication is unnecessary; all that matters is a diagnostic report at the lowest possible price. Lazy, overpaid, and easily replaced—these are the three basic messages we send when outsourcing night call.

No wonder our clinical colleagues installing equipment in their offices love radiology outsourcing. No wonder Congress is taking another sharp weapon, the axe, to reimbursement for imaging services. If we cannot save us from ourselves, we should not be surprised that legislatures are reluctant to do so. At the same time, they do worry about quality at the point and time of service, so it may be that laws will be passed (or JCAHO regulations enforced) regarding payment only for contemporaneous reporting of imaging services by providers who have real-time interaction with physicians acting on those reports, and whose quality is regularly monitored by their hospitals. If those providing outsourced services can comply, they may well become dayhawks. After all, they already have demonstrated that they can do part of our jobs for less.

Michael Brant-Zawadzki, MD, FACR, is medical director of radiology at Hoag Memorial Hospital, Newport Beach, Calif, and adjunct clinical professor of radiology at Stanford University School of Medicine, Stanford, Calif. He submitted his thoughts on request from Axis Imaging News.

Reference

1. Wikipedia: The Free Encyclopedia. Dagger. Available at: en.wikipedia.org/wiki/Dagger. Accessed May 18, 2006.