Here on the threshold of the 21st century, it would be tempting for a radiologist, having invested 10 years and hundreds of thousands of dollars in an education, to engage in a bit of self congratulations. Salaries are escalating, due in part to a sudden but real shortage of radiologists. The shortage has enabled groups in some markets to turn back the reimbursement erosion effected by managed care. A simultaneous increase in the number of radiological studies being performed is likely to continue, fueled by demographic trends, technological advances, and politics.

There is, however, a troubling aspect to the shortage. If there are not enough radiologists to read a steadily increasing number of studies, then who will read them? Another rising trend that very well may converge with the others, is the widening proliferation of information technology and the improving ability to move images digitally and, with Web technology, less expensively. Some are predicting that a percentage of radiological studies will be relegated to the status of commodity. Now most patients would probably applaud if their images were moved to a subspecialty radiologist should none be available locally, but I wager they would prefer their studies not be sent to a warehouse in Nowhere, Montana, because the rent is cheap and the price is right.

From the patient perspective and, I suspect, from the radiologist perspective, radiology as commodity does not sound like a good idea. Quality is not the word that comes to mind when commodity is mentioned. Quality corn feed? Quality wheat? Quality oil? Quality pork bellies? It is quantity that is the name of the commodity game, and if a provider were able to offer high quantity reads, and a good price at that, then that provider would be in the commodity business.

If indeed a significant percentage of radiology were to go to the commodity market, then to whom would fall the distasteful task of deciding which studies were least important? If a body part is to be outsourced, a perfect candidate would be the breast. The margins are thin to nonexistent and mammographers are among the rarest of radiologists. Of course the breast cancer lobbey is likely to find fault with that idea. If not a body part, maybe outsourcing a segment of the market would work. If a market segment is to be outsourced, let it be one without economic or political power and with limited access to the press. That would be pediatrics.

(Diagnostics as a commodity is not without precedent in medicine. One need look no further than pathology to see this is within the realm of possibility.)

Here is another troubling issue that will prove its relevance. A recent public radio segment about an ambitious Massachusetts state health program for colon cancer screening extolled the virtues of colonoscopy, but made no mention of barium enemas or the promising, noninvasive virtual colonoscopy. Over the sounds of a moaning patient (surely that alone had a dramatic negative effect on compliance for the Massachusetts program), the reporter described the mechanics of the gold standard in colon cancer screening, as the physician proceeded to snake an endoscope around the turns in the patient’s bowel. (Was the anesthetician unduly cautious?) The following Thursday when letters were read there were, alas, none from radiologists but a general surgeon did write in complaining that colonoscopies were not performed by gastroenterologists alone. Surprisingly, there were no letters from cardiologists offering their services. Where was radiology’s watchdog? Can not organized radiology find a radiologist with an outgoing personality to promote the services of the profession?

In the poignant and hilarious story by the late Southern writer Flannery O’Connor, Everything That Rises Must Converge, a matron is forced to confront her vestigial racism on a bus in a Southern town. The point is, it is impossible to embrace only one part of the truth. The other parts will inevitably enter into the equation. If radiology is to ward off the specter of being bought and sold as a commodity, it must inevitably adopt a stronger service ethic and then engage in some healthy self-promotion for the profession.

Cheryl Proval
[email protected]