John Pezzullo, MD, talks with a patient at one of four imaging centers operated by Rhode Island Medical Imaging, PSC, Providence.

For an academic radiology practice, Rhode Island Medical Imaging (RIMI), PSC, has an atypical model. The 50 member radiologists all have academic appointments at Brown University, one of the leading training facilities for radiologists in the country, but they are organized in a private practice instead of being employed by the university.

So when it became clear that a growing number of aggressively marketed, privately owned imaging centers and MRI facilities were encroaching on referrals and cross-sectional imaging volumes, RIMI radiologists were faced with protecting more than income: their mission was at stake.

“We use private practice in order to support the academic mission of the group,” explains John Pezzullo, MD, a RIMI radiologist who specializes in body imaging, and assistant professor, department of diagnostic imaging, Brown University. “We provide training for future generations of radiologists,” he explains. “We do cutting edge research. We are pioneering new technology such as radiofrequency ablation for the treatment of cancers and advanced vascular techniques such as renal artery stenting. One of our members just got a National Institutes of Health grant to further evaluate the utility of renal artery stenting. Those activities take a lot of time, and it is the private side that supports the group’s academic mission.”

In addition to serving as the Department of Diagnostic Imaging at Brown University School of Medicine, RIMI operates four outpatient imaging centers—three in the greater Providence area, and one in the southern part of the state—with six MRI and four CT scanners. The group also covers four hospitals in the surrounding areas: Rhode Island Hospital, Hasbro Children’s Hospital, Women and Infants Hospital, and The Miriam Hospital.

Marketing was not much of a concern for RIMI until it began to take a hard look at the expansion and marketing efforts being conducted by others in its geographic sphere.

“In 1990, there were about 12 MRI units serving a population of 1 million people in Rhode Island, and most of those were split between hospital and private practice radiology groups,” notes Pezzullo. “Currently, there are 53 MRI units in the state.” Pezzullo confirms that the group has seen significant growth in MRI units deployed by nonradiologists and entrepreneurs.

“There is a finite growth in MR volume on a national basis every year of between 10% and 20%, depending on what market you’re looking at, and our numbers were remaining essentially flat,” he says. “We came to the realization that we weren’t growing the way we should be growing in what turned out to be a very tough, competitive market. It was our realization that we had to jump into this or be the last ones to come around, and obviously with the potential to suffer pretty substantial losses in our outpatient revenue,” he says.

“The for-profit imaging companies and the companies that are not owned by radiologists have savvy marketing departments, dedicated people who do it all the time for them, going from office to office, touting their services; it’s really a slick operation. We were feeling the pinch of that. We decided we’d better get in the game or potentially lose our outpatient revenue,” Pezzullo says. Priot to 2002, RIMI did not spend a dime on marketing.

In 2001, the MRI and CT volume at the four outpatient centers was 803 and 1,099 examinations per month, respectively. After implementing the marketing strategy, MRI volume increased to 951 per month in 2002, and to 1,154 per month by 2003, despite the fact that during the same time period, six competing MRI sites opened in the same market area. By 2004, MRI volume was up to 1,380 examinations per month.

CT volume increased from the 1,099 pre-marketing level to 1,362 per month in 2002, dipping slightly to 1,293 in 2003, as the group closed two CTs it owned, before jumping to 1,584 per month in 2004.

“We feel that our marketing is well worth the money that we spend on it just because we’ve seen tremendous uptick in both of those numbers,” Pezzullo says. “It’s worked wonders for us, on a number of different levels. One, we’ve seen a definite uptick in the number of CTs and MRIs that we do. The other thing that it has helped out with is physician relationships: educating the physicians in the referring community about who exactly we are.”


The first step to implementing a marketing plan at RIMI was simply deciding to do it. “We’re a bunch of radiologists, all with advanced education, but none of us with any business savvy. None of us took classes in medical school having anything to do with marketing or business,” he says. “So one of the key things truthfully is getting people on board and saying, We have to treat this as a business. It’s not just medicine anymore.’ You have to make them realize that it’s a do-or-die situation, in fact.”

RIMI hired an outside marketing consultant in 2002 to conduct a market analysis, looking at patient and physician demographics, and the local competition—including who was coming into the state, who owned what, their capabilities, and proximity to hospitals.

Information was gathered via mailings, surveys, and phone calls. The consultant also held focus groups with referrers and nonreferrers to find out what they did or did not like about RIMI, and how the group’s service could be improved, among other areas.

The findings were submitted in a report to RIMI. “We found that there were quite a few more magnets in the market than we originally had anticipated,” Pezzullo says. “We weren’t paying attention to that. We know what’s going on with our own centers. We found that there was this efferent number of sites that were being developed or were in the process of being developed, not even owned by radiologists, but owned by subspecialists, either orthopedists or neurologists, for instance.”

Complaints and concerns were usually specific to whichever practice was responding, and included the usual suspects:

  • turnaround too long
  • unwillingness to release film to patients
  • reports unavailable
  • difficulty scheduling patients

The inquiries also revealed that RIMI “had fallen into the perception of radiologists being aloof, unavailable, and basically sitting in their offices from 9 to 5, slugging through a bunch of films without being that personable,” Pezzullo says.

“We had to overcome that perception,” he adds.


From the analysis, RIMI developed a comprehensive marketing outline to increase its name recognition, and educate physicians and patients about its services.

The group developed an in-house marketing department, initially comprised of two full-time employees, and now employing four full-time staffers to handle the day-to-day marketing and serve as liaisons between the referring community and the practice.

“One of the marketing results that the consultant found is that people really did not understand Rhode Island Medical Imaging, and who we were as radiologists in the state. People didn’t really understand that we were not only Rhode Island Medical Imaging, but the Department of Diagnostic Imaging at Rhode Island Hospital and the Lifespan health system, and the Department of Diagnostic Imaging at Brown University School of Medicine, among other things,” he says. “That was a key feature, and that’s something that we used in our marketing efforts.”

RIMI developed a twofold marketing strategy: direct-to-physician and direct-to-patient.


The direct-to-physician marketing effort included the development of radiology case breakfasts, through which RIMI radiologists met once or twice a week with subspecialists or whomever the group was marketing to that week—eg, a neurologist, an orthopedist—who were invited to bring MRI cases for a consultation.

“Those studies did not have to be done in our center. They could come with any films that they wanted, done anywhere—whether at the hospital or any of our competition—so that we could go over the cases with them,” Pezzullo says. “That’s important because we’re the only radiology practice in this state that essentially practices subspecialty radiology.”

For instance, for orthopedic case breakfasts, one of RIMI’s orthopedic radiology specialists would conduct the session. “You get subspecialty expertise while developing physician relationships,” Pezzullo says. “And it allowed us to gauge the competition, too. You’d have Dr X from Area X who would come in with three MRIs from a competitor, and, therefore, we know that Dr X is mainly sending his patients to the competition, and we’re able to get a sense of why.”

Another direct-to-physician marketing effort was continuing medical education lectures, which were held as a dinner in a restaurant. One of the group’s radiologists gives a lecture to physicians and their front office staff based on a general topic in radiology, such as the radiographic examination of low back pain, and when to order CT vs MRI scans.

“The thing that we found to be the best for direct-to-physician marketing was the physician luncheons,” Pezzullo says. The group holds two or three a week, for which a member of the marketing staff and one of the radiologists bring lunch to a referring physician’s office. The goal is to find out information such as whether there are any complaints or whether anything needs to be done to improve service.

“Those we found to be the most effective. One, because they’re extremely inexpensive to do, and two, again, it develops physician relationships,” Pezzullo says. “What that does is develop physician loyalty to our practice.”

The group also developed a promotions package that includes a folder with the group’s logo on it in which individualized ordering forms, the radiologists’ biographies, and other information can be placed. Apparel, mugs, and pens with the logo were also created. A new logo and development of other signage were part of increasing the group’s name recognition.

For some physicians, the group also developed individualized ordering forms. “It’s essentially saying that we’re willing to do whatever it takes to get your business,” Pezzullo says. “They’re not major changes, but for our bigger referrers who want things done specifically their own way, we’re able to tailor to them without giving up too much.”

Another change that Pezzullo says was key is the group’s web-based server, which allows referring clinicians to access images and reports of their patients online, almost immediately.

Physicians’ front office staffs play an important role in RIMI’s direct-to-physician marketing, and are always included in marketing efforts.

“For the most part, it’s not the patient who decides where they’re going, it’s not even the physician; it’s their front office staff,” Pezzullo says. “This came out of the marketing survey as well. The front office staff determines 40% of the time where the patient is seen, not the doctor. The doctor just gives the patient a prescription. They’ll bring it up to the front office receptionist at that physician’s office, and she’ll fill out the form for Rhode Island Medical Imaging or one of our competitors.”


RIMI’s direct-to-patient marketing plan included the development of a billboard campaign, which placed billboards in high-visibility areas, and ads in local newspapers and local magazines.

“[Those are] geared toward letting the patients know who we are, that they should be asking for our practice because again we are the only group that specializes in subspecialty radiology, and that our doctors are among the top radiologists in the country. Our ads are focused on letting people know that at Rhode Island Medical Imaging, all our doctors have professional appointments at Brown University Medical School, and that we cover all the major hospitals,” he says.

Other direct-to-patient marketing tools include radio spots, press releases, in-office pamphlets on various procedures, and the creation of a Web site.

“The global strategy I would like to see developed is to educate the patient so the patient becomes sufficiently savvy that, when they go to see another specialist who’s ordering an MRI across the hallthe MRI that he owns—they question whether the MRI actually needs to be done, and then question who’s reading that MRI. We’ve seen a little bit of that already with our direct-to-patient marketing,” Pezzullo says.


Pezzullo says it was initially “extremely difficult” to get the group’s 50 radiologists onboard for the initial marketing plan. “Doctors are notorious for not being good businesspeople, especially radiologists, who went into radiology because they may not like to interact with patients or other physicians,” he says. “In our practice of 50 people, we’ve developed a cadre of probably about 10 people that we can count on to do marketing. That’s worked out great because these are people who want to do it; they’re personable, they don’t mind talking to physicians.”

RIMI has honed in on what it has found to be the most beneficial marketing tool. “It’s rare that we’ll do a case breakfast anymore or a CME lecture. We really concentrate on doing the physician luncheons though because you know you can catch the physicians in the office during their lunch hour,” Pezzullo says.

Overall, RIMI now performs about 120,000 examinations per year, including mammography, ultrasound, plain radiography, CT, and MRI.

Pezzullo advises other academic imaging practices to jump in—or potentially lose out.

“It’s pretty self-evident what needs to happen if you want to really maintain competitiveness in the outpatient world, especially when there are so many external influences now—the for-profit imaging centers that are developing, the whole specter of physician self-referral that’s really eroding the practice of outpatient radiology. The way to do that is by jumping into the marketing game, and not being afraid to do that; treating the outpatient practice more in a business manner; and—the key thing for us—developing physician relationships,” Pezzullo says. “Develop good relationships and be available to the referring community, and educate your patients as to who you are and what you’re doing because it has an impact.”

Danielle Cohen is associate editor of Decisions in Axis Imaging News.