“During my training in diagnostic radiology, we never worked with radiation oncologists,” Dennis M. O’Donnell, MD, recalls. “Occasionally, they came to our department, and we would show them scans, but I don’t recall stepping once into the radiation therapy department.”

This schism has existed in radiology for 30 years, and in a world of two-dimensional images, it worked. Today, as three-dimensional imaging and image fusion become vital for diagnostic radiologists and radiation oncologists alike, some practices are seeking ways in which to reconcile the two specialties. One practice that has had particular success in doing so is Wake Radiology Oncology Services, PLC, of Cary, NC.

Radiology’s New Challenge: Marketing

Wake Radiology realized several years ago that changes in health care financing meant that the traditional methods of marketing (ie, none or a few measures aimed at referring physicians) are no longer adequate. Marketing has become essential, and the audience for it has changed dramatically. Whereas a referring physician is most interested in the range and quality of services offered by a radiology practice, managed care organizations are more interested in procedure price, market presence, participation in care alliances, and reputation. Moreover, there are new audiences to reach: corporate benefits departments and primary care gatekeepers.

Accordingly, in 1994, Wake Radiology began to develop a cohesive strategic marketing plan. Part of this effort was a survey of the marketing practices of other radiology groups.1 The practice also conducted demographic surveys and audience analyses in its practice area.

Among the findings of the survey was the prevalence of public relations activities by other radiology groups, as these efforts reach more decision-makers than do paid advertisements. Such activities — which include news announcements, articles, newsletters, speeches to professional groups, and participation in community events such as health fairs — also help the practice build credibility. Today, Wake Radiology Oncology publishes a newsletter and participates in the Annual Breast Cancer Golf Festival.

Medicine has a head start in marketing: there is a clear need for the services it provides. Taking advantage of that head start with a carefully planned program is the challenge for today’s radiology practice.

1. Smith PP, Schaaf RE. How public relations techniques are used by medical practices in the managed health care marketplace. Public Relations Quarterly. 1995-96;40(4):19-22.


Wake Radiology began 45 years ago as a purely diagnostic office practice with a single practitioner. Today, its 30 diagnostic radiologists work at seven freestanding outpatient imaging centers and five hospitals in five North Carolina counties, performing approximately 400,000 examinations every year. Included in the Wake Radiology network are six Carolina Breast Cancer Detection Centers and two MRI centers, one with two high-field magnets and one with an open magnet. The former center is equipped with MR-compatible injectors to assure the quality of gadolinium-enhanced imaging procedures. The various facilities offer the full range of imaging modalities, including plain radiography, CT, ultrasonography, mammography, MRI, bone densitometry, and nuclear medicine/single photon emission computed tomography (SPECT). Most of the ultrasonography machines are capable of color Doppler imaging, which is used to evaluate patients for deep venous thrombosis, carotid atherosclerosis, and erectile dysfunction, among other conditions.

The growing interest at Wake Radiology in the capabilities of three-dimensional imaging brought the practice into alliance with another group with a similar interest: radiation oncologists. When Wake Radiology decided to add radiation therapy to its services, it found that community radiation oncologists were not interested in joining a diagnostic practice or were unavailable because of contractual obligations. So Wake looked around for collaborators, and found the Radiation Oncology Department of the University of North Carolina (UNC), 30 miles away. This department has provided the desired in-depth expertise and staff stability. The radiation therapy arm at Wake Radiology Oncology now consists of three full-time therapists, a clinical physicist, a dosimetrist, and a specialized nurse. Approximately 600 patients were treated in the first year of operation.

“The Radiation Oncology Department at UNC provides professional services under contract, and Wake Radiology provides the technical services,” Joel Tepper, MD, chair and professor of the department, explains. “At least one physician is on-site at all times with an additional physician providing quality control, backup, and extra support 1 day a week.”

Radiation therapy and diagnostic imaging come together in Cary, where they occupy 16,000 square feet on the first floor of a four-story building that also is home to general surgery, medical oncology, and general medical practices. The suite is directly ambulance accessible by elevator from a ground-level ramp. Underground parking enhances patient convenience.

In addition to routine radiographic, fluoroscopic, ultrasonographic, and mammographic equipment, the suite has spiral CT and SPECT equipment, all of it DICOM 3 (Digital Imaging and Communications in Medicine) compliant to facilitate image fusion. This suite also houses a treatment simulator and an accelerator with a multileaf collimator that provides photon-beam and a complete range of electron-beam energies. The accelerator is linked to a computer network that monitors and verifies every aspect of treatment for safety and compliance with the treatment plan. Teleconferencing facilities are available.

Wake Radiology’s marketing material for physicians ordering diagnostic studies points out that “the quality of an image and a correct diagnosis of its content can make a major difference in how a patient is treated.” Thus, equipment is regularly upgraded, and the expertise of 11 subspecialties is represented on the staff. However, there is no drive for automatic acquisition of the latest technology.

“We would all like to do the newest things, but they are not always economically feasible or medically justified,” says O’Donnell, a thoracic specialist who is board certified in pulmonary, internal, and critical care medicine as well as radiology. One of the new modalities that the Wake Radiology specialists have chosen not to implement is electron-beam CT, as they think MRI will soon provide all of the same information without the cost of another scanner.

The practice likewise has not yet purchased a multidetector-array CT scanner, preferring to wait to determine whether this equipment will be essential. Wake does not provide mobile mammography services, and does very little outpatient interventional work.

“Most local hospitals around here have cardiac catheterization laboratories,” notes Robert E. Schaaf, MD, group president and managing partner at Wake Radiology. “It would be almost impossible for us to get a certificate of need (CON) for outpatient interventional angiography procedures at the Cary facility. However, in our hospital practice, we do the full gamut of interventional procedures.” Four of the radiologists are interventional specialists.

Wake Radiology is seeking to acquire a positron emission tomography (PET) scanner and will be submitting a proposal for issuance of a CON.

“North Carolina is very careful about who gets expensive equipment and facilities, which is good,” Schaaf says. “To prepare our proposal, we did demographic studies, evaluated trends in various populations such as cancer patients and their needs, and looked at what other providers offered. We also collected evidence of support from the community and other health care providers.”

The practice stresses the importance of regular upgrades to ensure that the greatest amount of diagnostic information is obtained. How are decisions made about upgrades and new equipment purchases?

“Once a month, we review where we are, where we want to go, and where we want to be 5 years from now,” O’Donnell explains. “We make an upgrade decision jointly when we think our imaging is not as good as it might be, given the state of the art. When we are talking about large equipment purchases, we pay particular attention to the views of those who will make the greatest use of it.”


The focus on maximizing the capabilities of the imaging department does not distract Wake Radiology from the value of established methods or the economic benefits of using them. The practice publishes a utilization management program guide for referring physicians that lists recommendations for the sequence of studies in 67 situations where a radiology consultation is likely to be sought. For 37 of those conditions, plain films, ultrasonography, physical examination, or endoscopy is the first recommendation.

It is typically the higher technologies, however, that are involved in staging and, in particular, the planning of treatment for cancer. And cooperation among diagnostic and therapeutic radiologists is increasingly important to outcomes.

“An enormous amount of what we do in radiation therapy relies on diagnostic radiology to define the tumor stage, show where the tumor is located, and do treatment planning very precisely,” Tepper points out. “We want to irradiate all the tissues that need to be irradiated but avoid irradiation of those tissues that do not.” Increasingly, this precision is obtained by 3-D treatment planning and image fusion techniques.

Per Halvorsen, MSc, DABR, chief clinical physicist, provided some details. “In the past, we would do a few iterations of a few treatment techniques, actually putting the patient through them,” he explains. “With the 3-D techniques, we acquire a large amount of information, typically a CT and perhaps an MRI scan, and use this data set to do 10 or 20 iterations without the patient’s presence. We save each anatomic structure of interest in a separate data file and compute what dose each organ will receive with each technique. Then we do objective comparisons to determine which technique gives us the highest tumor dose while minimizing the dose to normal structures.

“When we treat a patient with lung cancer, we irradiate a fair amount of normal lung tissue, and most of these patients cannot spare any. So we are acquiring SPECT perfusion data as well as CT images. Then we can aim our radiation ports to minimize damage to normal lung. We are looking at ways to examine all of the lymph nodes in the chains draining a breast cancer. Also, there have been studies showing that MRI spectroscopy data overlaid on MR images of the prostate give you a very good idea of where a cancer is. When the software becomes available for our MRI scanner, we will be doing fusion imaging of the prostate for radiation treatment planning.

“We are not experts in interpreting images, and we frequently find that we are not entirely confident about how to use a large volume of data. With the arrangement we have here, we can easily have a mini-consultation with our diagnostic colleagues.”


Emphasizing convenience for all of its customers — referring physicians, patients, and payors — is a strong focus at Wake. For referring physicians, there are Rolodex? cards showing which studies are performed at which centers, with the telephone number of each scheduling office and each center’s fax number. If the radiologist requires clinical or laboratory data before doing the study, space is provided for this information on the referral form. For example, the form asks for the BUN and serum creatinine concentration for all diabetic patients and those over the age of 50 who are scheduled for contrast studies. If the patient is to have an MRI scan, there is a list of sources of metal, not only pacemakers but war wounds that could have resulted in retained metal fragments. Each form also includes a map of the location of the imaging center, instructions on preparing for the examination, and an explanation of the patient’s responsibility for arranging payment. The business office is able to customize its billing and accounting procedures to comply with the proprietary systems of most payors.

Wake Radiology has gone to unusual lengths to make its services convenient for patients. Its MRI center is open from 7 am to 11 pm Monday through Friday and from 7 am to 8 pm on Saturday and Sunday. For each type of examination, the patient receives a pamphlet explaining what the study is, why it is being done, how to prepare for it, what to expect — including how long the study will take — how to find out the results, and what responsibility the patient has for arranging reimbursement. The booklet given to radiation therapy patients also includes a chart of the most common adverse effects of irradiation at various sites, along with recommendations on measures the patient can use to minimize or alleviate them.


The merger of diagnostic and therapeutic radiology “has worked out even better than we predicted for both patients and physicians,” Schaaf says. “The radiation oncologist orders only the studies that are needed, and all of those studies get done,” usually without sending the patient any further than down the hall.

Schaaf suspects there may be cost savings in building and maintaining a joint facility. “You can share waiting areas, examination rooms, and some staff,” he points out. “You can cross-train imaging and therapy technicians to help each other, and the diagnostic arm gains the benefits of sophisticated nursing, physics, and dosimetry services from the therapeutic side.” The arrangement with the university also gives patients access to research protocols of new treatment techniques.

Seeing a large number of cancer patients and others who are very ill has not increased costs inordinately despite the somewhat longer time it often takes to image such patients.

“We think the joint operation increases throughput,” Schaaf says. “Having the combined facility reduces redundant and unnecessary examinations. If, during the course of therapy, the patient needs a barium swallow or other examination, the procedure is available only footsteps away. The oncologist can review the films with the radiologist, and the disposition is immediate. Imaging of very ill patients is somewhat more time consuming, but we have so much more help around than the typical practice that the process goes smoothly. Also, we see many of these patients daily, so we are prepared for the specific situation, and because we have excellent relations with them and their families, the patients are highly compliant.” Quarterly patient satisfaction surveys help Wake ensure that its practice maintains good relations with patients and families.

Both the diagnostic and the therapeutic staff are enthusiastic about the joint facility. “I can’t say enough good things about working with therapeutic radiologists,” O’Donnell says. “When we image one of their patients, we have the medical history immediately available, and we can talk directly to the therapist to find out precisely what that person needs to know. We did not find it difficult to adjust to working with the radiation oncologists, because they are eager to have our input, and that is so pleasant.”

The university radiation oncologists appreciate the convenience of working at Wake Radiology Oncology. Also, the arrangement between UNC and Wake Radiology has expanded the university’s patient base.

“Before we joined Wake Radiology, we had not been providing radiation oncology services in the Cary area,” Tepper notes. “We did see some patients from that area, but it was an extra effort for them to come to a large medical center for their treatment. Almost by definition, the new arrangement is more convenient.” The university affiliation brings not only the expertise of the radiation oncologists who work at Wake Radiology full time but also back-up expertise whenever that is needed.


For those contemplating a similar union, O’Donnell has this advice. “Do not establish a joint diagnostic-therapeutic center with the idea that you are going to make a lot of money,” O’Donnell cautions. “Instead, think of it as another way to support excellent care and build your reputation and goodwill in the community. Then, if you have a well-run operation, you will be able to turn some profit.”

A joint venture should not be set up with radiation therapy being less than a full partner. “Many times, when attempts are made to add therapeutic radiology, people make the mistake of buying the cheapest equipment they can and then running it until it falls apart and has long since become obsolete,” O’Donnell observes.

In Tepper’s view, it is very important that the design of the facility, its staffing, and the equipment be determined in collaboration with the radiation oncologists. “If someone who does not know radiation oncology designs the facility and establishes the specifications, you are not going to have as efficient an operation as you could,” he says. When the treatment arm was added, the radiation oncologists defined the technical specifications for the equipment and rearranged the original clinic design to aid in patient flow.

Thirty years ago, technological advances in the respective fields of diagnostic and therapeutic radiology drove the specialties apart. Moving into the new century, it appears that further advances in both imaging and therapy are drawing them back together.

Online: Wake Radiology Oncology Services can be found on the Web at www.wakeradiology.com and www.wakerad.com.


Judith Gunn Bronson, MS, is a contributing writer for Decisions in Axis Imaging News.