Ten years ago, radiology was on the cusp of a revolution that would reshape practice patterns for the next 10 years. The specialty was still keeping banker’s hours, and most hospitals went without night coverage. PAC(S) was something you did before flying off to enjoy one of your 17 weeks of vacation, and if anyone gave RVUs a thought, it was because they had just been appointed to the RUC (whatever that was). Soft copy was a term that had vaguely obscene undertones.

That was then, and look at you now. On any given night, ambulances roll up to emergency departments all across America, where 8- to 64-slice CT scanners triage patients, and radiologists in New Zealand, New Delhi, or, more likely, new pajamas navigate many megabytes of data seeking answers to clinical mysteries. In one short decade, radiology has evolved and few hospitals in America go without 24/7 radiologist coverage. For many reasons, diagnostic imaging has become an indispensable tool in medicine today, so central to health care that it must be ubiquitously available.

Yet today, at the peak of its prosperity and prominence, radiology is a specialty under siege. The Deficit Reduction Act of 2005 went into effect on January 1, an arbitrary act devised by desperate lawmakers looking for the cash to fund the 2006 physician fee schedule fix. It was a desperate measure for desperate times, and all signposts suggest that there may be more to come. Next came the tough new standards for independent diagnostic testing facilities (IDTFs), designed to rein in abuses in the laboratory market, but adding cost and administrative hurdles for operators of IDTFs. Most recently, CMS made it clear that it intended to curtail imaging center activity as well by adding some significant revisions to those standards in a January 26 transmittal. On February 19, CMS withdrew those revisions.

Nonetheless, turf battles, self-referral, and attacks on reimbursement are but distractions from radiology’s bigger problem, the lack of one unifying concept behind which all factions in radiology can align, including academics and private practice radiologists, imaging center owners and vendors, the American College of Radiology, the American Healthcare Radiology Administrators, the Radiology Business Management Association, and the National Coalition for Quality Diagnostic Imaging Services. Radiology is definitely in need of what Jim Collins, author of Good to Great, calls a Hedgehog Concept, a simple, elegant idea that summarizes the indisputable value of the specialty. Collins borrows the term from Isaiah Berlin’s famous essay, “The Fox and the Hedgehog,” based on the ancient Greek parable. In this fable, the cunning fox attempts to attack the dowdy hedgehog day after day, but the hedgehog simply rolls itself into a ball of spikes to turn back the fox. As Collins notes, Berlin divides the world into foxes, who pursue many ends and see the complexity of the world, and hedgehogs, who distill the world into one single organizing idea.

Consider this as radiology’s Hedgehog Concept: the simple but sublime notion that radiologists are best qualified to act as stewards of radiation itself, the wonderful yet terrible energy that gave the specialty its start and still plays a vital role in imaging. It is as stewards, as well as physicians, that radiology can provide the best service and add the greatest value to the overall health care system. No one but a radiologist is better equipped to understand the potential benefits and dangers of radiation exposure, no one is better educated on the appropriateness of an examination for an indication, and no one is better positioned to begin keeping a tally of a patient’s dose over time.

Clearly, radiology is on the cusp of yet another revolution in practice patterns, and only by pulling its head out of the sand and accepting full responsibility for the power of radiation to help and to harm can radiology maintain preeminence in diagnostic imaging.

Cheryl Proval
Editorial Director