Farewell to RSNA 2016, Hello to the Future of Radiology

Dec. 2, 2016
The clinical practice of radiology is on the verge of transformation—and so is the policy, payment, business, and operational landscape of radiologic practice in the U.S., as radiologist thought leaders noted during RSNA 2016

As it does every year, this year’s RSNA Conference, held at the vast McCormick Place Convention Center in Chicago, has flown by like a meteor. And, as always, there has been a blizzard of sessions, meetings, discussions—and of course, marketing messages from vendors. And yet, somehow, this year’s RSNA really did feel different. One could feel the seismic shift taking place under the feet of everyone at the conference. Not only that—there was explicit acknowledgement this year of the transformative changes taking place in healthcare these days, to the extent that this year’s theme was “Beyond Imaging.”

What’s more, the “beyond imaging” theme worked its way into the opening keynote address of the conference, which took place on Sunday. According to the RSNA Daily Bulletin, RSNA president Richard L. Baron, M.D. told attendees in a packed opening session in the Arie Crown Theater at McCormick Place that “We should congratulate ourselves on the hard work and creativity that has pushed our specialty to this level. Yet we have to keep moving forward.” And, in a president’s address entitled “Beyond Imaging: Ensuring Radiology Impact in Clinical Care and Research,” Dr. Baron went on, according to the Daily Bulletin, to focus on four “ripple effects” that radiologists’ daily practices have on healthcare and the patient experience: delivering value under shifting reimbursement; working collaboratively as part of the healthcare team; continuing to innovate; and focusing on patients. “This shift does not require revolutionary changes to our practices and culture. I see it more as a return to basics,” he said.

Dr. Baron went further, saying that while radiologists have become adept at working with thousands of diagnostic images, the development of that skill set has come at a cost. “The best radiologists have learned to combine science and art,” he told his audience. “But most of us focus only on the image, practicing an extreme of science at the expense of art.” He further urged radiologists to refocus how they practice, going back to such practices as seeking face-to-face consults with referring and ordering physicians, something that has become rare in recent years.

Here’s the thing: it’s hard to imagine that speech being given even three years ago. Maybe even two years ago. But the reality is that, at a time of accelerating change in healthcare, it made sense of Dr. Baron, the president of RSNA, to give it at this year’s conference, because if any medical specialty is facing wrenching change right now, at least in the United States, it is radiology.

As one of the highest-paid specialties in U.S. medicine, radiology is inevitably going to be in the crosshairs of policy and payment leaders in the U.S. Congress and elsewhere. Consider this: according to a July report in AuntMinnie.com, a physician compensation survey conducted this summer by the American Medical Group Association (AMGA) found that the median annual salary for radiologists in 2016 was $490,399. Radiologist compensation had been fluctuating somewhat, though within relatively narrow confines, recently, with 2011 average compensation at $461,250, and that number falling to $453,216 in 2013. Nevertheless, the AMGA survey had found that radiologists made on average somewhere between $450,000 and $500,000 a year. What’s more, smaller medical groups actually saw higher compensation--$524,214, whereas medical groups with more than 300 FTEs saw median compensation of radiologists at $487,195. And this is at a time when, according to the “Medscape Physician Compensation Report 2016,” the average pediatrician made $204,000, the average endocrinologist made $206,000, the average family physician made $207,700, and the average internal medicine physician made $222,000. To be absolutely fair, Medscape’s survey found an average radiologist compensation level of $375,000, considerably lower than the $490,399 that AMGA’s survey found. But still.

In any case, it is hard to imagine that, long-term, radiologists’ incomes will stay where they are right now relative to those of other physicians or even those of other specialists, given the massive cost cliff that the U.S. healthcare system is about to go over, with the Medicare actuaries estimating that total U.S. healthcare expenditures are set to increase on the order of 70 percent over the next decade. The simple truth is that radiological services cost too much relative to our society’s ability to support them over the long term.

And, as the U.S. healthcare system inevitably shifts from being volume-based to being value-based, radiologists will find themselves under increasing pressure to prove their value to the care delivery chain, particularly as more and more patient care organizations take on financial risk and develop accountable care organizations (ACOs), participate in population health management, and use analytics to improve their efficiency, cost-effectiveness, and patient outcomes.

Not surprisingly, some of the leading thought-leaders among radiologists, such as Eliot Siegel, M.D. and Rasu Shrestha, M.D., are already skating to where the conceptual puck is headed. In their interviews with me this week, both Drs. Siegel and Shrestha sounded themes that were reflected as well in the presidential address that Dr. Baron gave on Sunday. And both, not surprisingly, spoke of the need to ally with CMIOs, CIOs, and other healthcare IT leaders, to find a way to collaborate as a team to bring more value. As Siegel said at the Philips media breakfast on Monday morning, speaking of the advent of PACS (picture archiving and communications systems) systems 25 years ago, “Twenty-five years later, I’m not sure we’ve achieved all the things we had hoped to. Sure, we have images anytime and anywhere we want to. But we were hoping we could really use the computer and coordinate with the electronic medical record, and really have the radiologist be a consultant.”

What needs to happen next, Siegel said, is that “Computers can do some findings, but the radiologist needs to put all those things together. And it’s a complex nexus of information we need—using our judgment, combined with the findings on the image. So what I want from the next generation of systems, is to be able to take advantage of all the amazing things we had hoped for 25 years ago, with a whole new generation of information systems to support us.”

And Dr. Shrestha said this: “We’ve traditionally been very volume-based in radiology. How do we move from healthcare being interpretation-centric and volume-centric, to being value-centered and population-centric? We need to use the data in ways that help us to holistically addressing the problems around the individual patient. What we need to do is to be able to work with not just the presenting symptoms, or reasons for exam, such as ‘headache’ or ‘cough’—often, that’s all the information you have.” Instead, in the context of the search for a transition from radiologists and other physicians and clinicians drowning in data, there is a huge opportunity to use artificial intelligence to change the way that radiology is practiced. “Machine learning is important in this context,” Shrestha told me. “Historically, we dealt with analog-based data. Now, machine learning gives the opportunity to look at data at scale: millions of similar images, with millions of similar types of cases looked up before, with best practices around certain types of pathologies. So how do we augment clinical decision-making? That’s really the promise of machine learning.”

In that regard, it was exciting to speak on Thursday with Steven Tolle, the chief strategy officer for Watson Health Imaging, the division of IBM that was created last year after the Armonk, N.Y.-based IBM acquired the Chicago-based Merge Healthcare, with senior IBM executives seeing an opportunity to dovetail the work going on at Watson Health, a division of IBM, with the data, information, and experience of Merge Healthcare, to begin to transform radiological practice.

Importantly, Tolle and his colleagues at IBM are not going into this alone. As a June 22 press release noted, IBM has founded “a global initiative comprised of more than fifteen leading health systems, academic medical centers, ambulatory radiology providers and imaging technology companies,” called the Watson Health medical imaging collaborative. “The collaborative aims to bring cognitive imaging into daily practice to help doctors address breast, lung, and other cancers; diabetes; eye health; brain disease; and heart disease and related conditions, such as stroke,” the press release noted, adding that “Members of the collaborative plan to put Watson to work to extract insights from previously ‘invisible’ unstructured imaging data and combine that with a broad variety of data from other sources. In doing so, the efforts may help physicians make personalized care decisions relevant to a specific patient while building a body of knowledge to benefit broader patient populations. This information may include data from electronic health records, radiology and pathology reports, lab results, doctors’ progress notes, medical journals, clinical care guidelines and published outcomes studies.”

Already, Tolle told me, “We’ve run about 10 million images through Watson so far,” which will help create a foundational database for “computer vision—training Watson to know what the heart, brain, lung, look like.” What’s more, a second goal, more ambitious, is “the automated detection of disease,” he told me. “If Watson can see where the heart muscle is and the blood is and use its algorithms to measure the wall thickness of the heart, we’re getting down to some very precise measurements. Things that humans do manually, but that are very dependent on human skill. Some companies are doing that. What’s unique is we’ve built this large knowledge base with 10 million clinical concepts and 50 million relationships between them.”

In other words, those involved in that collaborative are pushing ahead to create the foundation for evidence-based diagnostic imaging clinical decision support. And, doubtless, that could transform the practice of radiology.

Some radiologists no doubt fear being replaced by machines. But both Dr. Siegel and Dr. Shrestha have reassured me that machine learning and evidence-based clinical decision support will only enhance radiological practice, as radiologists will be able to use computers to improve their diagnostic processes, and give them more time—something in dreadfully short supply for most of them right now—to engage in the most precise, leading-edge diagnostic work they’ve ever engaged in. As IBM Watson’s Tolle said, “What we really want is to be able to help radiologists practice at the top of their license.”

Of course, there are so very many variables in the current landscape—among others, a change in presidential administrations, new legislative and regulatory mandates on the horizon (including the long-awaited mandate under Medicare for ordering physicians to make use of cost-effectiveness CDS tools), and broad consolidation both within the radiology group space, and among hospitals—and even among the remote-read radiologist organizations that are proving to be both partners and competitors to radiologists—that it is difficult to sort out some of the details of what the landscape will look like in the next few years.

What is inevitable, though, is that some combination of exploding healthcare costs, changes in the business and operational climate of medicine, and advances in information and other technologies, will compel changes to radiological practice in the next few years, at least in the U.S. For many radiologists, such changes appear threatening. But the reality is that radiology has always been about continuous change, throughout its history as a medical specialty. And in the end, in all of this, I will turn to the Roman orator Seneca, who said 2,000 years ago, “The fates guide those willing to change; those unwilling, they drag.” For radiologists—extremely intelligent and gifted medical specialists who have always turned to advancing technologies as professionals—it seems obvious that being dragged into the future should be a far less appealing prospect than that of leading change.

So let’s hope that practicing radiologists in the U.S. listen to the wise words of thought leaders like Drs. Siegel, Shrestha, Baron, and others, and move forward to embrace the future. Because that future could be very exciting—or very challenging, depending on which side of the “Seneca curve” one might find oneself. I honestly can’t wait to see what the landscape looks like at RSNA 2017. But for now, it’s time to look to the future—and plan for its coming.

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