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Radiology’s Contribution to Individual Healthcare and to Society – a Shift from Volume to Value

Few radiologists feel underworked, or that we are working less hard than we did 5 or 10 years ago. Imaging usage within medicine has been increasing steadily for many years, with a particular emphasis on complex cross-sectional studies, and we can cite the study numbers to prove it. Therein lies a multitude of problems. Ensuring availability of sufficient numbers of trained radiologists to cope with inexorably increasing workload requires long-term planning (and some crystal-ball gazing). Ensuring that imaging utilization is justified and appropriate requires education of referrers, dialogue between radiologists and referring colleagues and easily accessible tools to guide clinical decision support. And perhaps most fundamentally, why are we even viewing the issue of radiology workload through the lens of coping with volume? Traditionally, volume has been the measure of radiology’s contribution to healthcare. How many studies have been done, how many reports have we generated? No other medical specialty is subject to similar pressures to do more and more work with every passing year; it would not be considered appropriate or safe to expect a surgeon to operate on twice as many patients this year as last. Yet, the crude volume measure remains the standard by which our performance is often gauged. Avalue-based healthcare movement has been emerging for over a decade, in an effort to increase the value of healthcare delivery without necessarily increasing costs. Radiology societies, including the CAR, have been active in promoting awareness of the need for our specialty to adopt value-based measures and practices, and in advocating for a movement away from traditional volume measures to measuring and enhancing the individual and societal value delivered by radiology. Many strategies will be needed to effect this necessary shift from volume-based to value-based radiology (VBR), including (inter alia) education of patients, referrers and managers; enhanced multi-disciplinary clinical engagement by radiologists; and active research efforts on our part to demonstrate our value contribution. In this issue, Li et al contribute a very useful description of the value added to patient care by specific Emergency Radiology (ER) services and expertise. They consider many aspects of how ER specialists and dedicated imaging access can improve speed of diagnosis and patient management, thereby improving personal and societal outcomes in an area of medicine where rapid and timely diagnosis and intervention can be critical. Immediate availability of necessary imaging can be life-saving in acute situations. Even in less-urgent emergency care, easy access to ultrasound, CT and MRI for Emergency Department patients can reduce average length of stay and accelerate discharge. The necessity for suitably trained ERs is well-argued in Li et al’s paper. It is not enough to provide radiologist cover for Emergency Departments on a 24/7 basis (although this is a minimum requirement). Those radiologists who are available need to understand the specific nature of the acute situations they face, and the immediate needs of patients with major injuries or critical acute illness. Appropriate and specific ER training, as outlined in the paper and increasingly advocated by specialty and subspecialty societies, based on agreed curricula and validated by higher training qualifications, will and should become the expected standard. The need for continuous specialist cover raises the interesting issue of the place of teleradiology. Having radiologists provide day-time and over-night ER services without adequate rest will undoubtedly increase error rates. We know that radiologists have increased variability in ocular convergence capability after long work shifts, leading to visual fatigue, and consequently reduced accuracy in tasks such as skeletal fracture and lung nodule detection. Mental fatigue among physicians is also increased after long periods of intense decision-making, leading to decision-making ‘shortcuts’, with poorer judgement and more diagnostic errors. As outlined by Li et al, only larger radiology departments will be able to provide continuous service by appropriately rested and trained ERs. Pragmatic solutions will be required for smaller units, and teleradiological cover by ERs working remotely (and possibly in different time zones) may be the answer. However,