What You See Probably Isn’t

Fifteen years ago, when I first started to write about radiology, any attempt to manage or standardize the practice of medicine was met with resistance and derision. Notice that when putting together this issue, we ruled out calling our cover story, “Devising a Cookbook for Radiology.” In the interim, medicine has adopted a more introspective and self-analytical demeanor, resulting in what can only be characterized as a full-on cultural revolution. As our cover story reveals, radiology not only has adopted the techniques of continuous quality improvement, but has begun to standardize techniques and processes. While some of the impetus is coming from within the specialty, radiology also is feeling pressure from the outside. Now that income is at risk for both hospitals and physicians, the patient-care benefits of quality have economic implications that will be compounded over the coming years. Furthermore, a consolidation trend in the provider market has resulted in numerous multihospital integrated delivery systems wanting a standard method of care delivery that has been vetted and clinically validated—across all sites. In May, I had multiple conversations at the 2013 RBMA Radiology Summit in Colorado Springs, Colorado, about mounting pressure on radiology practices—especially those covering just part of a health-care system—to develop standardized protocols and processes across the system. This outward-originating force is requiring greater coordination and collaboration among unrelated practices (look for more about that in the August/September issue of Radiology Business Journal). The Light Within Not to minimize the standardization movement, but as important steps are taken to arrive at standards for the practice and delivery of radiology, it’s important that an equivalent effort be made to elucidate the art and craft of the practice of medicine in general—and radiology, specifically. Science has made radiology tremendously more effective since Röntgen isolated the first ray, but the art of radiology encompasses more than science: A radiologist must cultivate the ability to see both what is and what isn’t there. Interpreting an image means knowing anatomy, projecting the image into the third dimension, aggregating everything known about the patient with the interpreter’s experience to date, and then offering the best context, support, and evidence by which a referrer can make a diagnosis. As tempting as it may be, it’s not a job for dilettantes. Artist/scientist James Turrell says it best, in a video that is part of a retrospective of his work at the Los Angeles County Museum of Art (LACMA): “People think that what they see is something received, but it is something created. It took me a while to understand light and learn to work with it.” With his full white beard and mustache, Turrell is reminiscent of Röntgen, on the cover of the June 16, 2013, New York Times Magazine, which offers insight into the origins and essence of Turrell’s work—as well as the extraordinary effort that it takes to mount one of his exhibitions.¹ We now have an unprecedented opportunity to see Turrell’s work, with major retrospectives on display in Los Angeles, California; New York, New York; and (soon) Houston, Texas. Raised Quaker and, therefore, on the light within, Turrell’s medium is the cousin of x-rays, visible light, and his tools are architecture and a deep understanding of the science and psychology of perception. One needs to spend just several hours in the LACMA exhibition to get a sense of the nature—and pitfalls—of visual perception. Seeing Is Believing Back to the cover story in this issue of Radiology Business Journal: without establishing standards and standardization, radiology will be hard-pressed to convey the value of its je ne sais quoi. Providing evidence-based parameters, protocols, and measures that are the hallmarks of quality (and then measurements, as proof) is the difficult work ahead for the specialty—whether or not President Obama’s budget proposal to end the in-office ancillary-services exception is included in the 2014 budget. Having just interviewed cardiologist Wm. Guy Weigold, MD, for our Radinformatics.com publication, I have no doubt that there are specialists who are qualified to read their body parts. This is not a threat to the future of the radiologist. A lack of standards, though, is a danger. Coincidentally, radiologist Eric Hyson, MD, is called out for his expertise by Lisa Sanders, MD,² in her “Diagnosis” column in the same issue of the New York Times Magazine in which the Turrell article appears. Hyson identified the telltale tree-in-bud abnormality that is the mark of Lady Windermere syndrome, three months before the patient’s throat culture grew out Mycobacterium avium-intracellulare. Standards and the ability to see what is and isn’t there, bound by the bond of trust between physicians, are radiology’s best insurance against obsolescence.