Masters Of Radiology Panel Discussion Research Articles

Commentary: Masters of Radiology Panel Discussion—How Do We Maintain Control Over Imaging?

AJR:201, July 2013 and reasonable turnaround time. We also need to see hospitals as legitimate customers and maintain good relations with them. Occasionally we see groups in conflict with their hospitals. This is not a recipe for long-term success. A battle with a large customer base is an unenviable position for any enterprise. Like any other business, if we want to prosper, we need to provide value to our customers. Our patients’ and referring clinicians’ experience is increasingly dependent on how well we function as a team. Excellent individual performance is only part of the equation. Patients experience us as organized groups of professionals; we need to act competently as organizations, not just as individuals. That means we need to consistently get the details right—even minor reporting errors. It is the details that make us professionals. The rock group Van Halen famously had a rider in its touring contract demanding that there be a bowl of M&Ms in the dressing room with all of the brown ones removed. They used this as a quick, and rather accurate, test. They knew that if a venue operator didn’t pay attention to these small details, large, very important details were also likely to be missed—such as ensuring that the girders would support the heavy weight requirements for their equipment. In short, I believe that the best way to maintain control of imaging is to consistently do it very well. Beauchamp: How do we maintain control over imaging? We must continue to earn it by showing that we are the best stewards of imaging. First, and foremost, is to put the patients first. Quality, safety, and service are absolutely the key. We need to advocate for the patient by making sure that we constrain the use of imaging where it does not add value to care and foster the use of imaging only when it does. We cannot simply state that we are excellent, we must have measures of quality, safety, and service that we continuCommentary: Masters of Radiology Panel Discussion—How Do We Maintain Control Over Imaging?

Masters of Radiology Panel Discussion: Defining a Quality Dashboard for Radiology—What Are the Right Metrics?

839 that the overwhelming first priority should be safety. Process improvement and satisfaction deal with a variety of issues along the patient side. Ultimately, if we are to believe some of the items in the Affordable Care Act, outcomes and proof that our work impacts outcomes will be important to show. All of this has a cost. You may not know what the cost is when you start, but you are certainly going to have to pay it in time, energy, or money. Norbash: It is interesting that we have approached this whole concept of dashboarding, scorecards, and performance measurement, I think the national tendency is to initially start with some high-order principles in terms of why we are doing this. And in our organization, there are several needs we are trying to address, needs such as improving our reimbursements, creating education that spans different teams or factions that may exist, and creating a unified cohesive sense of direction. Thus, as we focus on those larger needs and look at what the domains can be, quality and safety are a central part of every discussion. But so is patient satisfaction, especially given Press Ganey scores, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), and reimbursement tied specifically to patient satisfaction as an independent domain. Ultimately, it all translates into reimbursements. In our organization and in our department specifically, we have picked certain domains that are sensible, for example, quality, safety, access, operations management, and financial performance. In each of those areas, we have tried to pick things that are sensible to all concerned, not just to administration. Ultimately scorecards only work if you have a larger framework around the housing organization that makes sense and, more important, if the constituent individuals in the organization buy-in to what you are picking. Masters of Radiology Panel Discussion: Defining a Quality Dashboard for Radiology— What Are the Right Metrics?

Masters of Radiology Panel Discussion—Is Imaging in Decline?

127 What people really want is health and not health care. We, as radiologists, must prepare ourselves to integrate not only current modalities but also molecular imaging and therapy into better utilization, diagnosis, and outcomes. Even if we succeed in these goals, we still must use the data to inform clinicians and improve their use of imaging. Even as radiology becomes less of an income center and tries to become more clinically productive, we must simultaneously master information and increasingly provide leadership to the entire health care enterprise. Kazerooni: It’s a new reality for radiologists, one that does not seem to have a rapid climb back to the past, and it’s something practices have to adapt to. Our value has been measured and judged for the past one to two decades on examination volume, relative value units, and turnaround times. As a specialty, we’ve become addicted to double-digit growth year over year, turning to “nighthawk” providers to read studies at night because business was so good during the day, abrogating our professional physician relationships. What we have not had to pay attention to—and is perhaps our greatest value—is in consultation, such as discussions about appropriateness of testing for the individual patient. There is often no positive feedback mechanism when a radiologist tells a provider a test is not needed. In fact, the feedback can be seen as negative, obstructionist, laziness, or the commentary of someone who is not a “real” physician. Working toward a reimbursement model that incorporates all we do, not a radiology report alone, would be a fundamental change and aligned with the accountable care organization model of care we are rapidly moving toward. Locally, we’re seeing continued reduction in the growth of radiology in our environment in southeastern Michigan and in the state of Michigan in general. It varies among Masters of Radiology Panel Discussion— Is Imaging in Decline?

Availability of Prior Imaging Studies

AJR 2012; 199:W530 0361–803X/12/1994–W530 © American Roentgen Ray Society Availability of Prior Imaging Studies In James Brink’s ARRS presidential address [1], one thing particularly struck me. He quoted Clyde Stevenson [2], a fellow Washington radiologist and president of the ARRS. As Dr. Brink noted, Dr. Stevenson stated, “The need for solid clinical information coupled with high-quality images and access to prior imaging studies is critical to our success.” Dr. Brink addresses the importance of clinical information and high-quality images but does not pursue the last point, about which Dr. Stevenson was most passionate. Dr. Stevenson’s 1966 speech continued, “All of us could flood the literature with instances in which lack of previous roentgenograms for review and comparison led to delay, increased cost, erroneous diagnosis, harm, and even death of the patient. An intense educational program is overdue” [2]. In 2011, we are still waiting for that intense educational program. How often have we heard the hospitalist say, “We can’t find the CD, so we’ll just have to repeat the scan?” How often have we recommended follow-up CT of a pulmonary nodule without knowing that a prior outside CT of the chest or abdomen identified the same nodule? Do we really expect an internist to realize that a CT of the kidneys, ureters, and bladder performed down the street 2 years ago should be requested? Another Washington radiologist, Norm Beauchamp, did mention the cost of repeat medical imaging in the emergency department in a recent Masters of Radiology panel discussion [3], but, in general, I find the radiology community strangely silent on this topic. The American College of Radiology white paper, “Radiation Dose in Medicine” [4] barely refers to the need for access to prior studies. Does it seem logical that we require patients to request their prior mammograms, but we don’t ask about a prior chest CT? We are undertaking huge efforts to decrease the dose of an individual CT, which is admirable. Now it is time to address exposure from repeat examinations and unnecessary follow-up. How can each practice optimize the chance that outside images are available to the interpreting radiologist? How can we leverage our ability to share digital images to create a single imaging record for our highly mobile patients? Is not that what “meaningful use” in radiology should look like? I encourage radiologists to “flood the literature” and lead the charge to optimize the availability of prior images by improving institutional processes, championing meaningful use initiatives, and working with third-party vendors. It is yet another way all of us can become clinically exceptional and fully engaged. Dawna J. Kramer Virginia Mason Medical Center, Seattle, WA DOI:10.2214/AJR.12.8875 WEB—This is a Web exclusive article.

Masters of Radiology Panel Discussion: The Future of the Radiology Job Market

127 Part of the question when you look at a microscopic trend is, “Does this extrapolate out to a long-term problem or not?” Personally, I am optimistic about radiology. I’m very bullish. The challenge that we’re facing is our inability to fundamentally and eloquently verbalize the added value we bring to every single interaction and transaction. We have to be more specific in terms of demonstrating how beneficial we are to health care delivery systems; to referring physicians; and, most importantly, to our society’s health. If we can truly demonstrate the throughput value of radiology and speak the language of value, then the sky is the limit for our growth and we will flourish. This is particularly true in an accountable-care organization (ACO)like capitated and bundled world where radiology is all about sunken costs and wholepatient throughput and less about rationing individual departmental transactions. In such a world, we may ultimately be facing a time of high-throughput radiology where radiology is depended on [in the medical field] and production management with novel developments, such as high-throughput computer-aided diagnosis (CAD), will advance to the point where we become reconciliators of unusual and abnormal findings. Similarly with therapeutic radiology, there will have to be high-quality delivery and an understanding of how radiology adds value. As you look at interventional radiology universally, it has to be more of a patient-centered engagement rather than a technologically proficient service. My sense is that as radiology evolves to meet the technical demands of the future, there will be a dramatic need for many more radiologists, but it can’t be business as usual. We’re going to have to change the way we engage payers and patients. We have to be much more descriptive in terms of the value we bring to every single diagnostic and therapeutic transaction. Masters of Radiology Panel Discussion: The Future of the Radiology Job Market

Masters of Radiology Panel Discussion: Maintaining Maintenance of Certification in the Field of Radiology

AJR:198, April 2012 Larson: Board certification provides a vital service to our profession. Traditionally, the purpose of professional certification has been to assure regulators and the public that professionals are at least meeting minimum professional standards. However, although it is important to have a “floor” for competence, stakeholders are increasingly demanding mechanisms that promote excellence, not just adequacy. Some of the four components of MOC are more geared toward ensuring that radiologists meet the minimum standard and others are better at promoting excellence. I would say that, as they currently exist, components one and two (professional standing, and lifelong learning and self-assessment) probably serve more as minimum standards. Interestingly, although component three (cognitive expertise), including the initial certifying examinations, is structured to serve as a minimum standard, in reality it also promotes excellence. For example, although the 4 hours spent in Louisville might help to screen out the least qualified candidates, that is not the true value of the examination. Rather, far greater value lies in the thousands of hours of deliberate practice candidates spend preparing for the examination. Specifically, the evidence shows that such practice is dramatically more effective at improving performance than work experience alone [1]. Component four (PQI) is a departure from the traditional concept of professional certification. It is completely focused on promoting excellence rather than enforcing minimum standards of competence or compliance. It is going to be an interesting experiment to see whether professional certification can be a vehicle for promoting excellence and innovation. In more market-driven industries, it is typically competition that incentivizes for the high levels of quality assurance and improvement that we are accustomed to. I would say that Masters of Radiology Panel Discussion: Maintaining Maintenance of Certification in the Field of Radiology

Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?

145 outside my domain of expertise, and I will keep my comments brief to hear more from our women on the panel. The sex imbalance in radiology concerns me on a number of levels but perhaps most because of its implications that, as a specialty, we may not be equally welcoming to all. In a time when women are at least equally represented in other medical specialties, it is not due to a sex imbalance in medical students. I do not know exactly what the reasons are, but it is worth assessing women medical students’ perceptions of the nature of the work, career opportunities, role models, work-life balance, etc., and then working to improve where we can. Norbash: To have increasing numbers of women join radiology, it would be helpful to create an atmosphere where women fundamentally are appreciated and valued, given parity where leadership and research positions are concerned, and given the autonomy and resources to create appropriate mentoring and support services. Simultaneously, there will need to be attention paid to resources and need to establish the appropriate environment to secure work-life balance. Specific actions should include formulating match lists to ultimately yield 50% of matched women in each department, formulating policies to ease women residents’ desire to start a family, and balancing faculty to promote and celebrate the advancement of women radiologists to positions of responsibility and leadership. Beauchamp: We also should keep in mind that diversity is an opportunity not an obligation. Extensive research shows that as you increase the diversity of your groups, productivity, creativity, innovation, and problem solving also increase. Also relative to this conversation is the case of diversity in terms of getting more women in medicine. We are missing an opportunity, given the Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?

Masters of Radiology Panel Discussion: Encouraging and Fostering Mentorship—How We Can Ensure That No Faculty Member Is Left Behind and That Leaders Do Not Fail

149 The best way for an effective mentor– mentee relationship to be formed is by the mentee doing a gap analysis. This analysis should identify what skills the individual has versus the skills that are needed to be successful. The individual should then recruit a mentor who can help fill these gaps. This approach often results in having a series of mentors. A reasonable 4-step process is to seek others who know more than you do in a desired area of growth, establish a relationship, acquire desired skills, and repeat. Monsees: First and foremost, mentoring has to be well engrained in the culture of the institution and it has to be in the mission. There also needs to be a clear understanding of what might be expected among both the senior and junior faculty members. One of the most crucial aspects is time. We are all asked to do more, and it’s very hard to figure out how to get all of it done. Also, we need to decide early on in somebody’s career how they are going to start out and what type of track will they choose. When I first started, there was one track and everybody was on the same track. Now we have options that people need to choose from. Someone may not know where they are going to end up a decade or two from now, but at least they can get an idea of where they want to start out. Also, expectations for advancement may be different depending on what track someone chooses and who is selected as a mentor. As things change in someone’s career along the way, it may be necessary to bring in other individuals to help. We also have to recognize that it is very time consuming to be a mentor. You have to reward generous mentors and people who have been successful at what they do. The rewards don’t have to be financial. They could be extra time, a pat on the back, or whatever an institution can give for that service that is important. I also believe that there are lots Masters of Radiology Panel Discussion: Encouraging and Fostering Mentorship—How We Can Ensure That No Faculty Member Is Left Behind and That Leaders Do Not Fail

Masters of Radiology Panel Discussion: The Commoditization of Radiology

Masters of Radiology Panel Discussion: The Commoditization of RadiologyHoward P. Forman1, David B. Larson2, Alan D. Kaye3, Ella A. Kazerooni4, Alexander Norbash5, John K. Crowe6, Marcia C. Javitt7 and Norman J. Beauchamp, Jr.8Audio Available | Share

Masters of Radiology Panel Discussion: Models for Health Care Performance in Radiology—How Do We Measure Our Productivity and Ourselves?

M. C. Javitt is an unpaid consultant to Code Ryte and her husband owns stock in Code Ryte. D. B. Larson is a case contributor to Amirsys and is reimbursed on a contract basis. INTRODUCTION. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: Measuring performance and productivity ties into many issues that are very current for radiology. One concern is how these measurements relate to the maintenance of certification (MOC) process and even the whole method of residency training and initial board certification. A second question involves how payment is linked to productivity. For example, how do we, within both private and academic practices, compensate and measure productivity? Third, we need to think about how we can measure the best in our health care performance and delivery in a time when we’re thinking more about accountable care organizations and about integrating radiology into the health care enterprise, as opposed to encouraging us to be an independently operated, standalone entity. Norbash: I don’t believe that unilateral determinations of productivity and reward systems generated by a chair have an enduring, positive influence, especially when contrasted with mutually agreed targets. A similar challenge is in determining the degree of autonomy given to individuals and sections versus the amount of central control necessary at the departmental and institutional levels. As our margins decrease, as our subsidy basis becomes challenged, and as we have to look at whether we have to cross-subsidize from our technical revenue to professional revenue to sustain departments, it becomes clear that the discussion is becoming more intense and more direct. Specifically, institutions and departments are becoming progressively more interested in describing and measuring the total amount of work that each person does. Many of the Masters of Radiology panel members have come up with complicated, formulaic systems that are very elegant and detailed and look at an individual’s contributions, including administrative, academic, teaching, and work contributions. We’ve also seen a number of complex formulas from outside of this group. One of these comprehensive formulas was beautifully done by Reuben S. Mezrich’s group at the University of Maryland Medical Center in Baltimore. In addition, there is a spectrum of work output, whether considering the departmental or individual benefits gained. When you look at a radiologist’s work, much of the academic output is not simply to the department’s benefit; much of the academic and research accomplishments can simultaneously be seen as self-promotional. On the other hand, much of the interdisciplinary conference and uncompensated consulting contributions within the hospital are directed at community benefit. As such, a radiologist who spends a considerable amount of time being consulted and pulled into conferences may not sympathize with the additional time granted to teachers and investigators for their pursuits, even though the collective contributions are fundamental to the functions of an academic department. Moving away from what’s self-serving, social service and institutional educational activities are very valuable. But, it’s challenging to come up with credible ways of reliably measuring the different performance indicators and assembling them to realize the total value of an individual’s contributions in a metric way. Part of the reason for this conversation on metrics is because we’re being called to task for our current accounting methods to show the value of radiologists to the organization and the institution. To date, our charge has been to generate more revenue, do more studies, and Forman et al. Masters of Radiology Panel Discussion

Masters of Radiology Panel Discussion: Who Is Accountable for the Appropriateness of Studies—The Radiologist, the Referring Physician, or Both?

M. C. Javitt is an unpaid consultant to Code Ryte and her husband owns stock in Code Ryte. D. B. Larson is a case contributor to Amirsys and is reimbursed on a contract basis. INTRODUCTION. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: I’d like to ignore the medical–legal aspects of this issue for purposes of our immediate discussion because they are well covered by Dr. Berlin and others. As well, I’d like to set aside, for the moment, the cost-containment issues one might raise, such as the role of radiology benefits management firms (RBMs). Instead, I want to use this topic as an opportunity to talk about the responsibilities of the radiologist and the clinician in providing the best care to patients. So, what is the radiologist’s responsibility and what is the clinician’s responsibility in making decisions about a patient’s imaging examinations, which include ionizing and nonionizing radiation diagnostic imaging? I frequently hear individuals in private practice say that in terms of imaging, their basic motto is that of Nike, “Just do it.” But at other times, I’ve heard people say that, whether in academic or private practice, radiologists have no ability to control utilization and therefore basically give up their responsibility to clinicians. I have always felt very uncomfortable with that line of thinking because I believe we’re the ones who best understand imaging. Beauchamp: Radiologists have to play a big role in determining what study is done for a patient. I believe their primary role is helping to establish educational patient-centered appropriateness guidelines, as opposed to being the imaging study gatekeeper making go–no go decisions at the point of study ordering. By educating—not obstructing—the radiologist becomes a partner— not an adversary. In terms of this guidance, the radiologist ultimately knows best, or should know best, whether a particular study can provide answers to the clinical question being posed. But this knowledge must incorporate input from our nonradiology clinical colleagues who have a great deal of knowledge to contribute as well. The best examples are provided by the policy formation of the American College of Radiology (ACR). For example, when it came to setting criteria for breast imaging, the ACR consulted with the American College of Surgeons, and when it came to cardiac imaging, it was the American College of Cardiology. Succinctly, it takes a village, and we need both radiology and nonradiology clinical input to get buy-in and the best possible outcome. Once established, one needs to determine how to operationalize these criteria so that the process is not an impediment. The methodology should not require that a radiologist review every study ordered. It has to be done so that these guidelines are readily accessible and easily implemented into the workflow, and it’s only by exception that a radiologist should be brought in to consult as a guide. The buck does stop with radiologists, but with education we will get to a bestuse approach much more expeditiously and sustainably. Kazerooni: I strongly agree with Dr. Beauchamp. Radiologists are ultimately responsible for the tests we perform or oversee our staff in performing. We are accountable to the patients on whom we perform tests and procedures, whether it’s because of the radiation or contrast we may be delivering or the cost we are adding to their health care. Begun in 1993, the ACR Appropriateness Criteria now cover 167 topics, most including variants of the primary clinical condition being discussed [1]. Not only can they be found online at www.acr.org/ SecondaryMainMenuCategories/quality_safety/app_criteria.aspxf, but also they recently became available for handheld devices. They have been developed by 10 diagnostic imaging expert panels and an interventional radiology panel in conjunction with 20 medical specialty Forman et al. Masters of Radiology Panel Discussion

Masters of Radiology Panel Discussion: Radiology Extenders—Challenges and Opportunities to Balance the Demands of Our Changing Work Environment

INTRODUCTION. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Javitt: We define radiology extenders as practitioners who work under the supervision of radiologists: physician assistants, nurse practitioners, “super” technologists. These physician extenders provide certain types of care that previously were given by radiologists to address the increasing demand for radiology services in the face of staff–physician shortages and de­ clining reimbursement. The radiology extender is a complex topic. The pros and cons of this issue depend largely on your specialty, your location, and your department. Radiology extenders definitely make us more efficient at our jobs from a labor standpoint and can help address acute staffing shortages or situations in which there are limits on the amount of time worked by house officers. They have allowed us to improve our efficiency and workforce capabilities, can improve the patient’s access to care, and can reduce repetitive tasks that we often find ourselves facing. On the con side, these challenges are complex as well. House officers may have trouble relating to the radi­ ology extenders. There may be a loss of direct or indirect subsidies for medical education. There is also the risk of problems with patient acceptance and with satisfaction and per­ formance issues on the part of residents. Additionally, the Centers for Medicare and Medi­ caid Services may recalculate how procedures that are performed by radiology extenders are reimbursed, which could significantly impact the reimbursement for our work. What’s more, once you train radiology extenders, they can then go out and work for nonradiologists. In short, if someone has a way to make us more efficient, then more power to them if they can implement that plan. Monsees: We took all of these issues into consideration when we contemplated radiology extenders as we tried to figure out how to improve our efficiency. And because we’re in breast imaging, there were financial issues, so we had to figure out a way to be fiscally responsible to the department as well. We did not want to use radiology extenders to do procedures; we wanted to limit those to our residents and fellows. However, we decided we needed some class of individual to help us become more efficient. We do a lot of communications, including a great deal of direct interaction with patients, because we’re dealing with breast imaging. We decided to try to see how they could help us in this regard, and we resolved to try nurses—they [nurses] have now become very important to our process. They don’t duplicate our technical staff and, in fact, are revered by our techni­ cal staff. They are also now a constant in the lives of our patients and play an important role in the continuity of care. We weren’t sure how we would do this, but we started this program about 6 or 7 years ago and hired an experienced oncology nurse. Even though she didn’t have experience in breast im­ aging, she was very smart and compassionate and really wanted to learn a new field. And you talk about an investment—it did take a long time to train and educate her about breast imaging. It took a long time before she could pull her own weight; I’d say a minimum of 6 months. There was the understanding that she would work with us as a seasoned professional, that she would make suggestions, and that we’d also make suggestions as to how she could help us and perform some of the time­consuming tasks we were doing. One of the things that we had Forman et al. Masters of Radiology Panel Discussion

Masters of Radiology Panel Discussion: Role of Communication in Today's Radiologic Practices

Masters of Radiology Panel Discussion: Role of Communication in Today's Radiologic Practices

Masters of Radiology Panel Discussion: Responding to Health Care Reform and Other Market Pressures

M. C. Javitt is an unpaid consultant to Code Ryte and her husband owns stock in Code Ryte. H. Hricak owns stock in Hologic. D. B. Larson is a case contributor to Amirsys and is reimbursed on a contract basis. IntRODuCtIOn. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: Today’s topic is how radiology practices should respond to the possibility of health care reform and other pressures facing radiology. Our panel was chosen based on specialty, career stage, or institution type. Our goal was to provide representation across the specialty. I’d like to start with how practices are responding to health care reform and to what extent you believe we need to embrace efficiency. Is it good, bad, or does it make no difference in our practice? Crowe: There’s a conflict between what drew many of us to medicine and the way we are often forced to practice today. Hyperefficient practice is necessary, but it is often synonymous with spending less time with patients and referring physicians. If your practice is driven solely by economics, it is a wonderful example of why economics is called the “dismal science.” This outlook fundamentally threatens the more enjoyable features of medicine and is one thing that I think is critical to maintaining one’s love of the field—feedback from one’s colleagues and interacting in ways in which teams or groups of people function to make patients better or systems better. So I’ll throw that challenging idea out on the table and let others share their opinions. Messinger: I have a little different philosophy on that. In my experience, those physicians who want to maintain a relationship with you by seeing you in person or on the telephone do it. Those who do not, haven’t and probably won’t. I appreciate what Jack said, but I’m not too concerned, at least in my practice, about that aspect of the pattern of hyperefficiency. Hyperefficiency by its very name should be good and probably is good in many respects. I am concerned, however, about how this trend is going to affect our workforce. Will it decrease the number of radiologists we need? If it does, how does that impact medical schools? Several years ago, we had more people saying “you don’t go into radiology anymore,” and that diminished the quality of our candidate pool. Now we’re seeing outstanding candidates, but I’m concerned that by becoming hyperefficient, relying so much on technology, and by trying to maintain a set income we’re going to try and “make do” with fewer radiologists. Javitt: My response is bound up in how I view our business as well as our responsibilities. Our work product is a report and that report does not reflect how much time it took to generate it or what cognitive skills were required to make it. But that is essentially the product by which our productivity and efficiency are judged. And my view is very grim because I think the hyperefficient practice we’re about to increase and promote will not equate cost and value; they’re actually at odds with one another. I think we’re solving for a cost-efficient system, not necessarily a system that places a value on accuracy or on the intangible things that we do as radiologists to take care of patients and the places where we interact with them. We need to marry cost and value to solve for hyperefficiency. Larson: A major source of this problem is that the reimbursement environment for radiologists provides strong incentives for productivity and weak incentives for quality. Individual radiologists and groups are financially penalized when they take time to focus on difficult cases, defer to subspecialists when appropriate, or work with hospitals to make system improvements. Many politicians and health policy analysts are starting to recognize this as a problem Forman et al. Masters of Radiology Panel Discussion