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Effect of Reorganization on Patient Care

¹ Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088.

Received December 16, 1999; accepted after revision January 14, 2000.

 
Address correspondence to C. D. Maynard.

Introduction

Top Introduction Survey Results What I Found Out What We Can Do

 
The effects of the current reorganization in the United States health care system, though affecting every geographic area of our country, are to some extent region specific. When Kay Vydareny asked me to discuss this complex topic at the 1999 Intersociety Summer Conference in Montreal, my first inclination was to decline. Nevertheless, my reluctance was no match for Dr. Vydareny's well-known powers of persuasion, and I accepted the challenge.

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Because I was uncomfortable offering the attendees of the Intersociety Conference only my personal interpretation of the effect of reorganization on patient care in radiology, I decided to solicit input from friends and colleagues. I wrote to all the chairs of academic radiology departments and to all former residents and fellows from my institution who are now practicing in a nonacademic environment. To get the perspective of both groups, I included in my letter a self-addressed postcard with two questions: Has reengineering of the health care system affected patient care in radiology positively? Has reengineering of the health care system affected patient care in radiology negatively? Respondents were asked to answer yes or no in each case and then to list both direct and indirect effects, whether positive or negative. Space was also provided for comments.

I was not prepared for the tremendous response. Not only were many cards returned, but I also received letters from radiologists venting frustrations with their practices. I felt like Dear Abby. One Sunday afternoon I decided to read every card and letter at one sitting to fully grasp the overall flavor of the responses. That was quite an experience, but at the end, I had a better understanding of what we are all facing in this rapidly changing health care environment. I will share the results of the survey, give my own opinion, and discuss possible actions to be taken.

Survey Results

Top Introduction Survey Results What I Found Out What We Can Do

 
Let me clearly state that the survey could not in any way be considered scientific. It was conducted only to give me an idea of whether my thoughts on the issues are on target or clearly off base. However, the responses are interesting, and in most cases, they support my own view of the effects, both positive and negative, of the current reengineering in medicine on patient care in radiology. The academic chairs and the radiologists in nonacademic practices indicated the pros and cons of their experiences related to reengineering.

Positive Impact
Positive aspects were noted by 43% of our former residents and 53% of the chairs.

Nonacademic practices.—Of the positive aspects reported by former residents, the most common were as follows: radiology departments becoming more consumer oriented, clinicians becoming more conscious of the correct procedure to order, development of a more businesslike approach in radiology, development of radiology subspecialists, emphasis on cost-effective diagnostic workups, increased use of minimally invasive procedures, and more importance given to outcome issues.

A few examples of comments made by the respondents illustrate the attitudes of our non-academic colleagues:

• "Made us define and meet quality standards...look at cost issues related to studies we recommend and perform." (Rockingham, NC)
  
• "More sensitive to what question the clinician wants answered; less likely to do `only what is ordered."' (Charlotte, NC)
  
• "Two high-quality radiology practices joining into more effective, competitive organization assisted us in providing higher quality services." (Austin, TX)
  

Academic practices.—Responding chairs listed emphasis on cost-effective diagnostic workups, more consumer consciousness (focus on delivery of care), initiation of intradepartmental efforts (Centers of Excellence), increased use of minimally invasive procedures, better coverage by full-time faculty, improved efficiency (simplification of imaging workups), increased productivity, reduction in unnecessary tests, and focus on outcomes.

The following comments sum up the feelings expressed by the chairs regarding positive aspects:

• "Focused attention on customer service and satisfaction." (Chicago, IL)
  
• "Galvanized academic community into supporting academic health centers." (Washington, DC)
  

Negative Impact
Negative effects were cited by 84% of the former residents in nonacademic practice groups and 86% of the chairs.

Nonacademic practices.—Our former residents in nonacademic areas shared considerable frustration with the changes in their practices. The most commonly mentioned negatives were increased workload, resulting in less patient contact time; limitation on patient access; decreased quality; turf issues; less money available for equipment; increased paperwork; decrease in ancillary personnel; removal of physicians and patients from the decision tree; and clinician overload.

Selected observations from their responses summarize the negative aspects:

• "When `good' medicine is at odds with economical medicine, it seems economical medicine triumphs to the detriment of patient care." (Winston-Salem, NC)
  
• "More work, less fun!" (Baltimore, MD)
  
• "Corporate compliance is a nightmare!" (Asheville, NC)
  
• "High-tech, high-productivity, low-touch environment." (Bristol, VA)
  

Academic practices.—The most commonly mentioned negatives among radiology department chairs were increased workload, less patient contact; limitation of access by patients; decreased ancillary personnel; reduced resources for equipment; service lines, with radiology serving a secondary role; decreased quality; less time for teaching and research; decreased support for graduate medical education; and limited resources for innovative programs.

The following comments sum up the academic community's overall opinion:

• "More bad than good." (Chapel Hill, NC)
  
• "Less care, less money, less satisfaction, less professionalism...changing medicine from a profession to a trade." (Mobile, AL)
  
• "Radiology 1999—survival of excellence is a naive euphemism. At this stage of the game, it is survival! Whether the result or product is excellent...does not depend on radiologists but the bureaucrats that hold the purse strings." (Augusta, GA)
  

What I Found Out

Top Introduction Survey Results What I Found Out What We Can Do

 
One of the most interesting outcomes was that, although some regional bias was present, by and large the climate was viewed negatively by the radiologists responding to my inquiry. Although some positive aspects have emerged from reengineering the health care system, they do not offset the "bad" that has been created. Everyone is working harder and has less leisure time or less time to participate in research and teaching than in the past. Obviously, different responses were given regarding specific aspects, such as academic time, but I noted little variation between the attitudes of radiologists in academic or nonacademic environments.

Like my friends and colleagues, I have observed both encouraging and discouraging elements of the changing health care system. On the positive side, we have become much more patient-care oriented and have gained a better appreciation of the need for efficiency and cost-effectiveness. The push to achieve more efficiency within our departments has resulted in the reevaluation of all activities in which we engage. My institution is well into a process called "mission-based budgeting," which is an attempt to equate what we are doing with what we are being paid to do. Because most academic radiology departments are supported primarily from patient-care revenues, this approach focuses our attention on who is paying for teaching, research, and so-called academic time. Although evaluating our activities is proper, it clearly shows the necessity of finding separate funds to support these endeavors. The university or hospital must fund our teaching and extramural programs from the National Institutes of Health, or industry must be secured to sponsor our research. This change will be a major one in academic radiology departments that have historically used patient-care revenues to fund various teaching and research programs.

On the negative side, the new system clearly has limited the patients' choices and has added to the hassle of obtaining care. The reality is that the workload has increased for radiologists, and both academic and nonacademic radiologists have less time available for academic activities or leisure. Of much more concern is the long-term damage to graduate medical education and research. With decreasing financial support for graduate medical education at the national level and less discretionary funding from surplus patient-care revenues in academic departments, the quality of our training programs and our research will undoubtedly be at risk. Also at risk is the introduction of newer techniques because most innovations are first attempted in academic medical centers.

What We Can Do

Top Introduction Survey Results What I Found Out What We Can Do

 
As the reengineering of health care continues, I do not foresee any slowdown in the changes around us. What should we do? One chairman responded to my survey with a letter in which he suggested that I might have asked the wrong question. Perhaps I should have asked, "Has radiology positively or negatively affected the reengineering of the health care system and the delivery of patient care?" (Pittsburgh, PA). I think the point is well taken. Reengineering is occurring whether we like it or not, but are we doing everything we can to make the changes positive?

Without question, every radiologist needs to become involved with the process of reengineering. I offer five possibilities. First, take a more active role in the process—locally, regionally, and nationally. We must all become involved in the reengineering process, from helping to make radiology services more cost-effective in our own institutions to supporting efforts to maintain adequate access for the patient. Second, combat the devaluation of academic health centers. These centers are the bloodline of future radiologists and the origin of most newer techniques. Third, increase public awareness of the value of radiologists. We are a vital cog in the machinery of the health care delivery system, but our value is poorly understood by patients and payers. Fourth, stop maintaining incomes through increasing the workload. The time will inevitably come when doing more to offset declining reimbursement will result in poor radiology. Fifth, place the patient's interest first; take the high road. The patient needs an advocate. Every change we anticipate should be preceded by a simple question: Is this going to be better for the patient?

In conclusion, radiology is well. Only the system is sick. It is our job to help fix the system.

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Maynard, C. D. Search for Related Content PubMed PubMed Citation Articles by Maynard, C. D. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?