A commodity1 is some good for which there is demand, but which is supplied without qualitative differentiation across a market. It is fungible, i..e. the same no matter who produces it. Examples are petroleum, notebook paper, milk or copper.
Teleradiology (or any other service industry for that matter) is not generally included in lists of commodities. Nonetheless, there are organizations in veterinary medicine that are attempting to commoditize teleradiology. I was recently asked by a representative of one of these companies “what is wrong with commoditizing teleradiology?” I apologize for the delay as it has taken some time to get back to you. Respectfully, here is your answer.
A story to define the issue
Recently, I was doing a digital prepurchase consultaton with a veterinarian who worked at a large veterinary practice. He was striking out on his own and wanted help purchasing a digital radiography machine. When we talked about the needs of his new practice, he mentioned that teleradiology was not important to him. I probed further and he said that teleradiology "..is a waste of time. All of the reports are just wishy washy rule out lists and I can cover my ass like anyone else. These interpretations do nothing for me."
To understand why this veterinarian was getting wishy washy reports, lets look at the pressures on the teleradiologist at a commodity service to understand why his teleradiology experience was suboptimal.
The roots of a teleradiology disaster - why commoditized teleradiology does not work
At Animal insides we work with many residents starting new jobs and help them evaluate employment contracts from referral hospitals and teleradiology services. Some trends in these employment contracts shed light about the situation; and why you will be getting wishy washy reports from these services. The following are topics that are discussed in a real life teleradiologist employment contract and a discussion of why the terms of the contract lead to wishy washy reports and a teleradiology experience that is not worth the cost of the interpretation.
Pay the radiologists less to get cheap reports: I would be ostracized by my peers2 if I listed the reimbursement rates paid to commodity radiologists but suffice to say that the reimbursement rate from this company is lower than any I am aware of in the industry. As they say, "if you want good clean oats, you have to pay the going price. If you don't mind oats that have been through the horse......those are a little cheaper!3" Lowering the reimbursement rate to the radiologist attracts inexperienced radiologists and many residents right out of their residency are taking these positions. In my experience4, radiologists right out of their residency, although they mean well, do not have the experience to unequivocally state their opinion in a radiology report and this is one cause of wishy washy reports that tend to be little more than a laundry list of rule outs.
Homogenize the reports with macros: Some companies encourage radiologists to use predefined macros. This will certainly cause the complaints we hear that "the reports are all the same." Importantly, the use of predefined macros will homogenize the teleradiology experience and help make the radiologists interchangeable. Creating a commodity by making the radiologists interchangeable leads to a situation where radiologists are reluctant to go out on a limb in a radiology report. Because of the risk of being replaced or "switched out" with a new radiologists, a radiologist is more likely to offer a laundry list of rule outs rather than give their honest opinion when missing a lesion might mean losing their job.
Crack the whip and make the deadline more important than the quality of the report. With some commodity companies if reports are not read by a deadline the radiologist does not get paid. This deadline business may be the crux of the reason why commoditized teleradiology creates a subpar teleradiology experience. By placing these tine constraints on the teleradiologist, the radiologist will work as fast as possible so they never get behind. This will, in some cases, preclude telephone calls, long reports with added information, and will ultimately result in a degradation of the relationship between the radiologist and the referring veterinarian. How would your associates feel if you put terms like this in your associates employment contract? What do you think would happen to the quality of medicine in your practice? How eager would your associates be to please your clients if they did not get paid if they fell behind? Reports that are cranked out as fast as possible are more likely to be wishy washy rule out lists rather than insightful interpretations where the radiologist is willing to take the time, go out on a limb, and gve their heart and soul to the case.
A commodity means no choice: With commoditized teleradiology services, veterinarians do not get to choose their preferred radiologist5. Rather, cases are sent to the void and read by whomever happens to be cranking out reports and making deadlines. By eliminating the relationship between the radiologist and veterinarian, commodity teleradiologists become even more expendable and can easily be replaced by someone else. This further incentivizes radiologists to make wishy washy reports and never go out on a limb because fear of missing a case could mean losing their job.
When the radiologist is a commodity you might not be getting the full story. In our teleradiology practices6, we do not accept certain types of studies as we feel these studies are sub par and our moral compass7 will not let us read them. Futhermore, when we receive cases that have significant technical errors we will call the referring veteirnarian to discuss the case and not read the case. The sitaution is much different at a commodity teleradiology service. When I talk with radiologists working for commodity services, I routinely ask them "how do you read these cases?" The responses vary but common responses include "if I do not read them someone else will" or "if I do not read them I will get fired" or the ever popular "I just read what is on the images and cover my ass." As you can see, these commodity radiologists must read what they are presented with because the bottom line in a commodity service is putting dollars in the investors pocket rather than creating a sustainable relationship with the pet owner, patient, and referring veterinarians best interests in mind.
The bottom line with all of this is that commoditizing teleradiology results in a situation where potentially inexperienced and underpaid radiologists are pressured to create wish washy reports because they need to meet deadlines. Furthermore, because a relationship with the referring veterinarian is lacking and these radiologists are interchangeable these radiologists may be afraid of going out on a limb in their reports because missing a lesion may mean losing their job.
Your choice of a teleradiology provider is really a statement about you and your practice.
* Do you prefer your wine to come from a box or a bottle?
* Do you prefer to eat fresh grilled fish or are fish McNuggets just good enough on a first date?
* Do you provide fast and cheap medicine in your practice or do you provide high quality medicine that is supported by a deep relationship with your clients?
If you are a wine in the box, McNuggett eating, veterinarian, who runs a shot clinic - you should seriously consider using a commodity teleradiology service. Conversely, if you are a veterinarian who realizes that you can have things good, fast or cheap - but not all three.. you might consider all of your teleradiology options before you fall for that free trial, that long term contract, or settle for wishy washy reports.
The Silver lining: The good news with all of this is that you have options. Teleradiology services are not created equal. In part two of this series we will discuss what teleradiology can be and how to get the most out of your relationship with your teleradiology provider...Stay tuned.
Footnotes
1. Wikipedia definition
2. Chances are that after this article I will be on the outs anyway. It has been a good ride. Nice knowing you everyone. Please put "He Tried" on my epitaph.
3. Thanks to the Animal Insides Army and Dr. Jones for that one. Yes - they call you guys the Animal Insides Army.
4. I thought I was a superstar when I got done with my residency but after a few months realized I was little more than an imploding white dwarf supernova. It took me about 5 years to gain the experience I feel is required for many teleradiology applications. If you are a resident reading this - stay at a university or referral hospital for 3-5 years after your residency. Your career and your patients will be glad you did.
5. Even Burger King lets you have it your way. How about as a minimum teleradiology requirement we try to do better than Burger King?
6. Removed...for now. Check back later for footnote #6.
7. Our guiding principle is always to ask ourselves the following. "If this was our mothers dog - would we read these images?" If we even pause for a millisecond in answering the question, we contact the veterinarian to discuss the situation.
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