In a previous article in this series we began to explore the issues surrounding the employment of radiologists at veterinary referral hospitals. This article continues the discussion as we look at turf wars, after hours coverage, and providing radiologists with the tools they need to do their job effectively.
What gets read and what doesn’t.
In most cases, salaried radiologists are asked to read every study in the hospital. This is because the other specialists do not “pay” for the individual study.
Conversely, in production scenarios, regardless of how production is calculated in the practice, as a support service, radiologists have a “parasitic” relationship with the other specialty services. In most cases, the read fee for the radiologist is deducted from the gross production of the specialist ordering the study. Inevitably, this leads to a situation where specialists may not want all of their cases read.
Determining which cases are read and which ones are not read is of paramount importance in any employment agreement in order to avoid future conflicts between specialists. One approach is to allow specialists to pick and chose which cases are read. In most cases, however, a determination of which cases are read as a routine bases is made as a decision by the administration. The same may be true with ultrasound studies. If all of the ultrasound studies go to the radiologist perhaps the per case fee should be decreased compared to a situation where only the difficult cases go to the radiologists.
If clinicians are allowed to pick and choose cases, an argument can be made that the radiologists reimbursement should be higher per case if clinicians are allowed to pick and chose cases. The justification is that if clinicians are allowed to pick and chose, the "easy" and "routine" cases will not be interpreted. The overall complexity (and time it takes to interpret and report cases) will be higher for the subset of cases provided to radiologists. As such, their compensation should be increased.
Internist turf battles
In the ideal world, at least from the vantage point of the radiologist, all ultrasound studies at a referral hospital will be done by the radiologist. In theory, that is what the radiologist is trained to do and that is what they are hired to do. As we all know, however, we do not live in the ideal world. As such, turf battles between radiologists and internists are common. Truth be told, ultrasound carries the most production bang for the buck for radiologists and internists so it is not surprising that turf battles are common. If there was no money in ultrasound, this whole turf battle business would not be an issue.
When considering hiring a radiologist at a referral hospital, deciding who performs ultrasound studies is of paramount importance. Who does the ultrasounds from the emergency service? Who does the ultrasounds from the surgeons, oncologists, etc.? Failing to answer these questions will result in case poaching and unnecessary headaches at the hospital. Leaving internists and radiologists to "play nice" and sort it out amongst themselves is a poor management technique akin to letting Lay Leno and David Letterman sort out their differences.
Regardless of how much the administration supports the radiologists with regard to ultrasound, it is up to the radiologist to market themselves to the hospital and win over each and every specialist. Making the other specialists WANT to give them the ultrasound is a much better long term survival strategy than having the administration MAKE them give you the ultrasound studies. During the internal marketing of their ultrasound skills to the rest of the hospital, it is recommended NOT to use the argument that so many new radiologists use. This, fundamentally flawed, argument is “I was trained to do this – I am the best. While I am in the building, all cases must come to me.” The flaw in the argument is not that you have more training. The flaw in the argument is that there are many internists with serious ultrasound experience so you might not be the best at the hospital. The other flaw is that if you use the “I am the only one who can touch the probe” argument, the rest of the hospital will hammer on you and say something to the effect of “OK Mr. Radiologist Hero, if we are so stupid and incompetent, how come you don’t mind us doing ultrasound when you are not in the building. Do you want us to call you in on the weekends and at night? Do the animals that come in on the weekend get worse care because the internist does the ultrasound on Saturday morning?” You have been warned about using the “I am god” argument to get the hospital to send you cases.
One argument you can use in your negotiations is that a radiologist can improve the efficiency of the internist by doing imaging studies while the internist sees more patients and does other procedures. Another argument you can use, regardless of modality is that if the same person orders the test, interprets the test and then formulates therapy based on those two related and biased opinions, when things go wrong they really go wrong. Fundamentally, that is bad medicine for animals just as it is for people.
Turf wars part deux – the neurologists
Folks, the battle was fought and the radiologists (for the most part) lost. Don’t push it with the neurologists. They control the MRI and they read their own cases. Unless you are a special case radiologists with SIGNIFICANT MRI experience, you are fighting an uphill battle to take control of that MRI machine. Please don’t shoot the messenger.
What happens on overnights and weekends? What are the expected turnaround times?
Radiologists do not work 24-7. The referral hospital, however, operates 24-7. Inevitably, the question of who interprets emergency and overnight cases will arise in employment negotiations. Is the radiologist responsible for these cases? Can they wait until the next morning? Is the radiologist on call 7 days a week? If not, how will the emergency cases be handled? In many cases, overnight and weekend cases are handled by teleradiology services. There are numerous services that provide 24-7 and stat coverage with turnaround times of just a few hours.
Hospital administrators, should, be cognizant of how farming out overnight and weekend cases to a teleradiology service will affect the production, income, and morale of the in-house radiologist. Most radiologists calculate their expected income based on the number of cases obtained at the hospital which includes the overnight and weekend cases. If many of these cases are farmed out, this will negatively impact the production of the in-house radiologist.
Teleradiology services have also placed pressure on in-house radiologists as films sent to teleradiology services generally carry a 1-2 hour turnaround time. In many cases, in-house radiologists cannot provide this turnaround time as they might be in meetings, doing ultrasounds etc. Defining the expectation for film turnaround time should be defined in the employment agreement.
One option to bridge the needs of the in-house radiologist and the needs of the hospital is to start an in-house teleradiology service1. In this situation, the referral hospital contracts directly with a team of radiologists and the in-house radiologist is the head of the team. Cases sent to the in-house teleradiology service can be put on a time delay such that the in-house radiologist gets first crack at cases and after a certain time delay cases are sent to the broader pool of radiologists. Similarly, the in-house radiologist also has the option of reading for STAT and weekend cases. DVMinsight is one PLATFORM referral hospitals use to create a branded in-house teleradiology service.
Proving radiologists with an efficient method of reporting cases.
Hospital administrators must realize that radiology is a volume business. Radiologists make their living by doing dozens of cases every day. In order to be successful, they must be provided with an efficient method of reporting cases and performing their job.
Unfortuntely, hospital administrators often assume that radiologists will sit down at the PACS, look at the cases, navigate over to practice management software to figure out what is going on with the patient, and then type a report into the practice management software. This process is a recipe for disaster because this process requires the radiologist spend an inordinate amount of time (not to mention dozens of mouse clicks) on each case. If a radiologist is asked to interpret 40 cases a day and each case requires 3 minutes of mouse clicks and searching patient records that is an extra 2 hours2 of wasted film interpretation time.
Hospital administrators must understand that although radiologists are generally self sufficient, they are not technical staff. Radiologists, in order to be efficient, must be provided with a list of cases that need to be read. This list MUST include a patient history/reason for the study. In general, the technical staff should be responsible to submitting case requests to the radiologist.
Radiologists must also be provided an efficient method of reporting cases. Searching the practice management software for the proper record and manually typing reports is a time sink. It is HIGHLY recommended to provide the radiologists with an efficient reporting system including voice recognition software or a transcription service. In human medicine, expensive software programs called radiology information systems (RIS) serve this purpose. In veterinary medicine, most digital radiography and PACS systems are devoid of RIS functionality.
Discussion of how a radiologist will report cases should be included in the employment negotiations. If RIS functionality is not present at the hospital the radiologist should take the lead and be prepared with a suggestions during negotiations. One option is to use a cloud based PLATFORM such as DVMinsight to provide RIS functionality to the in-house PACS. Radiologists should understand that every dollar spent on efficiency creates several dollars in production. We have already established that an inefficient system can result in as much as 2 hours of lost productivity daily. Paying a few dollars a day for RIS functionality will allow the radiologist to read numerous more cases each day. Taking the responsibility for paying for RIS functionality out of the radiologist production fee or flat fee is one method radiologists can use to increase their productivity without requiring the hospital to pay for software or hardware. Taking the responsibility of paying for or recommending an efficient method of reporting cases will pay off in the end for the radiologist.
Radiologists need to be their own marketers
This article listed a number of items that must be addressed in employment agreements before a radiologist is hired at a referral hospital. It cannot be overstated that even the best employment agreement will not prevent turmoil at the hospital. We have seen too many cases where radiologists3 do not understand the relationship between the radiologist and the referral hospital and the role of the radiologist at the hospital.
Radiologists must understand that before they can be successful, they must win over the other specialists at the hospital. Your radiology prowess is not assumed and ACVR credentials do not equal trust or loyalty among your peers.
Radiologists, as a support service, must operate like any support service. This means “service with a smile.” It is recommended that all radiologists have an “open door” policy and promote discussion with the other specialists. Radiologists must be available by phone or email to discuss cases at the hospital (yes even after you leave the hospital). Finally, radiologists must learn to leave their “attitude” at the door.
NOTES:
- This suggestion is a bit self serving as DVMinsight is our sister company and many referral hospitals are now using DVMinsight to do this type of thing.
- Actually, it is more like 2.5-3 hours considering that radiologists should be taking a break each half hour to keep their eyeballs in good working order
- Usually young radiologists coming out of their residency and have not yet had the chance to fail on their own
If you are a radiologist or hospital administrator who would like to talk in more detail about issues surrounding employing an in-house radiologist or you would like more information about how DVMinsight can help create a successful radiology environment at your referral practice, please contact us at www.dvminsight.com