As I travel around the country to meet with imaging executives in practices and hospitals, it is always interesting to me to discover the physicians and administrators who have a unique grasp of what it takes to succeed in today’s changing radiology profession. It is not scientific, but I would say that my study size is a statistically valid representation: it has been consistently on the mark in proving my hypothesis. What is my hypothesis? It’s that those who are at the forefront of competitiveness in their respective markets are the ones with true entrepreneurial instincts. These top performers are the anti-bureaucrats, those who abhor the historically institutional nature of many hospital and practice settings. There is a huge distinction between the two groups I see: there are those who understand the difference between practices, centers, and hospitals, and have transformed their respective cultures; and there are those whose referrals and patients are treated as numbers and units, where customers are taken for granted. I believe that many consecutive years of double-digit annual scan volume growth created practice cultures that reflected entitlement mentalities, environments that paid scant attention to the economic headwinds gathering these past few years. These practices just assumed that they would weather the storms, just as they have in the past, and that there was really no need to change their cumbersome and often atrophied cultures. As a result, many of these groups—which are, to a large degree, bureaucracies—are now finding it very difficult to move quickly to protect their levels of revenue. The most successful groups have been those that from the very start operated their enterprise with an entrepreneurial mind set, never taking customers for granted, always working the hearts and minds of their referral sources, creating an business atmosphere that is antithetical to bureaucracy. These leaders, able to react quickly to events and opportunities, are aware of the need to build customer loyalty and sensitive to the valuable contribution to the hospital or practice made by their dedicated employees. These are the businesses now enjoying continued annual volume increases while many practices are struggling. A number of radiologists that I talk to have a difficult time accepting that this is true. They feel that their superior clinical skills should be all that is required for them to succeed. In a perfect world, that would no doubt be the case, but we do not live in a perfect world—and in any given market, there are choices to be made between radiology practitioners with equal levels of top level clinical skills. Choice empowers those who get to choose. And those who get to choose have made it clear that it is not “business as usual” in the medical imaging arena. Entrepreneurial imaging executives get that part and have no problem in going out of their way to persuade referring physicians to use their services by their customer service actions, streamlined processes, immediate report turnaround times, accurate and unambiguous interpretations, and convenient access for the patient. In essence, they understand that the entire referral experience needs to be a positive one, and they accept the responsibility for making that happen—throughout their entire organization. What can bureaucratic organizations that have become too institutionalized learn from those that are succeeding even now? Move quickly, get a renewed sense of purpose, learn to act like an entrepreneur and watch the new possibilities unfold. Curtis Kauffman-Pickelle is publisher of ImagingBiz.com and Radiology Business Journal, and is a 30-year veteran of the medical-imaging industry. He welcomes your comments at ckp@imagingbiz.com.