Pandora and the Very Scary Box

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Out of the box flew all of mankind’s misfortunes

An amazing thing happened in the month of June 2009. The father of modern teleradiology resigned from the company that has become synonymous with teleradiology, NightHawk Radiology. We all know him: Paul Berger, MD.

It was a remarkable exit, really, and one we are privy to only because every move he makes is public record, as member of the board of a public company. Berger sent a letter to NightHawk employees, and it is brief and worth quoting from here:

I have been fortunate to be a radiologist for 35 years and part of a remarkable profession. I feel a great sense of duty to all radiologists and the patients they serve. The Company has embarked on business and strategic initiatives which in good conscience I cannot support and do not wish to be a part of going forward. I have discussed this at length with management and the Board of Directors to no avail. I thus find it necessary to resign from the Board of Directors effective June 8, 2009.
—Paul E. Berger, MD

What happened?

This also is a matter of public record: Berger lost control of his company late last year, when he was replaced as CEO by David Engert on November 17, 2008. This we also know: On June 8, a company called Imaging Advantage took over radiology services at Mercy Health Partners, Toledo, Ohio, displacing its radiology group of 30 years, Consulting Radiologists Corp. All radiologists were offered on-ground positions with Imaging Advantage, and they were given three weeks to consider the offer. NightHawk is Imaging Advantage’s teleradiology provider. The day Imaging Advantage took over at Mercy Hospital was the day that Berger resigned.

I do not know why or how Consulting Radiologists Corp got into this predicament, but clearly, the relationship was not cozy. From Wiley’s interview (page 19) and other sources, I gather that the hospital wanted improved turnaround times and 3D reformats. The radiology group struggled with an ineffective PACS implementation, and everyone knows clinicians find 3D reformations more useful than radiologists do.

How Berger lost control of his company is not a mystery: he helmed a public company, and the stock plummeted, along with all other stocks. Wall Street’s geniuses got involved.

The story of Pandora is a favorite of mine, as a woman. We get to be the protagonist in this story (unlike most others). There are a variety of interpretations of the Greek myth, but the classic Edith Hamilton compilation1 shares just two. They boil down to this: In the beginning, there were just men, and woman was man’s punishment for being tricky with the gods. She opened the box that contained all misfortunes, and though she tried to close it, she could not. Fortunately, the gods also tucked in hope.

Methinks Berger opened the box here; in resigning, he is trying to close it, which, of course, he cannot. Teleradiology has become part of the fabric of the specialty. Because Berger is a man of ethics, he could not endorse the displacement of entrenched local radiology groups. He knows too well that it is not all about the interpretations.

Our world may be flattened, but it is still our world. We have to live here. The ACR code of ethics requires radiologists to notify the local radiology group before entering into talks with the hospital administration. Imaging Advantage did not do that, but it also is not run by radiologists, and, I suspect, does not consider itself constrained by the college’s code. The business world, where the greatest transgression is failure to achieve profitability, operates on different principles.

It’s pretty clear that Berger believes teleradiology companies should be serving the radiology group, not the hospital. In the case of Imaging Advantage, it remains to be seen whether it can patch together an effective radiology service with teleradiology, locum tenens, and on-the-ground employed radiologists for Mercy Health Partners in Toledo. None of the Consulting Radiologists Corp radiologists took its offer.

What I think is that train has left the station. If a teleradiology group—no matter who owns it—can move in, convince a hospital it can meet service levels, and put a few bodies on the ground, it will. Hospitals are struggling with lower admissions, diminished endowments, and reduced access to credit—so, local radiology, this is your equivalent of a second wakeup call. New practice models are emerging. Take a look at what Advanced Radiology Services,