The Sorcerer’s Apprentice: A Conversation With Jeff C. Goldsmith, PhD

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What happens when you cross a futurist and a radiologist?

In October 2010, Oxford University Press published The Sorcerer’s Apprentice: How Medical Imaging Is Changing Health Care, by Bruce J. Hillman, MD, the effective father of the ACR® Imaging Network, and Jeff C. Goldsmith, PhD, a health-care futurist known for his contrarian views.

The two met at the University of Virginia, where Hillman is the Theodore E. Keats professor of radiology and professor of public health sciences and Goldsmith is associate professor of public health sciences. Goldsmith is also the president of Health Futures, Inc, a consultancy based in Charlottesville, Virginia.

The pair has turned out an engaging, thoughtful, and compelling book that is equal parts science, history, and health-policy analysis; it is a must-read book for anyone who practices, uses, or pays for medical imaging. Radiology Business Journal sat down with Goldsmith to discuss some of the ideas explored in the book and their implications for the specialty.

RBJ: What is the story behind the book? How did a futurist and a radiologist come to collaborate?Goldsmith: I’ve been interested in this profession and technology for years because the rest of medicine seemed to me almost to be standing still, compared with radiology and imaging. There are so many other parts of medicine where technology has not developed as rapidly as people expected, but this area has consistently exceeded expectations.

I also thought it was an incredible success story that no one has told, as such. Here’s a profession that has done a remarkable job of leveraging technology in a digital world—and it became, as a consequence, one of the most successful knowledge disciplines. It was a story worth telling from a management standpoint.

When I was getting serious about the research on the book, I went to talk to Bruce and asked if anyone had told this story. He said, “Not really—and by the way, I’ve been thinking about doing something like this. Why don’t we work together?”

Both of us were thinking along the lines of trying to explain, to lay readers and to the policy and business community, how this technology works, how it is used (and perhaps misused), and how society could get its arms around it. We hit upon the metaphor of the sorcerer’s apprentice to explain how hard it is to control a complex technology, and that mixture of fascination and fear people have toward it. It was a great metaphor for describing how disruptive imaging has been.

RBJ: In your discussion of our dysfunctional health-care payment system, you make the case that the use of other people’s money for health care creates a suspension of normal economic forces. In your words, the invisible hand of the market is not enough to solve these systemic problems. Could you give our readers a sense of what you recommend in your final chapter?Goldsmith: Third-party payment introduces this problem of moral hazard: If you are not directly responsible for the cost of a service, then you have to put an enormous amount of trust in the people you rely on to perform that service, to make sure that it is needed and is performed in a responsible way. As we went around the country, we kept hearing—and not just from the usual suspects, like health insurers—that there was a great deal of unnecessary imaging.

Moral hazard (and how you manage it) was one of the themes in the book because our political and health-insurance systems haven’t gotten their arms around the moral-hazard problem. We talk about how to get to the point where appropriate use of technology is the norm, is rewarded by the payment system, and is recognized by patients and the technology’s users.

Radiologists have been ahead of the curve when confronted with policy challenges. They did it with digital standards. They did it again with relative-value payment approaches. Through the ACR, radiology has been very aggressive in developing appropriateness guidelines backed by applied clinical research. The expansion and use of that information in guiding payment policy, both public and private, are going to become crucial in the next seven to 10 years.

RBJ: You write that since initiating the sustainable growth rate (SGR) in 1997, Congress has let it stand just once, effectively creating a $300 billion pothole in Medicare, with imaging accounting for more than the average share of that debt. What impact has this had on radiology’s standing in the medical community,