The Sorcerer’s Apprentice: A Conversation With Jeff C. Goldsmith, PhD
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, and what are its implications for the development of new imaging technologies? Goldsmith: Many physicians don’t understand the SGR—the fact that Congress placed an arbitrary economic cap on growth in Part B Medicare physician payment 13 years ago. The fact that imaging costs were growing much more rapidly than other Part B costs also was not widely understood in the physician community (even though physicians were doing the ordering). It inflamed policymakers, however. As early as 2000, there were warnings (and an increasingly strident voice from the Medicare Payment Advisory Commission and its staff) that something needed to be done. Imaging payment reductions have come thick and fast this past four years, without a lot of assessment of the effects on reducing volumes and cost. Medicare’s imaging expense went down 13% in the first full year after the DRA (2007). The DRA actually had a much more profound effect on cardiology and orthopedics than it has had on radiologists because radiologists are better integrated into hospital imaging activity. The policy community doesn’t understand that imaging is now deep into a recession quite unlike anything seen in the past 30 years. In late 2008, Health Affairs published an issue that highlighted the so-called imaging boom. People working in this field realized that the discipline and technology had already gone under the front wheels of the bus by 2008, and by the end of this health-reform cycle, they now have gone under the back wheels. The deep recession also has hurt elective-imaging volume. There’s a sort of instrument lag in the policy world; the people driving the bus think we are fighting double-digit rates of growth in high-tech imaging. In reality, imaging volume is growing in the low single digits or not growing at all. In some markets and systems, we’re seeing full-blown volume declines approaching double digits in the major high-technology modalities. There’s also something like a 30% fall in imaging-equipment sales (since their peak in the middle of the decade) in the wake of the DRA; I’m concerned that the past four years may have done fundamental damage to the economic foundation of the technology. There is a delicate balance between containing growth in imaging spending and extinguishing the research-and-development investment in imaging technology. If you continue the trends of the past four years, you create an environment where the big-ticket investment that’s required to build out the technology—particularly molecular imaging—just isn’t going to be there. One of the major contributions we hope to make is to give people a better understanding of the relationships among payment policy, utilization, and technology investment. RBJ: You discuss an interesting—and disturbing—economic catch-22 that threatens the future of personalized medicine: the “daily reclassification of diseases into ever smaller markets of more accurately defined diseases.” What can be done to promote investment in therapies for effectively smaller markets? Goldsmith: This problem not only is going to slow the development of molecular imaging, but is going to affect the course of the broader biotechnology industry. In the book, we quote a scientist as saying that, in the future, every disease is going to be a rare disease. Diagnosis will not merely be physiological; diagnosis will occur in a specific genetic context for specific individuals. We need a different payment model for these things. In this book, we grope for new payment models that encourage not only personalized diagnosis, but technology that enables you to diagnose and resolve a clinical problem in a single session. In diagnostic therapy (theranostics), there may be diagnostic molecules that can be modified and used to kill a pathogen or cancerous lesion. We need to move to a payment model that encourages diagnosis and treatment to take place in the same setting. RBJ: In the last chapter, you say that subspecialization can foster more effective team medicine. What roadblocks will radiology have to navigate to become part of the team? Goldsmith: The discipline has been so successful that it really hasn’t had to collaborate, and it has viewed disciplines that might find radiologist-developed technologies useful as competitors. Bitter turf struggles with cardiology and orthopedic surgery have taken place largely out of the view of the patient. If patients understood that there was actually controversy about whether a specific discipline was qualified to image them, it would raise anxieties—and questions such as, “Why aren’t you guys working together?” I understand why people aren’t working together, but I also think that radiology has clung, perhaps a decade too long, to this idea of a generalist practice model. If they are going to be successful, particularly in an era of molecular medicine, radiologists either are going to subspecialize (which will take decades) or are going to acknowledge that the radiologist’s training is not so broad that it encompasses things like applied genetics. These are things that radiologists learn in the basic-science phase, very early in their education, but don’t necessarily come back and apply, in a clinical context, in later phases of their training. With molecular imaging, you have a rapid convergence of molecular pathology and radiology—and the potential for a collision, and yet another turf struggle. I see the alternative potential for mutually reinforcing strengths. Why can’t pathologists and radiologists work together to create centers for molecular diagnosis and therapy? It’s about making the pie bigger. The whole medical profession is sufficiently weakened by economic and political forces that it is not really prudent to launch a new set of turf struggles right now. That would be really counterproductive in the policy world. RBJ: In the 1797 Goethe poem “Der Zauberlehrling” (on which Disney’s “The Sorcerer’s Apprentice” is based), the sorcerer cleans up the mess created by the apprentice, with the admonishment that powerful spirits should only be called by the master himself. Have radiologists been vocal enough about the dangers of imaging moving into the hands of others? Goldsmith: They’ve been vocal about it, but in a way that might be perceived as parochial and self-serving. It’s not enough to say that others are not adequately trained to use these tools. Radiologists do, in fact, have a far greater depth of awareness of the effect of the technology on their patients, and also of the subtleties of diagnosis, than any other clinical discipline has. The overarching question is this: What is the best way for patients to get the best care? If I am offered a choice between a discipline that understands the physiology of a particular organ system (like the heart or digestive system) better than anyone else and a discipline that understands the diagnostic technology that might address that organ system—or the choice of a multidisciplinary center of excellence where those disciplines work together to answer a complex clinical problem—where am I going to go? Moreover, what is the payor going to perceive as the configuration of knowledge that produces the best value for the patient? Eventually, payors will get around to cutting the patient in on some of the savings that result from having a definitive diagnosis from a team of caregivers. We are moving toward an era of team-based medicine, and the radiologist has a tremendous amount of power to bring to that team (and, in many cases, will be in the best position to convene and organize the team). My argument is that you can define your discipline as having control over all of these modalities and tools, or you can define your role as solving a clinical problem. When you define it in that way, you end up drawing the circle of potential participants a lot wider—and making the pie bigger, as a result. RBJ: You clearly understand all of the problems and threats facing radiology, yet you are very optimistic about its future. Why? Goldsmith: Lewis Thomas, MD, (1913–1993), the New England Journal of Medicine’s famous essayist/biologist, talked about how expensive halfway technologies (those that treat the symptoms of a disorder, but neither prevent nor cure it) were in the 1950s. An example of that was the iron lung: You couldn’t cure polio, so you ended up with patients in iron lungs for the rest of their lives. Another halfway technology was coronary-artery bypass graft surgery. Imaging technology may be, at this point in its evolution, a two-thirds (not halfway) diagnostic technology. Imaging doesn’t always answer the question of what is wrong with the patient; instead, it can raise expensive questions for follow-up work. From technology and medicolegal standpoints, it is urgent to go the rest of the way. The sooner we can get the technology to the point where an imaging exam is truly definitive, the more solid the ground on which the profession will be standing. Elegant images are not enough. We need elegant functional characterization and definitive prognosis. It is urgent for this field to change both its business models and its policy positions to address some of the concerns that are coming out of Washington. There’s still not the sense of urgency that needs to be there about addressing the issue of the appropriate use of this technology. That’s my biggest concern. If you are as successful as radiology has been in this political climate, it’s actually a handicap. You can’t afford to be defensive about it, but you also can’t continue to behave as if fighting to defend your turf is the appropriate response to the present climate. Ironically, because of its extraordinary success, wealth, and strength, the profession is actually in a weak political position. There’s not a lot of sympathy for radiologists in Washington right now. RBJ: What’s the most important thing for radiologists to know about how they should move in this world? Goldsmith: Radiologists’ colleagues accurately perceive them to be the best at business among physicians. Why not use those skills—and the ability to adapt to uncertainty—to organize new business models, new subdisciplines, and new economic relationships, as well as to participate aggressively in the experimentation that will go on as a result of the Patient Protection and Affordable Care Act? Radiologists can use the perception that they are effective organizers to their advantage. This is a profession of experimenters, tinkerers, and people who are willing to take risks, try things, and see how they work out; it’s that adaptive skill that’s the real asset of the discipline. I’ve never seen more uncertainty in medicine than right now. That presents radiology with a great opportunity to exploit what I think is a tremendous evolutionary advantage. Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, for imagingBiz, Tustin, California.