No matter how good your service is or how expert and reliable the care, if someone isn’t taking care of the back of the house, health care is out of business. I learned that the hard way when my wonderful dentist (who used to tell her elderly clients that there was a sale on fillings: two for $25) could no longer pay the rent, sold her business to another dentist with dollar signs in her eyes, and left to teach part-time at the University of Southern California and volunteer at the Venice Free Clinic. Fortunately for my dentist, her husband was gainfully employed, but I’ve been searching for a suitable replacement ever since. That is the genesis—and continues to be the basis—of the uneasy relationship between physicians and health-care administrators: No money means no mission. As a health-care business journalist, I have walked the tightrope between physician (specifically, radiologist) and administrative interests for the past 15 years, seeking that happy place where the twain could meet concerning quality, service, technology, and health policy. What something cost, until recently, was a verboten topic. I’ve seen some pretty dismissive behavior by some physicians in the presence of administrators, and I’ve also heard some embittered talk from administrators about radiologists. That’s all water under the bridge now. Administrators and physicians have a quest in common, and it’s all about the money: If you don’t find a way, together, to reduce the cost of care (and preserve or improve quality), then we will end up with a national health service or go broke paying for what we now have. Today, after many years of wary truce, physicians and administrators find themselves seeking common ground. At the moment, however, the ground is anything but steady. If you feel like Jimmy Stewart atop a bell tower, I’m not surprised. The confluence of uncertainties adds up to an extremely vertiginous environment for all physicians, but especially for radiologists. The Big Conversation At present, the big conversation in physician–hospital relations revolves around alignment; now, more than ever, a practice’s ability to get along with others is of paramount importance. Despite several well-publicized hospital–radiology practice meltdowns, there is no evidence that radiologists have greater difficulty getting along with hospital administrators than other specialty physicians have. Radiologists do, however, have some particular challenges, and more than a few of your health-care brethren are sitting on the sidelines, indulging in some good old schadenfreude at your expense. At a recent health-care conference, a specialist in mergers and acquisitions observed that radiologists have been living high on the hog for a lot of years—and now it’s over. What are these challenges that are peculiar to radiology? You know them well by now, but here they are again: First, when digital imaging delivered you from the hospital basement, it also dramatically reduced the interactions you had with your physician colleagues, not to mention hospital administrators. A centralized reading room might be efficient, but it’s also isolating. Second, at a time when the big tanker that is health care in the United States is turning toward a patient-centered approach, radiology finds itself focused on (and beholden to) referrers. Third, after many years of lavish use, imaging became a cost center—not just for the government, which foots half the nation’s health-care bill, but for the hospital as well. In engaging radiologists in the task of managing imaging utilization, hospitals are asking radiologists to shrink their market. A “Twilight Zone” Moment It is disconcerting, and more than a little humbling, to be asked by your administration to do away with inpatient imaging, but that is precisely what Jonathan Kruskal, MD, PhD, reported (maybe a bit tongue in cheek) in his presentation on Massachusetts health-care reform (see the article on page 52) at last year’s RSNA meeting. It is the kind of request that makes you wish very hard for a “Twilight Zone” moment, when suddenly everyone goes back in time—maybe just back to the 1980s, before cross-sectional and functional imaging came into their own—and has to make do with exploratory surgery and, God forbid, the stethoscope. Sure; you want to do away with imaging? Take this! Many things have changed in the past five years, but one thing remains the same: Medical imaging is as valuable and critically important to patient care as ever, and probably more so. All of the population management in the world will not keep everyone healthy; people will continue to get sick and have accidents, and when they do, their physicians will need medical imaging to find out what is wrong, to target therapy accurately, and to monitor treatment. These tools will only improve with the integration of genomics and proteomics. If you have been waiting until the writing is on the wall, however, to do something about that little trinity of challenges, it is on the wall now. You have met the enemy, and it isn’t the hospital administrator: It is inaction. The best defense, right now, is having a great offense.