OPINION

Whose Cows Are They? Philip J. Kenney, MD

Today is my birthday. I am not going to say which one, but it is probably a sign of aging that my childhood memories are becoming more vivid. When I was growing up in the 1950s, I spent every summer at my grandfather’s farm. Grandpa had a dairy farm in a valley up a dirt road about a mile north of the Pennsylvania border, and when I was born, it had no electricity, party-line phone service (in those old days, several homes were on the same exchange, and you could pick up the phone and hear others talking), and a hand-dug well that went dry every time there was a drought. As I recall, my grandfather had about 40 cows, and his farm was 150 acres. This was a hardscrabble farm; my grandfather could not afford hired help. Of course, neighbors helped one another with major things like harvesting the corn or hay, but for day to day, he was on his own. Running a dairy farm meant that he milked his cows twice a day. Every day. Each one. Saturday and Sunday too. Every day. Every week. Every month. Every year. As far as I know, my grandfather never took a vacation, possibly in his entire life. He bought the farm in 1914 and kept it till his death, leaving it to my father, who kept it till his death (and I still own part of it). I remember one time, as I sat on Grandpa’s lap in his rocking chair, he said that he had to go milk the cows. I asked him, “Why do you milk your cows every day?” He said, “They are my cows, who else is going to do it?” As I implied above, my grandfather bought his farm well before, and kept it throughout, the Great Depression, a feat so many family farmers failed to do and a testament to his work ethic (and some good luck as well). 340

Recently, it has struck me how different is the attitude one hears regarding work today. My perception is that this change in attitude is increasingly pervasive among health care providers, but I work in radiology. See if any of these attitudes sound familiar:  “Oh, I avoid reading those studies; they are so low in RVUs.”  “I try not to read studies from that place because the quality is not good.”  “I hear we don’t get paid much, if at all, on that contract, so I just don’t read those.”  “I don’t like to be interrupted because it hurts my productivity.”  “There is so much cherry picking going on. Every one of my normal exams has suddenly vanished from my work list.” I’m not sure whether these attitudes reflect changes in health care economics, changes in leadership, or changes in attitudes. I suspect all 3. Certainly as reimbursement has tightened, priorities have shifted, not just for radiologists but for most health care providers in general. Clinical services have become more harried and more lean, not necessarily leading to enhanced patient care and service. At the same time, the number of administrators in health care has increased at a greater percentage than the number of radiologists and nonradiologist physicians. Certainly, there is more administrative work, but could this trend signify a long-term change in the way health care is practiced in our country? Possibly. Additional factors are at work here as well. As reimbursements have tightened, real-time productivity has increased per radiologist (and per nonradiologist physician as well), and team building activities

such as local collaborative consultations with colleagues have gone down. Radiology groups have become larger and more fragmented. In the area where I work, we have gone to an arrangement of overlapping shifts (eg, 7 AM to 2 PM, 8 AM to 3 PM, 10 AM to 5 PM, 2 PM to 9 PM), which has some advantages for efficiency, having the most people at the busiest part of the day. But it was also interesting how rapidly people concluded that once you reached the end of your shift, it was time to go. The concept that perhaps your duty was to the cases completed during your shift vanished quickly; now we (myself included) leave whatever is still on the work list to the person coming on shift. Those are not my cows anymore; you can have them. Not surprising, when radiology is increasingly seen as a commoditized service. Working at an academic center, it has been, shall we say, amusing to see how often those who actually have academic or administrative time still have so many important meetings, conference calls, and so on, on the days when they have clinical duty. Or the specialists, whether neuroradiology, musculoskeletal, or abdominal, who now seem incapable of reading a chest x-ray in the work list along with what they are reading—really, you cannot recognize a normal chest radiograph and get it off the work list? What residency did you do? There is a phrase that has become part of the lexicon fairly recently: “taking ownership.” Although it is a phrase that is often abused, there is something to it. My grandfather truly took ownership of his farm and his cows. It was his farm, and he would do everything to keep it. If that meant milking his cows

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Opinion 341

every day twice a day with no vacation, he was fine with that; it was what he wanted to do. It was a simple equation: to keep the farm, he needed the milk to sell; he needed the cows to make the milk; to feed the cows, he needed to harvest the hay and corn. And it all worked; he just had to milk the cows twice a day, every day. Let us examine that concept of “ownership” as currently used in our discipline. It has become a bit of a “buzzword,” but it may have some meaning, on reflection. What is it, however, that we should claim ownership of? In my childhood, I focused on my grandfather’s tasks: the milking of the cows. We now often again focus on tasks, such as reading the emergency department cases, or the chest work list, the body CT work list—in other words, the radiology “read.” Think about this: do we have ownership only of the tasks, such as work lists? Is the “read” or the written report our sole product? If so, we should not be surprised as our specialty becomes increasingly commoditized or awarded to the lowest price provider. We should not be surprised as increasing numbers of health care administrators, policymakers, and payers see radiology providers as interchangeable and easily replaced. My grandfather had ownership of his cows. It was in his best interest to keep them healthy and productive, even happy in a cowlike way. The milking, hay mowing, feeding, cleaning stables, and so on, were

tasks, but the point was not limited to getting those tasks done; it was to have a pasture full of healthy cows. The tasks were means to an end. Do we now take ownership of our patients? Do we even think of them as our patients? Or just tasks, relative value units, or “reads” to pile up, reports to file? Richard Gunderman and Alison Tillack [1] recently published an opinion piece in Radiology titled “Empathy’s Vital Role in Putting Patients First,” which is quite relevant to this discussion. It may be a challenge for many radiologists to be truly empathetic, but it would seem beneficial to radiology to be more patient-centered than taskcentered. One can hear much talk about the future of radiology, concerns that “radiology as we know it will no longer exist.” Are we really worried that the work will go away? Or that the enjoyment and fulfillment will go away? The excellent salaries, generous time for academic endeavors, meetings, and other noninterpretive professional services. If we really take ownership of our entire radiologic product, which includes our interactions with patients, health care providers, and the community, and do it right every day, perhaps we can get through the equivalent of the Great Depression and move on into a brighter future. I contend that if we concentrate on doing our work passionately and define our product as going beyond the radiology “read” to include patients’

and clinicians’ experiences in our radiology suites, we will have best chance of “keeping the farm.” We have done well with technology; perhaps we can be the managers of the milking machines of the future. As with my grandfather and his cows, we should realize that it is to our great benefit to have our patients, referring physicians, and to an increasing extent payers and policymakers happy with their experience with us. In writing this, I by no means intend to impugn any of my colleagues. I don’t necessarily think that if you have a bad contract that pays poorly, you should just suck it up and read it—or maybe you should until you renegotiate the contract or dump it! I do not at all expect anyone to work every day without vacations. As a matter of fact, on this, my birthday, I happened to be on a shift that got off early, so I am writing this at home with the sun still up. But when I left, every work list assigned to me was empty, and every clinician was contacted about significant results. I milked my cows, all of them. ACKNOWLEDGMENT Thanks to Jonathan Berlin for substantial advice and proofreading. REFERENCE 1. Gunderman RB, Tillack AA. Empathy’s role in putting patients first. Radiology 2013;269: 315-7.

Philip J. Kenney, MD, University of Arkansas for Medical Sciences, Department of Radiology, 4301 W Markham, #556, Little Rock, AR 72205; e-mail: [email protected].

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