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222

utsourcing Off-Hour Imaging Services

ynthia S. Sherry, MD

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Y BEST IDEA

ronically, they’re the same: myest decision was also my worst de-ision! About 4 years ago, I decidedalong with my 24-person radiol-gy group) to outsource our off-ours ER business offshore. Weiscussed and analyzed the meritsnd demerits of this solution to ourounting discontent with night

all, and though there was a minorlement of internal dissent, thearge majority ultimately decided inavor of giving it a try.

Taking this concept to reality in-olved a few steps and finesse withey stakeholders. The first step waso query the ER doctors to find outow they would react to the change.hey were surprisingly supportiveecause they predicted that reporturnaround times would improvend that wide-awake daytime con-ultant radiologists across the globeould be sharper than local sleepy

nd overworked radiologists. Plus,ne of their barriers to orderingests was removed since they noonger had to be concerned aboutadiologists’ resistance to theirrend toward ordering more andore imaging studies on their pa-

ients. Once they were assured ofhe professional pedigrees of ouronsultants, they supported ourransition.

The next step was to query theospital administration. Once thedministrators had the sense thathe emergency department doctorsupported the concept, they passedt on to the legal department, whichltimately gave it a green light.The next barrier was the IT de-

artment, which initially vetoedhe plan on the basis of network

ecurity concerns. However, the IT m

urus were eventually convinced ofhe safety and integrity of the plan.

Finally, our outsourcing plan be-ame a reality. What a great deci-ion! Once it was implemented, weorked nights only as backup tour off-shore consultant radiolo-ists. The benefits of this arrange-ent were immediately apparent.e got our nights back (to sleep),

lus we got the following days backecause we weren’t sleep-deprivedombies. True, we had to do theork of providing final interpreta-

ions the next day, which meanthat we were paying twice for theoverage: once for the consultantso provide preliminary readings,hen again by dedicating our ownadiologists to reread the studies theollowing day to provide peer re-iew and final reports. But weidn’t mind; it was well worth theosts because our lifestyle was soramatically improved. Plus, weound it easier to recruit the creamf the crop, too: none of the newlyrained and most sought after radi-logists wanted to join a practicehat required them to work nights.dditionally, once the way wasaved clear for the emergency de-artment doctors, it was a smallatter for us to extend the plan to

over inpatient after-hour studies asell.At our hospital, like many others

cross the country, most otheredical specialties had already fig-

red out better or more profitableays to cover nights, and thereforeost of the medical staff viewed the

adiologists as simply being in syn-hrony with the trend. I admit thathere was a little push-back and re-entment by some of the attending

edical staff, but nothing very seri- s

0091

us, just minor back-hallway inter-ittent weak criticisms.

Y WORST IDEA

o why was this also my worst de-ision? Even though things had runairly smoothly for a while, weould not deny the few mishapslong the way. The most significantroblem surfaced at one of ourmall suburban hospitals, wherene disgruntled ER doctor becamehe tail wagging the dog. He wasike a pit bull, so opposed to ourutsourcing solution and so tena-iously vocal and persistent that,aking a long and painful story

hort, we ultimately lost the radiol-gy services contract at this hospi-al. Yes, there were other service-elated issues that came into play,nd as a group, we were willing toddress all of them, but we were notilling to give up our outsourcedight coverage and go back to thelden days of working all night.

The period after losing the con-ract was a very difficult time for us.ot only were our pride and repu-

ation injured, it was also necessaryo implement corresponding cut-acks, reduce our workforce, ando the tough job of letting someadiologists go. We did try re-ponding to a few requests for pro-osals to regrow our business byaking on new nearby hospital con-racts, but we never won a singlene. There is probably more thanne reason for our failure to winny of these contracts, but it is safeo conclude that our method ofight coverage was not winning anyopularity contests in our medicalommunity. This period of intro-pection led us to reanalyze our out-

ourcing model and the attendant

© 2010 American College of Radiology-2182/10/$36.00 ● DOI 10.1016/j.jacr.2009.11.008

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My Best Idea/My Worst Idea 223

ownstream impact on our overallob security, our position in the med-cal community, the financial rami-cations on our bottom line, andhe overall effect on the professionf radiology as a medical specialty.e are a little sadder but wiser and

etter equipped to more thor-ughly and objectively digest theealities and ripple effects of beingependent on this coverage model.First, we found that although

ur administration accepted ourutsourcing, they were not pleasedbout it, and we were on thinnerolitical ice than we realized. The

egal department also resurfaced itsuality concerns in the wake of ourusting from the sister hospital.heir quality concerns were effec-

ively quashed by our peer-reviewtatistics, but as everyone knows,erception is the reality we musteal with. Additionally, our finan-ial reanalysis revealed that we wereeaving more money on the tablehan we initially realized. This un-nticipated financial drain was oc-urring through a combination ofost revenues from a poorly reim-ursed financial class of patients weerve at night and an overall grow-ng nighttime imaging volume.aking it a step further, we began

o see how we could turn nightsnto a profit center if we did it right.

We also began to face significantntangible considerations. In someays, punching the clock at 10 PM

einforced the impression that weere not a necessary part of the

edical team. We became more an- t

illary, nameless, and faceless shiftorkers, viewed as abandoning our

olleagues and our patients. An in-estigative reporter even did anvening news spot on how our hos-ital sent nighttime images overseasithout patients’ even being aware!e had always prided ourselves as a

ervice-oriented, high-quality radi-logy group and were having trou-le reconciling this self-image withurning into pumpkins at 10 PM.

We also began to understandow this model commoditized ourroduct. If anyone can do our jobnywhere, we could just look forhe cheapest provider. Further-ore, we reasoned, if night work

an so successfully be outsourced,hat argument could there be toot outsource our day business?he argument that Thomas Fried-an [1] advanced in his book Theorld Is Flat was taking hold in ourinds; Freidman even wrote that

e wouldn’t want to be a radiologistn this day and time because ourxistence is so threatened! Good no-orious examples of Friedman’s pos-ulate becoming reality are the To-edo and Florida debacles, whereinong-standing, reputable, and high-uality radiology groups were re-laced overnight, allegedly on theasis of service issues, by companieshat minimize on-site coverage withack-of-all-trade radiologists and relyn outsourcing (day and night) forccess to radiologist specialists.

It dawned on us that the modelf outsourcing our night work ac-

ually threatens not only our liveli-

ood but the very existence of ourpecialty as a profession; nobodyver questions the value of imagingn the modern practice of medicineoday, but many question the valuef radiologists. It is ironic that thisould occur at a time when imagings remarkably advancing technolog-cally and volumes of imaging testsre steadily growing. We are likerank and April Wheeler (portrayedecently by Leonardo DiCaprio andate Winslet) in Richard Yates’s [2]

ward-winning novel Revolutionaryoad. We try to escape from that ele-ent of our life that we find undesir-

ble or tedious without recognizingow that element is crucial to makingur professional lives as rewardingnd gratifying as they are. To thatnd, like the Wheelers, we have beenilling to take measures that poten-

ially undermine the core of our pro-essionalism.

As a group, we are in the processf figuring out how to take back ourights and do so profitably. Wegree that in so doing, we can pro-ide a higher level of service to oureferring staff and our patients andecure our position and standingithin our hospital and medical

ommunity. We don’t want to endp like April Wheeler.

EFERENCES

. Friedman TL. The world is flat. New York:Farrar, Strauss; 2005.

. Yates R. Revolutionary road. Boston: Little,

Brown; 1961.

ynthia S. Sherry, MD, Texas Health Presbyterian Dallas, Department of Radiology, 8200 Walnut Hill Lane, Dallas, TX 75231;-mail: cynthiasherry@texashealth.org.