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1 From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, BL-428 CHS, Los Angeles, CA 90095. Received April 23, 2004; accepted April 26. Address correspondence to the author (e-mail: denzmann@mednet.ucla.edu).
No radiology meeting would be complete these days without some discussion of turf battles. Who is invading whom, of course, depends on your professional affiliation. Radiologists favor the view that technical prowess should be the defining attribute in what is often depicted as a Darwinian professional struggle. Radiologists tend to define Darwinian fitness narrowly as technical skill or technologic sophistication. They are frustrated by the failure of other medical professionals to share this point of view. An analytic perspective distanced from war and survival analogies might reveal a less emotional approach to the issue. Turf issues, while sometimes initiated by technologic innovation, are fundamentally not about technology but rather are about medical practice models. Radiology’s ability to address turf issues could improve if radiologists better understood the interaction between new technology and business models (ie, practice models).
The business model as a construct can be employed to analyze turf issues in radiology or any other subspecialty. The business model equates with the medical practice model, which varies between subspecialties, and it describes how physicians generate cash. The basics of your medical practice model may be determined by answering the following questions: (a) What are you selling, or what are your customers hiring you to do? (b) Who is your customer? (It is good to have a handle on your referral base.) (c) What concatenated and parallel sets of activities are required for the delivery of your service? (d) How do you generate revenue, and what is the cost structure (eg, capital equipment, drugs, supplies, personnel) required to do so? (e) What is your competitive strategy? Why would customers hire you instead of someone else? The business model essentially describes how inputs like training, technical skill, technology, equipment, facilities, professional staff, and hard work are converted into patient care services for which someone is willing to pay.
Since radiology relies so heavily on technology, it is important for radiologists to grasp the interaction of new technology with medical practice models. This process is not intuitive. As a basic concept, technology by itself has little value until it finds a home in a business model, which means that someone is willing to pay for it. To get a better feel for this interaction, radiologists should read The Innovator’s Dilemma (1), in which technologies are differentiated not by their inherent characteristics but by their effects on business (practice) models. The main effects are categorized as either "sustaining" or "disruptive." These adjectives were chosen not to describe the technology but rather to characterize its effect on the dominant business model among the organizations affected by it.
Sustaining technologies fit neatly into the extant business model. Technologies of this category, no matter how inherently radical or revolutionary, still serve the needs of the main customers in a fashion familiar to them and in a way they currently value. Both computed tomography (CT) and magnetic resonance (MR) imaging are good examples of sustaining technologies. Not only were these technologies radical, but radiology played no role in their invention. In fact, they both originated outside the United States. Was it simply blind luck that radiology could cash in on MR and CT technologies? No, because radiology could integrate both into its practice model without much difficulty. While completely distinct from conventional radiography, CT and subsequently MR fit into radiology’s large-scale imaging operation by providing imaging-based information to essentially the same customer base among referring physicians. CT, originally marketed to neurosurgery, failed to find a home in that practice model. Other specialties could not manage integration because their practice models could not readily incorporate these high-fixed-cost technologies. Radiology could and did integrate CT, a process that then paved the way for facile adoption of MR imaging. It was good fortune that these technologies landed in radiology’s lap, but, as stated earlier, technology without a business model is not particularly valuable. Both CT and MR were sustaining technologies, and their interactions with radiology made them valuable and enriched both diagnostic radiologists and equipment manufacturers.
Disruptive technology travels a different route and has contrasting effects. It does not easily fit into the extant business model’s cost structure and does not meet that model’s main customers’ needs, making it generally unattractive. This inhospitality causes disruptive technology to migrate to a different business model. In doing so, the technology disrupts established models, a process that often has negative financial consequences.
Why do technologies prove disruptive? Business models are not skeletons, but, rather, bodies of behavior patterns that reinforce the model. They are stabilized by their cultures, which, once established, are hard to change. Therefore, an innovation will meet with resistance if its adoption requires substantial alteration of a model’s culture. Resistance to change is compounded if the culture has been particularly successful. Technology will bypass such obstacles and find a path to a different, more accommodating, business model. It took a creative technology company, Apple, rather than a big media company to put together a business model (iTunes and iPod) for selling downloadable music by using disruptive digital technology. Wal-Mart, the near antithesis of Hollywood, is following suit. Digital imaging is certainly proving disruptive to radiology’s old film-manufacturing friend Kodak. Disruptive examples are plentiful.
Let’s examine, in light of this framework, the current turf issue between radiology and vascular surgery, an issue precipitated by vascular stent technology. Since the two practice models (of radiology and vascular surgery) differ considerably, their interaction with stent technology might also differ. In general, the radiology service is a large-scale operation in which a high daily volume of work needs to be completed accurately and efficiently. Productivity and efficiency are emphasized. Vascular surgery, on the other hand, provides a more customized service in which daily volume is low. Surgical results and continuity of care are of greater concern than productivity or efficiency. The value proposition for radiology is high-volume, wide-ranging, and efficient service, while for vascular surgery it is focused, low-volume, customized service. Interventional radiologists situated in radiology departments and vascular surgeons in surgery departments address different markets. Interventional radiologists treat primarily inpatients and to a lesser extent outpatients. The hospital itself is a key customer. Vascular surgeons treat primarily outpatients, albeit in the operating room (OR) setting.
These services encompass different activities. Interventional radiologists are expected to provide a variety of services in the context of a hospital-based angiography lab by using a broad set of technical skills to handle a spectrum of procedures that extends beyond the treatment of vascular disease. For vascular surgeons, the procedures are predominantly vascular and are performed in the OR, but only during a portion of the working hours for which the OR is available. Except in emergencies, scheduling accommodates the surgeon. In contradistinction, interventional radiologists are responsible for efficiently using the capacity of the angiographic suites for all patients scheduled in them for the entire day, every day. Scheduling accommodates the patient, the hospital, and efficiency (capital and labor). The daily inpatient work simply has to be done. Teamwork is helpful. These work parameters are reflected in the compensation system, with interventional radiologists generally having salaried positions and incentives to run a service, whereas compensation for vascular surgeons is more directly related to individual production. The competitive strategies also differ, with interventional radiologists relying on technology, innovation, speed, and efficiency, whereas vascular surgeons rely more on personalized and customized care. These are significantly different practice models, and, not surprisingly, the cultures surrounding them are dissimilar, as well.
We will refer, in shorthand, to the culture of interventional radiology as a "cath-lab" culture and that of vascular surgery as an OR culture. The cath-lab culture is one of ownership because interventional radiologists have responsibility for their laboratory, equipment, supplies, and trained personnel. Because they work in the angiographic suite all day, they own it. The OR culture is one of renting, as vascular surgeons are visitors both to the OR and to clinics and expect those facilities to be available to them at their convenience. They do not expect to manage either site. Owners and renters have different expectations of staff and space. These different practice models exist and do so legitimately.
While established medical practices hover around the status quo, patient services can and do move. This occurs when technologies change the nature of services. For some medical practices this will be disruptive, but for others it can be sustaining. Services once thought to require customization may be simplified by new technology that makes them candidates for delivery in a large-scale setting. The treatment of coronary atherosclerosis once demanded a complicated cardiac surgery procedure performed by highly trained surgeons. Then came simplifications due to angioplasty and stents. This technology found a new home in the practice model of the interventional cardiologist. Cardiologists adopted this technology, while cardiac surgeons did not and probably could not, given their practice model. The technology was disruptive to cardiac surgery. This patient service migrated from the OR to a new setting, the cardiac catheterization laboratory. An interventional cardiologist using stents of various types can treat the same disease in many patients in the same laboratory throughout the day. This service migrated to a large-scale setting because of a disruptive technology.
This same vascular technology has not prompted a similar dramatic shift of services in vascular surgery. Why not? For vascular surgery, angioplasty and stent implantation became a sustaining technology, as the practice model could integrate the technology with only minor alterations. In the adoption of a sustaining technology, the incumbent business model has the advantage. Vascular surgery is the incumbent. For interventional radiology and vascular surgery, stent technology is not a differentiator; rather, the practice models are. Radiologists sometimes complain about vascular surgeons who claim expertise after adopting techniques that interventional radiologists believe were developed by their specialty years ago. No one owns a technology; it has wanderlust and seeks accommodating venues. Radiologists seem surprised when what they see as clear technical superiority on their part does not carry the day in these turf issues. It becomes less surprising, once we see that it is not the technology per se that is decisive but rather the business model in which the technology is successfully embedded.
Currently, interventional radiology and vascular surgery use two distinct practice models to treat similar vascular diseases by means of minimally invasive technologies. The clinical competition between the two specialties hinges not on technical superiority but rather on contrasting practice models. Innovative technology is often misunderstood, and it needs to be reemphasized that the disruptive aspect of a technology is not the technology itself but rather the perturbation of the business models impacted by it. To quote Christensen, the father of the concept of disruptive technology, "[If the innovation] appears to be sustaining to one or more significant players in the industry, then the odds will be stacked in that firm’s favor, and the entrant is unlikely to win" (2). The number of innovative software companies decreased sharply after they encountered the incumbent, Microsoft. At present, patients and referring physicians seem to favor the incumbent model. On the basis of this analysis, it should be clear that the simple duplication of the OR model in the setting of the angiographic suite offers radiologists no real competitive advantage. Radiologists instead should be investigating ways to combine features of different practice models to create a new and competitive one. Interventional cardiologists, as well as some interventional neuroradiologists, have done this by combining customized care with large-scale efficiency. True teamwork, based on the idea of division of labor, which dates back to Adam Smith, contrasts with the solo approach and could yield a means of differentiation. Incorporating a multidisciplinary approach in patient care based on a "tumor board" paradigm, which utilizes a multispecialty team to make decisions about treatment, is another potential tack. As long as sophisticated imaging is a value-added component, radiologists remain in the running to create a new, viable practice model.
Ironically, new interventional radiology practice models are disruptive to the conventional diagnostic radiology practice model. The disruption is heralded by the need to incorporate direct patient care. It is noteworthy that radiologists’ attempts to create new interventional radiology practices have not been without tension and have led to friction between interventional and diagnostic radiology. For a disruptive technology to exist and thrive within a parent organization, a degree of separation is a virtual requirement. This reality must be tolerated. Variants of a practice model necessarily differ and can be successful only if they experience and grow in a different environment. New interventional practice models will need to incorporate direct patient care while leveraging the economies of scale inherent in conventional diagnostic radiology practice models.
While turf issues are often charged with emotion and politics, the fundamental issues really revolve around the practice model. Recognizing this could be salutary for developing a competitive strategy, dealing with extant models, generating new models, and modifying organizational behavior and structure to generate more options. While a variety of business models can and do coexist, distinct practice models serving the same clinical need do not coexist well in the same physical and cultural space. Their respective cultural differences can cause confusion and conflict in day-to-day work flow and behavior. Sometimes it is simply best to let practice models compete and let the customers determine which best fulfills patient care needs in different clinical settings. As healthcare evolves in an uncertain market, the use of variant practice models to deliver patient care services may be advantageous. The greater the diversity of models, the greater the business and intellectual space available for new technologies and other innovations to take hold and grow.
Since radiologists have a tendency to overestimate the importance of technology, it behooves them to expand their understanding of how technology interacts with clinical practice models and why the practice model is the dominant factor in turf issues. Nothing holds radiologists back from creating practice model variants that can exploit their fascination with and expertise in technology.
REFERENCES
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  L. R. Kavoussi, M. Nielsen, and S. B. Solomon Percutaneous Image-guided Urologic Procedures. Radiology, April 1, 2006; 239(1): 11 - 12. [Full Text] [PDF]
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