Outlining the Future of Rural Radiology
Radiologists harness technology and small-town values to serve patients in rural areas.
They wake up early in the morning and go to bed long past dark. On a given day, they might put a hundred miles on their car, driving dusty back roads to towns called Baxley and Alma.
When they enter a hospital room, they're greeted by people they've met at cookouts or who know their father from the rotary club. Once their work is done, they arrive home and walk through their front door, which has stood unlocked and undisturbed all day long.
Although this could describe a country doctor from a bygone era, it's also the profile of many of today's rural radiologists. These physicians have bucked the trend of urbanization and hung up a shingle in the countryside, where imaging specialists are few and far between. They use such technology as physician portals and voice recognition software to manage their workflow, while meeting face-to-face with patients in a way that urban doctors often cannot.
Country State of Mind
Many radiologists work in sparsely populated regions out of a love for small-town life. Others were born and raised in areas untouched by urban sprawl and wish to remain there. With U.S. migration trends showing higher growth in urban than rural areas, however, it is becoming more of a challenge for practices to deliver high-quality patient care to a dwindling population and remain economically viable.
According to the 2010 U.S. Census, just over 19 percent of the U.S. population resides outside of cities. Between 2000 and 2010, the rural population declined as a share of the U.S. population, while the urban populace increased by just over 12 percent. Despite these numbers, however, many radiologists prefer the close-knit, friendly atmosphere that rural medicine often affords.
Robert S. Pyatt Jr., MD, FACR, of Chambersburg Imaging Associates in Chambersburg, Pa., provides imaging services for two hospitals in an area of slightly more than 175,000 people, covering 1,200 square miles. Pyatt considers being a "country doctor" a state of mind. Before coming to Chambersburg, he grew up in Somerset, Mass., and worked at Bethesda Naval Hospital in Bethesda, Md., two densely populated areas.
In urban settings, says Pyatt, "it's more impersonal; you don't know referring physicians or patients as well as you do in a more rural place. You don't develop that linkage." Indeed, several of his patients over the years have been family friends. "it is not unusual for women who my wife and I are friends with to come in and want to have a mammogram done," he say. "They'll tell the tech, 'Please have Dr. Pyatt read my mammogram.'" Then he meets with them personally to go over the findings.
Gary H. Dent, MD, of South Georgia Radiology Associates, LLC (SGRA), a nine-person radiology practice in rural Baxley, Ga., concurs" "I like working in a rural setting because you can forge a more personal relationship with people. I get follow-up calls from patients all the time. I even get Christmas cards from some of them." And it's not just patients. Dent has known one of his partners since he was five years old, and when recruiting new talent, he makes a point of hiring physicians who want to live in rural Georgia as well as work there. He does this, he says, because doing so "builds inherent trust with hospital staff and patients."
One of Dent's priorities is ensuring that he or one of his physicians is on call to meet with doctors and patients whenever necessary, 24 hours a day, 7 days a week. His aim is to remind doctors and patients that a human being is reading their images. "You can't put a value on having a radiologist sitting in a hospital talking to a referring physician," he says.
By embracing certain technologies, Dent's staff has the flexibility to both work in an office and travel to client hospitals. His practice employs a PACS that generates workflow queues from all 10 hospitals SGRA serves. Since these hospitals cover 15 counties with a total population of 250,000, reading such a high volume of images while trying to maintain a physical presence at hospitals would be impossible if not for this technology, which allows Dent to allocate studies to employees based on their workload at any given moment.
Similarly, Lawrence A. Liebscher, MD, FACR, a member of ACR's Board of Chancellors, chair of the Commission on General, Small, and Rural Practice, and a partner at Cedar Valley Medical Specialists in Waterloo, Iowa, relies on the technological tools to enhance the viability of his practice. A town of 100,000 people, Waterloo is home to Allen Memorial Hospital, which is served by Leibscher's six-member practice. He and one other partner provide imaging services for entities outside of the hospital, including an outpatient imaging center, two critical-care hospitals, and six primary-care facilities. Some of these sites are situated in small metropolitan locations but many of them are in rural areas, and all are located within a 30-mile radius of the practice. Since the remote sites are part of the Iowa Health System, Liebscher has been able to ensure that they are all linked to his PACS.
"As a result," explains Liebscher, "all of the images created at any site simply show up in my work list along with the exams performed at the imaging center where I am based. The rural sites appear no different than any of our other institutions. No one entity has preference over another." In this way, he is able to ensure consistently high-quality image readings for each site. In addition, staff radiologists at Cedar Valley Medical Specialists use voice recognition software tied into their RIS, which all of the medical facilities are plugged into. "So the reports automatically go back to the remote sites immediately and are incorporated into hospital and clinic electronic medical records," says Liebscher. All of this affords small facilities that could not support a full-time radiologist on site the opportunity to benefit from interpretive services with rapid report turnaround while maintaining the close personal relationship between the radiologist, local clinicians, and technical and administrative staff. "I remain an engaged, well known member of the local care team," explains Liebscher.
What the Future Holds
While adding a personal touch can help rural radiology practices survive in tough economic times, some country hospitals have bypassed them in favor of an alternative approach: hiring national or regional teleradiology groups. These companies provide around-the-clock teleradiology services to hospitals, many of which are located in out-of-the-way areas of the country. In addition, the groups employ dozens of radiologists in a range of subspecialties, allowing them to tailor the services they provide to individual hospitals. In other words, the company makes sure that specialists are working on the most appropriate imaging caseloads. This approach is not always possible at small, rural practices, which are usually unable to hire physicians with a wide range of training.
Although teleradiology groups work to deliver final image reads around the clock, enabling greater efficiency to their clients, many rural radiologists are less than upbeat about them. Liebscher hopes that circumstances do not conspire to allow only a handful of large radiology groups to dominate medicine, relegating rural radiology to the margins. For rural doctors, losing a contract with a local hospital "can mean having to move away from family and personal history," he notes. "Teleradiology firms or large regional radiology groups can play an important role in providing support and backup to the small rural practitioner. In such a situation there is valuable synergy. But the threat of being displaced is real and disturbing for small group and rural practitioners."
Times are changing, but there is still a need for radiologists who are familiar with rural America. These physicians are intimately involved in patients' health care in ways that urban doctors and teleradiologists are often not. As teleradiology groups contend for rural hospital contracts, radiologists will have to formulate new business models that can offer financial efficiencies, while at the same time doing what they do best: providing a face to radiology.
By Chris Hobson