World is your oyster, not a barracuda

July 14, 2003

"I've lost my job. Are you guys by any chance looking to hire?""Sorry, Bob, unfortunately no. What happened?""Well, I had kept my job even after the hospital outsourced the ER stuff to Australia.""Excuse me. Sorry to interrupt. Dr. Dick, could you

"I've lost my job. Are you guys by any chance looking to hire?"

"Sorry, Bob, unfortunately no. What happened?"

"Well, I had kept my job even after the hospital outsourced the ER stuff to Australia."

"Excuse me. Sorry to interrupt. Dr. Dick, could you take a look at this CT for me?"

"Come back in 20 minutes."

"But the patient is coding in the CT scanner."

". . . in 20 MINUTES, I said. Go on, Bob."

"Then the hospital cut a deal with a group from Malaysia for plain-film readings during the day, but they still needed someone to do BEs, UGIs, and localizations in the hospital, so I kept my job. Then . . ."

"Dr. Dick, I am operating in an hour. Could you confirm for me the level of the disc on this MRI?"

"I'm on my break. There must be a million films in that folder. If you want to put them in order and hang them on the light box, I'll look later."

"He seemed annoyed."

"Ignore him. Go on."

"Then all the CTs and MRIs got outsourced to India, so those rads were let go, but I still kept my job in the barium pits. Then this year, the Chinese came out with those robotic fluoro units. Soon they were doing BEs from Beijing, and I was out of a job."

"Bob, it's your own fault. When I saw this coming, I played on the paranoia of the medical staff and got them to pass a bylaw that no studies would be sent out of the hospital."

"But overseas competition must have driven down your income, too?"

"I actually made a ton of money in the radiology commodities market. I was so confident that selling blocks of overseas radiology readings on the commodities market would fail that I took out huge short positions. They went down, and I made money. Not because they went out of business, but because the Malaysians drove the prices down further. I thought the Malaysians would go down, so I went short again. I'm really glad to hear the Chinese are doing well. I'm betting bigtime against the Indian contracts, and then I'll retire."

"Dr. Dick, I have hung all the films in order by date and sequence. My surgery starts in 15 minutes."

"Wait. Are those outside films?"


"I'm not going to read outside films that I didn't even get paid for. Give Dr. Chin in Shanghai a call."


"Bob, this is a great hospital to work at, but we get a lot of attitude like that from the clinicians."

Dr. Dick could learn from the Swiss. In 1968, Switzerland had a stranglehold on the watchmaking industry, with a market share of 65% and 85% of worldwide profits. That same year, they invented the quartz watch and didn't even bother to patent it. The makers of the finest, most precise watch movements in the world thought, who would want a watch without any moving parts?

The Japanese, on the other hand, were not hampered by such a mindset. Within 12 years, the Swiss watch industry had less than 10% of the market and less than 20% of the profits. It would never recover.

This story shows the power of disruptive technologies. Few people predicted the impact of microchips, computers, or the Internet. How many of you have considered that your purchase of a hospital PACS may be laying the groundwork for a similar scenario?

Up to now, radiologists' jobs have been protected by geographical isolation. But with digital departments and the ability to whisk images to any part of the world in seconds, your competition is about to become every radiologist in the world.

An article in Business Week described how thousands of jobs are being shipped abroad because someone making $10,000 a year in India can replace a $130,000-a-year Silicon Valley engineer. This article explained how Massachusetts General Hospital is sending its CTs to Wipro Ltd. in Bangalore to be read. The rumor that these radiologists are being paid $15,000 a year created a firestorm, with calls to boycott Mass General and outlaw such a practice.

Even my local IPA sends its medical billing paperwork to India for processing. At one point, a railroad strike in India blocked toner for the printers, and all payment of claims came to a standstill.

History is rife with attempts to restrain trade through boycotts, tariffs, guilds, laws, and even sabotage. In the short run, they may succeed, as Dr. Dick has. But in the long run, his unhappy clinicians will find a way to outsource. Think every hospital needs an inhouse radiologist to do BEs, UGIs, and localizations? Think again. On Sept. 7, 2001, a doctor in New York removed the gallbladder of a woman in France, using telerobotics.

A major U.S. data management company is already developing a business plan to treat radiology as just another opportunity to create a new subsidiary, using its vast experience in moving and processing data abroad. These people are far more sophisticated and better funded than most mom-and-pop radiology practices.

If laws, guilds, and boycotts can't save us, what will? If radiology is becoming no different from pork bellies or soybeans, how can we protect our jobs? The answer is simple: Differentiate yourself from the others. The best way to do that is service:

- Know your customer. No one else can know your customers like you can, because you see them every day. Does Dr. Adams want the angle of the big toe measured on all his films? Then do it for him. If Dr. Gupta wants you to suggest an appropriate follow-up time, then suggest one. If Dr. Kildare wants a kickback, turn him into the feds and collect the reward. (You can't do everything they want!)

- Learn the personal touch. Many radiologists view patients as some sort of foreign life form. They went into radiology to get away from patients. The new consumerism demands that you make a connection with them. Improve your interpersonal skills and empathy.

- Encourage complaints. Walk into a roomful of radiologists and say there is patient/physician outside who wants to complain, and I'll bet you won't see anyone leaping up to deal with it. Yet this is an excellent opportunity to figure out how to improve your practice. Encourage complaints, and you will build a better practice over your competition.

- Know your weaknesses. Does your group lack subspecialty coverage? Do you have trouble providing night coverage? Is your turnaround slow? Then accept the inevitable and hire one of these new groups to actually strengthen your group rather than being afraid of them.

International radiology used to be something done somewhere else, but it is about to reach into every hospital in the U.S., even Dr. Dick's. Are you prepared for that level of competition? Are you prepared to use it to your advantage?

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at or fax at 650/728-7206. He also answers questions posed by readers in the "Ask Eric" column on