_{Published on January 22, 2021}

Alexander Norbash

2020–2021 ARRS President

I cannot get the image of the raging forest fires out of my head, even though I saw the carnage from the safety of my sofa on my iPad. Even so. And a close friend of mine lost his house and everything within it, leaving with only the clothes on his back and what little he and his family could carry. And he is grateful that his family lost no lives that day. Literally today, 12,600 firefighters are fighting 14 major wildfires in California, which have already claimed more than 4 million acres. Twelve-thousand firefighters in California alone. That is about half the number of radiologists in the entire U.S. And 4 million acres? Rhode Island has a surface area of less than 1 million acres, Delaware slightly under 1.6 million acres. Even Connecticut is slightly below 3.6 million acres. Our country is on fire, and we go about our daily lives…

What do forest fires have to do with radiology? I submit that health care may be more akin to an uncontrolled forest fire, rather than the controlled and carefully harnessed fire in a foundry that allows us to forge steel and alloy.

Natural questions include pondering the nature and distinction of solvable and unsolvable problems, as well as attribution. When do you stand by and watch a forest fire consume your house, and when do you fight it without endangering your life and health? Couldn’t anything have been done to prevent this? Can’t anything be done to fix this? If solvable, is the solution really cleaning forest floors, ridding them of combustible biomass before flames have a chance to perform the same function? Is this really attributable to global warming, and is it too late to do anything? Are forest fires even a necessary evil that allows renewal and rebirth, despite the massive sorrow accompanying the human experience?

Although a raging forest fire is terrifying, especially when you are fighting the fire and sense it closing in on you from all sides, a single candle’s dancing flame is hypnotizing, and its generation of light and energy is magical. A collection of votive candles can be moving and sacred. A campfire can be comforting and protective. I recall many campfires I sat around as a boy scout, where we shared stories, enjoyed each other’s company, and felt both close to nature while safe and comfortable. Even though there was a dark silence surrounding us, inside that cylinder of light and warmth projected by the campfire was the illusion of safety. If you will forgive the analogy, although our health care ecosystem from a 30,000-foot perspective may be a forest fire, the single flame of an individual patient interaction or single health care encounter is sacred and at times life-affirming for those of us who are moved by the nature of trust patients place in our hands.

For those who have not visited San Diego, we are arid and considered a coastal desert, and our terrain is varied, including steppes, buttes, mesas, and multiple valleys. As you would surmise, we are situated in close proximity to a number of mountain ranges. As you ascend on drives in these mountains, at higher elevations, you encounter beautiful forests. Whether driving to Mount Palomar, which houses a spectacular astronomical observatory on top of a peak, or the Anza-Borrego Desert 90 minutes northeast, the majesty of nature is undeniable. As you drive through our pine forests, spectacular vistas come into view, and off to the sides of the roads, you can’t help but notice groves with massive trees showing charred trunks. Where these charred trunks are found, the undergrowth is different. There is little brush, there is filtered and streaming light, and oddly enough, one finds fields of wildflowers in these clearings. Many decades ago, I recall reading Norman Maclean’s Young Men and Fire, regarding the 1949 Mann Gulch Fire. This book is a management mainstaple regarding tactics, leadership, communication, and learning systems. Several of the preventable fatalities were attributed to firefighters refusing to chuck their equipment and heavy packs in order to lighten and therefore save themselves. So many unnecessary casualties—a costly lesson for future literal and figurative firefighters. Do we learn from each other? Are we willing to jettison our heavy and cumbersome conventions to save ourselves?

Perhaps health care is somewhat analogous to a forest fire raging out of control. Some of us feel a sense of anxiety about the unpredictable winds of the future and how they will affect us. There are many changes perched on our doorsteps, preparing to hit us hard. Whether planned evaluation and management code adjustments threatening us with over 10% of our income this coming year, Rad Partners and MEDNAX merging 10% of all U.S. radiologists into one consolidated supergroup redefining the structural nature of practice, or large-scale venture capitalist and hedge fund purchasing of radiologist practices affecting our autonomy, we lack control and fear for our safety. Similar to a clearing forest fire, perhaps we’re in for rupture of our status quo as an essential step in reordering the foundation and practice of radiology.

Certainly, the COVID pandemic has significantly changed our academic practices, and who knows which of the changes we are seeing will be durable and which will be enthusiastically thrown out at the earliest possible opportunity. Have the COVID pandemic, civil unrest, and financial crisis all served as combustible agents where health care and, more specifically, imaging are concerned? The COVID pandemic has directly affected our financial practices and our procedural practices, underscoring inequities in care that have resulted in extraordinary mortality rates where the disenfranchised are concerned. Civil unrest has reminded us of these same persistent inequities in care. The financial crisis; more of the same. It is natural following a crisis, perhaps even more so following multiple simultaneous crises, to discuss and understand what we have learned. We are midstream and in no way past our crises, nevertheless, it helps to elevate our vision and see where we are heading as an essential exercise and to grant us temporary respite from today’s challenges. If nothing more, at least it allows us to lift our optimistic spirits, instead of suffocating under the weight of what is undeniably present in today. Perhaps in looking to tomorrow and moving toward action we should focus collectively on how we can provide the best possible care to the largest number of patients. I submit that the central reason for the forest fire which is health care could well be inequity in care delivery, misbalanced and at times exaggerated profitability, and a lack of effective population health. Does the public know about radiology, care about it, and fight to protect and elevate it? This repair work necessitates my personal engagement as a single radiologist. This demands my involvement in driving down costs, attempting to ensure the propriety and efficiency of imaging in each case, and eradicating inequities as much as possible. No one else is picking up the ball and confidently addressing the issues. Regrettably, these actions are neither natural, nor have they really been expected of me to date. My job to date, as an individual radiologist, has been to manage worklists, ensuring that individual dictations are correct. That said, if I focus on my work RVUs and bonus, and do not ensure the essential and full appreciated value of my contributions as a radiologist, will I be effectively valued?

I’m sorry to end with a cliffhanger; a question to which I do not have a ready answer. What can I do, apart from drilling down on my worklist as an individual radiologist, to serve the largest number of patients most effectively, or has my campfire already contributed to the creation of a massive and clearing forest fire? I fear the response to this question will determine whether we become giant redwoods, or whether we will feed fields of flowers.