In his 1998 novel, A Man in Full, Tom Wolfe offers up a wicked description of a "workout artiste," a mesomorphic banking executive with a rapier tongue who specializes in recovering losses for the lender from delinquent debtors. Wearing suspenders printed with a skull-and-crossbones motif, the artiste deftly disassembles the ego, assets, and composure of the once-imposing real estate mogul sitting before him. This is precisely the sort of fellow you would like to see go to work on the people who were at the helm of Enron, Tyco International, and Adelphia. This is not, however, the sort of man you would like to see restructure the health care system. Ours is a kinder, gentler business whose narrow margins are due in part to the fact that a significant percentage of its services are rendered gratis.

So it is with tongue in cheek that we refer to our cover subjects as turnaround artistes, one a physician and the other an executive administrator, both of whom succeeded in reviving imaging servicesfaltering in one case and failing in the otherat their respective institutions. Beginning on page 11, they tell their stories. When Dr Kessler arrived at Graduate Hospital in Philadelphia, he found an imaging department so demoralized, both emotionally and technologically, that the hospital's own physicians were referring outside the institution. Imaging is not a service that hospitals can afford to lose without a fight, and that is what Kessler and his fledgling practice proceeded to do. As for Mr Couris, he is evidently one of imaging's master team builders, as that is what it took to wrangle a conglomerate of four hospitals, five imaging centers, and three radiology groups, into one smoothly functioning imaging service, seamless across the enterprise of Morton Plant Mease Health Care. We wish them continued success.

Looking out over a cityLos Angelesthat is struggling with its own health care meltdown, what emerges is a quagmire of social, economic, and political issues so impossibly tangled that they defy solution. (Perhaps this is how our turnaround artistes felt when they first perceived the scope of the problems at their institutions?) Faced with a budget shortfall that prompted closure of 11 community clinics and is expected to reach $800 million by 2005, Los Angeles County supervisors have been told by Governor Gray Davis that he will not forward their request for yet another federal bailout until they more seriously consider closing down more clinics and converting two hospitals to outpatient clinics, leaving two working county emergency departments out of a previous five. Not incidentally, the closure of these hospitals would impact the number of residencies available at the University of California, Los Angeles medical school and render homeless a research institute with a budget of $58 million annually that currently supports close to 1,000 research projects and clinical trials.

There are two choices when handling scarce resources: manage or ration. We are inches away from rationing care here in Los Angeles. As federal, county, and state officials continue to sidestep the issues of the uninsured, the administrators of these and other institutions like them do the best they can to keep the boat afloat. Managing and administrating radiologyand health care in generaldoes not command the huge bonuses and salaries that are evident in the corporate world. Indeed, the personal rewards are smaller, and the challenges and responsibilities greater. I encourage you to contact me with your own stories and best practices, so they can be shared with the readers of Decisions in Imaging Economics.

Cheryl Proval

cproval@medpubs.com