In other essays in this monograph, I touched on some of the difficulties radiologists face in trying to determine if what they do is best for patients. The focus of my criticism was not the concept but rather the measurement of appropriateness criteria, the product of a noble effort undertaken through the auspices of the American College of Radiology to offer what some may view as the most proper sequence of tests to reach a diagnosis for many clinical applications. I viewed the methodology as flawed, especially because the criteria are based on radiologists, if you will, “speaking to” but not “conversing with” referring physicians. As a program, appropriateness criteria are deployed in a manner both insular and distant, consistent with our customary practice patterns. We are a special type of medical consultant. Typically we do not see the patient or even know much about him or her before making a judgment about a diagnostic plan. In its present iteration appropriateness criteria will be ineffective until we also establish a formalized reciprocal dialog with referrers. Our remoteness is by itself self-defeating with respect to affecting change for the sake of better rather than more utilization of imaging resources.