Applied Radiology

Considering myself to be both experienced and interested in ethics and ethical behavior, I enthusiastically accepted an invitation to write about contemporary ethical dilemmas of radiologists, only to find that I couldn't even come up with a definition of ethics, let alone a discussion of ethical questions. The subject, in my mind, had a nebulous character, much like my understanding of the physics of MRI: I had a little knowledge and a real interest, but no solid grasp of it. A little research and some time have helped me clarify my own thoughts about ethics. The physics remains somewhat vague.

Ethics are the rules of human conduct, in our case, the rules of professional conduct. Doing what is ethical is doing what is right according to those rules, but I don't think most of us know what they are. Who has formulated or codified them? Who has seen them written or heard them? We were not taught about ethics in our residencies and certainly were not examined for our knowledge of them when we completed our training. Ethics were something we took for granted, and ethical was what we intended to be despite an embarrassing ignorance of the subject. We either learned them in kindergarten or from our mothers. Of course there were the guidelines of the Hippocratic Oath, the Ten Commandments, and the Golden Rule, but for the most part, we were on our own.

For those of us who strive to act ethically in our professional lives, help is on the way, as the American College of Radiology works hard to develop not only a code of ethics but also a list of standards of practice and appropriateness to tell us when and how to carry out examinations. Will these efforts solve our ethical dilemmas? Not completely, but they will provide starting points for ongoing discussions and considerations, and they should facilitate the introduction of ethics into our academic curricula.

Some of the issues already identified by the ACR Task Force on Ethics include managed care, self-referral, billing, advertising, communication, confidentiality, treatment of uninsured patients, group partnership, informed consent, and appropriateness criteria. Each could and will be the subject of endless discussions. But every discussion needs a starting point, and for our discussion that point should be to define the functions of a radiologist. We cannot know what we, as radiologists, should or should not do unless we understand our role. However, a definition of that role is not as simple as we might think because it has to include what our patients and colleagues need and expect from us, as well as what we think we have to contribute. I would like to oversimplify the definition by saying that our role is to help our colleagues diagnose and treat their patients. That is our "raison d'etre." Ours is a supporting role rather than a leading one.

What is involved in this task? First of all, we must be knowledgeable in the appropriate areas of medical and surgical practice so we can converse and consult in a meaningful way. We must know anatomy and appreciate exactly what information our colleagues need in order to diagnose and treat their patients. We must "speak their language" if we expect to be involved in their work. As it is impossible for any of us to know all there is to know in every area of medicine, the trend towards subspecialization within radiology has been absolutely necessary and we must resist any pressures working to reverse it. The degree of subspecialization required of a radiologist will be determined by that of the referring doctors, and each of us must prepare for the medical community in which we intend to work. Unless we are capable of providing meaningful consultations within that community, we are not fulfilling the obligations of our role.

In addition to medical knowledge, we are expected to be experts in the use of the technology available to us. Just a few years ago this was an easy task, but not any more. Our colleagues expect us to be able to select equipment that is the best available for the needs of their patients, to design examinations that will provide exactly the information they need to plan treatment, to carry out those examinations in a safe and efficient manner, and to convey the results to them quickly and accurately. How can we be expert in all the amazing devices available today? The truth is most of us cannot, and we must again be prepared to subspecialize along technological lines. We need CT specialists, MRI specialists, and ultrasound specialists, just to name a few, if we are to make optimal use of the wonderful machines available today. If we do not have those among our ranks who are truly expert in the application of each of these technical miracles, then we have earned no place in their use.

What is our duty to our patients? Whenever a radiologic examination is requested, the patient is our responsibility until that study is completed, interpreted, and reported to the referring doctor. Our job, as we have already discussed, is to perform the examination in such a manner that the clinician is able to diagnose or treat the patient. However, there is another, all-encompassing rule we must obey: do no harm. A radiologist may cause harm to patients in various ways: by allowing them to be physically injured while under our care, by injecting them with harmful substances, or by damaging their organs, for example. However, I suspect the most frequent harmful event is the unnecessary examination. Examinations done with no prospect of assisting diagnosis or treatment are harmful, not only to patients but to the entire healthcare system. How do we eliminate this? We must screen all requests and advise clinicians when they have requested something that we know will not be helpful. For this approach to work, we have to earn the respect of our colleagues. If they know that we have the medical and technical knowledge to reinforce our opinion, they will usually agree; however, if they suspect we are harassing or second guessing them, there will be trouble.

The concept of efficiency, the state of being productive with minimum waste or effort, should be a well promoted concept in all areas of medical practice, although I seldom hear the term used by my colleagues. Efficiency involves not only eliminating unnecessary examinations but also selecting those examinations that will provide the most useful information with the least inconvenience, discomfort, and risk to the patient, and with the least expenditure of time, effort, equipment, and money. It means ending an examination when the desired information is obtained and limiting the number of films, views, or images taken to only what is necessary. It means using MRI only when it will provide important information not available with CT or ultrasound. Surely, to be inefficient is to be unethical.

We have now talked about three principles that describe what it is we radiologists should be doing: 1) do only what helps a colleague diagnose or treat a patient. 2) do no harm, and 3) be efficient. With these in mind, perhaps we can consider some of the questions we face in our practices. The revolution in health care financing is putting pressure on us to change the way we practice, to change in order to survive. The changes we make will have to withstand ethical evaluation if we are to maintain our medical professionalism. It is my hope that most of us do not intend to limit ourselves to becoming prosperous technicians or successful bureaucrats.

Most changes will be attempts to keep our incomes up in the face of falling remuneration due to shrinking fees and fewer examinations. What can we do ethically to maintain income in the face of powerful forces seeking to diminish it? Unfortunately, the obvious answer is to carry out as many lucrative examinations and procedures as possible and collect as much as we can for them. To maximize income, we should promote those studies with the highest number of relative value units and pursue those patients who have insurance that pays the highest fees. We should avoid those patients unable to pay and those who have insurance that pays poorly. We should cultivate those clinicians who request the most radiological examinations and encourage them to make use of our facilities. Although these approaches might be financially rewarding, they are not compatible with our principles and we can not adopt them because they are obviously unethical.

Sophisticated billing is a useful term to describe the maximization of fees billed to those bodies we have come to call third party payers: insurance companies, government agencies, and health maintenance organizations. The key phrase here is the third party payer. We no longer bill patients, but rather their insurers, so we feel no qualms about getting the bill up as high as we can. We want to collect as much money as possible for the work that we do, but the fact that these inflated bills will get paid, one way or another, does not make them morally correct. The fact that a patient's insurance will pay for a costly examination does not mean it is right, just as refusal to pay it does not mean it is wrong. It means that a computer is either accepting or rejecting what we have submitted. We must be scrupulous in our billing and collecting. We cannot allow ourselves to do unnecessary examinations, to take unnecessary views, to recommend inefficient studies, or to inflate our bills. When payers refuse payment or harass us we must confront them and insist on payment for work done. We have to learn to communicate with payers' computers by careful ICD9 coding, but if we allow those computers to determine our ethics, we are making a big mistake.

The problem of uninsured and underinsured patients is enormous. There are over 40 million of these cases and their numbers are rising as managed care organizations exclude as many of the expensively ill as they can. We cannot refuse to perform necessary examinations on these people lest we give up all claim to professionalism. Furthermore, we should be working to encourage our professional bodies to support healthcare programs at state and national levels that will provide universal healthcare coverage. If this is offensive to us, we should ungrudgingly provide free radiology to the uninsured.

Many of our colleagues feel that we are not contributing to their patients' care when we report on their examinations. I suspect there may be some truth in their arguments, such as in cases where I am obliged to report films of patients with installed devices which are unknown to me. We should not close our minds to the possibility that some films do not need to be reported on by radiologists. However, implementation of policy changes to reflect this would have to be done very carefully and experimentally.

Financial pressures are causing other such "turf" battles as various groups or specialties look for ways to increase their incomes. Clinicians have the unique ability to refer patients to themselves for diagnostic procedures, and many of the examinations that we think of as our own can be done by others who can guarantee a steady flow of work. We must emphasize this opportunity for unethical practice whenever we get the chance and educate our communities to its prevalence. I have been surprised to find that medical students are completely ignorant of the concept of self- referral, evidence that this is missing from the ethics curriculum at many medical schools. The fact that all radiological examinations are initiated by clinicians with no financial motive is a most admirable feature of radiological practice, and I don't think we do enough to stress that fact to the rest of the profession. When we involve ourselves in any of the fee-splitting schemes at our disposal, we abandon our overriding claim to ethical practice. Our defense must be to provide expertise, skill, and knowledge, which are difficult to compete with, and to speak out unmistakably when a turf battle threatens.

What will happen to radiology? Be assured that the face of this specialty will change, though the direction has yet to be determined. The fact is that if income from radiological examinations is going to diminish and if digital imaging achieves the efficiencies that appear to be possible, then fewer radiologists may be needed. To survive, we will have to carve out an indispensable place in the overall healthcare picture, but I think we should admit the possibility that oversupply of any medical specialists opens the door to the possibility of unethical practice. AR

Dr. Cumming is Professor of Radiology and Pediatrics at the University of Florida in Gainesville.