Dr. Phillips is a Professor in the Departments of Radiology, Neurosurgery, and Otolaryngology; the Head and Neck Surgery Director, Division of Neuroradiology; and Vice Chair of Finance in the Department of Radiology, University of Virginia Health Systems, Charlottesville, VA. He is also a member of the editorial board of this journal.

Given the floor for a moment, and with a broad-based largely radiology audience, I would like to place my two cents upon the table regarding the new generation of "turf battles" being waged by radiology and other specialties. Many specialties have now developed "requirements" for their trainees in traditional radiology roles. A "request for opportunities" in radiology procedures morphs into a training "requirement" over time. We, as radiologists, find ourselves being requested to train other specialties in our procedures. Our payback? These services will continue to send us patients, at least until their own trainees are practicing in sufficient numbers to dominate. The interventional radiologists find themselves particularly hard-pressed for endovascular treatments. Although radiology has done much over time to benefit other specialties, the hospitals, and, more importantly, the patients, we have few friends as these battles wage.

Who suffers? At the outset, plainly, our trainees suffer. They see fewer cases, become more and more disenchanted with these subspecialty radiology opportunities as they see more incursions from other specialties, and the whole chain becomes self-fulfilling. We, as radiologists, also feel that patients suffer. The radiology community has worked hard to develop and perfect many of these techniques, often on patients who had no viable treatment alternative, and often, initially, for little reimbursement. We practice and preach radiation protection, and have been available at any time, day or night, to perform them. Lastly, we, ourselves, obviously suffer. We set standards for expertise and require additional training for our fellows, yet find physicians with 3-month "certification" applying for, and receiving, credentials. We continue to lose procedures and reimbursement.

Although I do not tend to doom and gloom, I have not been able to hear many positive notes on these issues. The professional organizations have little clout, apparently. We could try a similar course as the other specialties. Imagine a directive from the radiology community requiring programs to offer "opportunities" in cardiac catheterization and stent placement, or in performing minor vascular/urologic/biliary surgery to be approved by the Residency Review Committee! But this doesn't seem to be a fruitful course. It seems that our typical response, "radiologists can perform this procedure most skillfully based on their training" holds little sway these days.

I have read and reread a book entitled A Bomb in the Brain (Charles Scribner's Sons, New York), by Steve Fishman, a widely published journalist from New York City. It deals on a very personal level with his intracranial hemorrhage from an arteriovenous malfunction, his subsequent medical evaluation and surgery, and his personal and researched views on a number of medical topics. A section pertaining to the development of neuroradiology as a specialty is particularly pertinent. Early on, neurosurgeons performed neuroangiography, but Dr. Joseph Ransohoff, then chief of neurosurgery at New York University believed that the budding subspecialists from neuroradiology should perform them. Government investigators were actually sent to see why he said so. "Because they do them better," was Ransohoff's response (p. 56).

Perhaps there is no right answer, but much more careful attention to these issues must be paid by the American College of Radiology, the Association of University Radiologists, the Radiological Society of North America, the American Roentgen Ray Society, the American Board of Radiology, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties. We don't want to throw the radiology baby out with the turf bathwater.