Of turf and surf
Dr. White is a Professor of Radiology at the University of Maryland School of Medicine in Baltimore, MD, and a member of the Editorial Advisory Board of Applied Radiology.
A longstanding concern for radiologists is that other specialists will wrest away our imaging business. This problem is not unique to radiologists; other specialists, such as psychiatrists and ophthalmologists, face a similar challenge.
However, radiologists view themselves as the poster children for this issue; it is often said that radiologists introduce and mature imaging technologies, while other specialists move into our turf and appropriate the technology. That statement is not without an element of truth.
For example, when multidetector computed tomography (CT) was developed, enabling cardiac CT to be performed on conventional scanners, there was great excitement that it would replace invasive procedures like cardiac catheterization with a simple diagnostic test. But there was equal concern in the radiology community that radiologists would be displaced by cardiologists.
After all, the earlier technological implementation of cardiac CT, electron beam CT, was practiced by both cardiologists and radiologists,but the cardiologists won control of the patients. Other procedures also evolved from radiology or shared radiology-cardiology models to the single specialty cardiology model—namely, echocardiography and, to a large extent, nuclear cardiology. An objective observer might reasonably expect cardiac CT to follow the same path. However, more than 10 years after multidetector CT was introduced, neither widespread adoption nor wholesale appropriation of cardiac CT by cardiologists has occurred.
A cynic might say, “Wait another 10 years.” However, the current environment is arguably quite different in ways both economically and noneconomically that suggest history may not repeat itself.
When the earlier technologies joined mainstream medicine, for example, the economic climate was far friendlier than it is today, and they were not subject to particularly rigorous validation techniques. The current fiscal situation is far more difficult, and cardiac CT has been scrutinized very carefully. Many studies have shown cardiac CT’s benefits in a number of indications; major cardiac imaging societies have published statements affirming them. Nevertheless, third-party payer coverage has lagged. Indeed, while Medicare has approved cardiac CT for many indications, other insurers have done so inconsistently and haltingly. This variable reimbursement makes it difficult to start and expand standalone cardiac CT programs.A second economic issue relates to capital. Cardiac CT scanners are far more expensive than echocardiography and nuclear cardiology equipment. It is impractical for a practice to place such a scanner in an outpatient setting and expect to generate a profit on referrals from that practice alone unless the practice is very large. Moreover, self-referral rules in some states make it illegal for cardiologists to refer patients to scanners owned by those same physicians. Thus, cardiologists must either convince hospitals to purchase CT scanners for them or compete for space on scanners shared with radiologists.
Noneconomic issues also cloud the picture. Cardiologists must find time in their busy schedules to interpret cardiac CT scans. True,cardiology groups have become more specialized, making this a surmountable challenge. Nevertheless, cardiac CT interpretation is time consuming and requires Level 2 American College of Cardiology (ACC) certification. Also, compared to radiologists, cardiologists are less familiar with the cross-sectional presentation of CT and the technical and radiation-related considerations needed to produce optimal studies. A unique aspect of cardiac CT that also causes difficulty for cardiologists is its clear depiction of extracardiac anatomy. Even a field of view tightly coned to the heart includes some portion of the lung, mediastinum, bones, and the upper abdomen, and even cardiologists trained in cardiac CT have minimal experience with imaging outside the heart.
So, what is the current surf like for cardiac imagers? Today an uneasy—in some cases, unholy—alliance exists between cardiologists and radiologists. Several models exist, with some weighted toward radiologists, some weighted toward cardiologists, and still others weighted toward a shared approach. The radiologist-weighted model is straightforward: Like other physicians, cardiologists refer patients to radiology practices where the CT scans are performed and then interpreted by the radiologists.
In the cardiologist-weighted model, the cardiac part of the study is interpreted by the cardiologist, and the extracardiac parts are over read by a radiologist, before being signed by the cardiologist. This model excludes the radiologist from interpreting cardiac CT—a fact viewed by many radiologists as undesirable. But it does provide some compensation and potentially valuable experience in observing cardiac CT.
In the third scenario, the reading is shared; in some practices, cardiologists read on certain days and the radiologists read on others. In other practices, they interpret as a group while rotating the billing responsibilities. The model at a particular site is usually an outgrowth of history and local politics; I know of no formal study evaluating the frequency of each arrangement, but my impression is that the radiologist-weighted and hybrid models are more common in larger academic hospitals.
It is optimal when both radiologists and cardiologists can contribute to patient care. In cardiac CT imaging, this can be done if both parties have the appropriate collaborative attitude. Sometimes this is not possible, and when the surf gets rough, radiologists have to look elsewhere, such as to internal medicine, family medicine, and surgery, to build cardiac CT volume.
Ultimately, however, the biggest error that radiology as a specialty can commit is to fail to provide the education and society support to stake our claim to cardiac imaging.
It is our responsibility not to abandon the turf.