Essays

Essays May 2012

Prescription for Sustainable Medical Imaging in Canada? Ask the Experts: The Radiologists

Deljit Dhanoa

The old aboriginal adage "Don't judge a person, until you've walked a mile in his moccasins" aptly applies to the opinion piece by Mr. Will Falk1. The radiologist's role is poorly understood by laypeople, policy makers and physicians in other specialties. To make sweeping statements without fully understanding the purpose of the radiologist is damaging not just to the medical specialty itself, but also, to the health of Canadian patients.

Traditionally, radiology was defined as the medical study (logos) of radiation (radius or radiatio). The radiologist is a unique physician who interfaces between the technical aspects of radiant energy and transforms the pixels of light into an intelligible diagnosis that other physicians and patients can understand. The services that radiologists provide reach far past interpretation of the images they oversee. Radiologists are responsible both ethically and legally for the appropriate arrangement of tests (called "prioritizing" and "protocolling"), the quality of imaging studies produced, and patient safety issues surrounding the acquisition of each study including complex subjects like nephrogenic systemic fibrosis and contrast induced nephropathy. These are daily concerns that most non-radiologist physicians do not appreciate. Radiologists are also the primary providers of image guided procedures and therapies including those that facilitate dialysis, performing cancer biopsies, inserting intravenous lines for medications, angiography and angioplasty as well those that destroy tumors using image guidance. This collection of knowledge and skills are not transferrable to other specialities on an ad hoc basis any differently than expecting a family doctor to perform open heart surgery or an geriatrician to deliver a baby.

It has been suggested that non-radiologists are capable of replacing the daily function of a radiologist. From my years as an emergency physician, and now as a practicing radiologist, it is clear to me that other specialists are not just unaware of the patient risks and benefits associated with imaging studies but are also ill-equipped to interpret imaging abnormalities, especially those outside of their field of training. Furthermore, requesting that a non-radiology specialist interpret studies, their time will be diverted from their regular patient care responsibilities thereby making them less efficient doctors. Additionally, the suggestion that the practice of radiology be farmed out to physicians who specialize in specific body systems would not just jeopardize patient safety but would increase costs, especially by self-referral. Physician self-referral is the practice of a physician ordering tests on a patient which are performed by himself or a facility where he has a financial incentive for the referral. Proponents of delocalization of the interpretation of medical imaging should familiarize themselves with the works of David Levine and Vijay M. Rao.2 Levine and Rao's position, which has been proven correct in the United States of America, states that the utilization of diagnostic imaging dramatically increases when medical imaging is decentralized due to the problem of self-referral. American policy makers have been scrambling to limit the number of self referral medical imaging studies since these studies have substantially increased costs south of the border. The decentralization of medical imaging would recreate a problem the United States has managed to finally limit after years of false starts and challenging negotiations. An example of self referral more close to home is the emergency physician using ultrasound in Canadian emergency departments. Will Falk's argument implies the emergency physician, who is the "expert" in emergency medicine, should be providing the imaging exclusively for patients in the emergency department. The ACEP (American College of Emergency Physicians) has already created numerous billing codes for emergency physician ultrasound and it would not take long for the CAEP (Canadian Association of Emergency Physicians) to fabricate similar codes. In fact, the emergency physicians in British Columbia have already attempted to bill for their ultrasounds. A typical emergency department visit for abdominal pain is billed as $29.52 in British Columbia but with an "ultrasound mill" in full operation the emergency physician adds an extra $54.50 per abdominal pain almost doubling his cost to the system with questionable benefit3,4. According to the provided reference3 Ontario emergency doctors are already apparently billing their provincial government for their emergency department ultrasounds. An ultrasound trained emergency doctor assessing a patient in circulatory shock could bill the system multiple codes justifiably following Mr. Falk's logic.5 Clearly the "digital physical examination", where the emergency physician uses his ultrasound machine to diagnose each patient arriving in the emergency department and then demands compensation from the public healthcare system, is wrought with disaster.

There has also been an inaccurate implication that the practice of radiology follows Moore's Law1. Moore's law is a technical rule stating that the number of transistors on a chip doubles every 24 months. While this has held partially true in computing and can arguably be applied to medical imaging hardware, the assertion that it applies to the human brain analyzing medical images is false. Although data density on a chip may have doubled every 2 years, the evolution of the human brain has remained stable since 1965. The engineering specification for developing a CT scanner may follow Moore's Law but the medical practice of radiology cannot since it is the human brain that interfaces with the CT scanner. If an analogy is to be drawn using scientific law then the law of conservation of energy would be a more accurate comparison. In short, when enhancing technology there is a trade off; one cannot realize a benefit without realizing a cost elsewhere similar to how energy is not created, only conserved. Such is true in the practice of modern radiology as the authors Fine, Symons and Prieditis have eloquently stated6: the more sophisticated diagnostic imaging becomes the more complex the studies are to interpret. If anything Canadians are obtaining significant value for their taxpaying dollars as radiologist's fees have not increased proportionately to the technological complexities of diagnostic imaging machines. In addition to this, radiologists are more frequently being relied upon for their consultation services 24 hours a day, 7 days a week, 365 days a year with most provinces and territories not paying extra premiums for this service. This is a significant bargain for governments when comparing services in other private and public industries across the country. What is the premium a plumber collects for a plumbing emergency on Easter weekend? A garbage collector during a public holiday? The last time my furnace broke down on a cold Boxing Day three years ago, 15 minutes of labour and the $10 replacement part I could have purchased myself cost me over $500 due to the premiums added on for the holiday service. To suggest that the radiologists' fee schedules should decrease given the increased complexity of the technology and the extra afterhours work provided is rhetoric from individuals who do not understand the role of the radiologist or her valuable contribution as a central pillar in modern day medicine.

The one point I can agree on with Mr. Falk is that the appropriate utilization of medical imaging needs to be examined in greater detail. Until this issue is fully examined the seemingly rash conclusions drawn regarding the reform of the current practice of radiology should be withheld. The irony of Mr. Falk's article is that at the very institution he quotes, the University Health Network, I was involved in a project which addressed the topic of appropriate utilization of medical imaging. Unfortunately, any benefit derived from that initiative is no longer of value in Ontario due to the reflexive nature of healthcare leaders delisting specific imaging studies and dismantling our healthcare in the process. It is the work of some policy advisors, such as Mr. Falk, who have fueled the politicians to hit the panic button and, rather than let the clinical scientists develop an evidence based, reasonable approach to utilization of medical imaging, the politicians have unfortunately delisted crucial medical tests in Ontario and leaders in other provinces are contemplating following suit.

Before policy makers deconstruct our healthcare system further by delisting additional services and throw open the doors to privatized healthcare additional work must be done to address our current sustainability issues in healthcare both on the provincial and federal levels:

CALM: all parties involved, including policy advisors, should exercise calm and avoid reactionary decisions based on wide sweeping statements and should incorporate opinions from all sides of the table in a timely fashion before the next round of action is taken.

COSTS: promote bulk purchasing of medical imaging equipment and software solutions across regions to limit costs much the way this process has been maturing in pharmaceutical and other medical equipment purchases. Also limit self-referral by maintaining interpretation from an unbiased imaging expert, namely the radiologist.

EDUCATION: we need more physician educated health policy makers as it is the physician who understands what it is like to be the clinical scientist, the guardian of patient welfare, and the gatekeeper of appropriate resources. We could use additional assistance of policy advisors, such as Mr. Falk, to help educate and mentor more young doctors to enter the realm of healthy policy.

APPROPRIATENESS: more work needs to be performed by radiologists along with policy makers to assist in the creation of practical recommendations to guide clinicians on appropriate utilization of medical imaging. It is the on-site radiologist who must liaise with local medical leaders and administrators to implement and maintain these guidelines.

QUALITY ASSURANCE: the formation of quality assurance radiology atlases should be created where quality assurance initiatives can be developed through regional networks and benchmarks for quality indicators can be compared. It is the on-site radiologist who will continue to be responsible for the quality assurance of all imaging studies and imaged guided procedures and therapies.

LEGAL REFORM: the legal defense of physicians who follow appropriateness guidelines for medical imaging should be bolstered to limit the practice of defensive medicine and inappropriate testing. This should also include rigorous defense for radiologists who decline to perform studies in the appropriate clinical setting.

Finally, the economic solution of tendering bids for radiology services has also been offered as a cost control mechanism by policy advisors. While this gamble may control costs in the short-term this solution will diminish patient service and compromise quality . Competition in markets cannot be sufficiently controlled by government as much as policy advisors would like to believe. Subsequently, medical imaging will be commoditized and quality sacrificed as competing imaging service providers cut corners during the "race to the bottom" of the price wars7. In addition, when medical imaging groups provide remote consultations the local hospital loses the added value that the on-site radiologist provides; including the cost-effective image guided procedures and therapies. Competition is a core value in Western society, but rather than focusing on price to balance a short-term provincial or federal budget we should focus on quality of care as a long-term sustainable strategy. To suggest that medical imaging in Canada can be commoditized jeopardizes the quality our patients expect to receive and emphasizes the lack of understanding of the added value radiologists bring to Canadian healthcare.

Modern medicine has been transformed into an imagecentric vehicle which the radiologist is best suited to guide as it is she who truly understands the advantages and limitations of sustainable digital imaging. Policy makers should partner with radiologists to realize a long-term plan for appropriate medical imaging before irreversible decisions are imposed. Rather than referencing Moore's law, the aboriginal proverb regarding walking in another person's shoes applies to the practice of radiology and its transformation. And there is no better advice to follow than the wisdom of our Canadian ancestors to address the sustainability of our national healthcare system.

References:

  1. http://www.longwoods.com/content/22475
  2. David C. Levin and Vijay M. Rao. Turf Wars in Radiology: The Overutilization of Imaging Resulting from Self-Referral. J Am Coll Radiol 2004;1:169-172. http://www.qualityimaging.org/analysis/TheOverutilizationofImagingResults.pdf
  3. http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/pdf/6-emergency.pdf
  4. https://www.bcma.org/files/Emergency_Medicine.pdf
  5. Peter J. Mariani. Ultrasound Use and “Overuse”. West J Emerg Med. 2010 September; 11(4): 319–321.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967680/
  6. http://www.longwoods.com/content/22892
  7. Forman, HP. et al. Masters of Radiology Panel Discussion: The Commoditization of Radiology. AJR April 2011 vol. 196 no. 4 843-847. http://www.ajronline.org/content/196/4/843.full

 


About the Author

Dr. Deljit Dhanoa, BASc, MD, MBA, CCFP(EM), FRCPC, DABR is a former emergency physician and Assistant Professor at the University of Toronto who is now a practicing radiologist with special interests in health policy and appropriate utilization of diagnostic imaging.

References

See additional essays and commentaries on this subject at these links:

Radiology as an Example of Moores Law in Healthcare - Getting to Sustainability by Will Falk 

Comments

Will Falk wrote:

Posted 2012/05/28 at 06:53 PM EDT

This article inaccurately quotes my prior work. That work says that there is a Moore's Law analog at play in parts of healthcare not that Moore's Law is directly applicable to radiology. I have written on the notion of Moore's Law applied to healthcare in a number of articles. To be fair, my radiology-specific article is not as clear on this point as my other writings (available on mowatcentre.ca).

On the subject of decentralization of radiological interpretation. It is clear that a number of specialties are quite appropriately taking on a role in image interpretation. I agree wholeheartedly with the author's point about the dangers of overuse ("milling" as the author calls it).

I am in agreement with a number of other policy points made by the author. Clearly appropriateness, QA, bulk purchasing, and the other suggestions all merit a lot more time and policy energy. I think that this article adds to the ongoing discussion and welcome that.

Radiologists have made huge improvements on behalf of patients and have greatly improved care and diagnosis. This is the results of thousands of hardworking physicians and others.

Let's continue the policy and clinical discussions and improve the value of care for all.

 

Del Dhanoa wrote:

Posted 2012/05/29 at 01:08 AM EDT

Hi Will,

I apologize if you believe my work has inaccurately quoted your article. This is why I used the word "implication".

"There has also been an inaccurate implication that the practice of radiology follows Moore's Law..."

Regardless of what you have written in your articles; you have the Minister's ear.

The interpretations your listener's perceive from your writings and opinions have the potential to significantly impact healthcare and not always for the best.

History has proven this last month: Deb Matthews' actions imposed against radiologists using the arguments that technology has made our work "easier" when, in fact, it has made it more complex.

 

Antony Raikhlin wrote:

Posted 2012/05/29 at 01:30 AM EDT

Will Falk published an essay, titled: Radiology as an Example of Moores Law in Healthcare
In his reply above however, Mr Falk now claims that he's been "inaccurately" quoted and that he never said that Moore's Law applies to radiology. Interesting choice of title then...

 

Derek Ritz wrote:

Posted 2012/05/29 at 01:46 PM EDT

I'm sorry if I am missing some nuanced points of policy -- but there seems to be a bit of inconvenient arithmetic here that is the "elephant in the room".

Radiologists that are paid on a fee for service basis have seen their incomes rise (dramatically!) because of efficiency gains that came about as a result of public monies invested in DI/PACS systems. These professionals are neither working longer nor harder -- but they are getting paid more.

There is an analogy (from Mr. Falk's article, cited above) that usefully frames what we should be re talking about here: it is like paying pilots by the mile, and then (with public money) replacing their twin-props with jets.

Surely THAT situation doesn't make sense to anyone, does it Dr. Dhanoa?

 

Antony Raikhlin wrote:

Posted 2012/05/29 at 08:44 PM EDT

Hi Derek,

I am a radiology resident in my final year of training, so I have some perspective as well.

DI/PACS has improved efficiency in that it allowed radiologists to move from one study to the next more quickly (i.e. it is faster to click a button than to manually mount films on a lightbox). But no technology (that I’m aware of) has yet replaced the human brain nor increased its processing prowess. There is a finite limit to how fast one can process information. Radiologists are not machines on an assembly line. Radiologists are tasked with carefully inspecting, analyzing, and scrutinizing every image of every study to detect disease and to synthesize their findings into a potential diagnosis. Whether you’re looking at a computer screen or film on a lightbox, the amount of time it takes to inspect each image is about the same. However, as others already pointed out - and what Mr. Falk, Mr. Drummond, and their ilk fail to recognize (or at least publicly discuss) - is that the complexity and the number of images generated for each study has increased many fold (also, thanks to improved technology of modern CT and MRI scanners). This of course benefits our patients since it gives us the tools to detect lesions/disease that were previously undetectable. But it did not make the radiologist’s job easier. On the contrary, it has become more complex, and in many instances, the overall interpretation time per study has increased accordingly.

With regards to public money being used to upgrade to DI/PACS – well, it is because it primarily benefits the PATIENTS (not the radiologists). Having digital images as opposed to hard-copy film ensures that they are more easily stored (cheaper for the system and less likely to get lost), transferred from one location to another (eliminating wasteful duplication of studies), and are available for comparison later on (again, giving the radiologist a more powerful tool to arrive at the correct interpretation). And as already mentioned, each of these digital images now offers a wealth of new information (e.g. improved resolution/contrast, post-processing, reformatting, etc) – again, great for patients, but more complex work for the radiologists.

I hope this clarifies that comparing the work done by radiologists to pilots getting paid per mile is completely invalid. A more direct analogy would be to compare a radiologist to any other doctor who transitioned from seeing 5 patients per hour to 10 patients per hour because of increased efficiency of his/her office staff. I think it is clear to most that the doc in the latter scenario IS working harder. And many are also working LONGER.

 

Janet Lawrence wrote:

Posted 2012/05/29 at 09:27 PM EDT

I feel I must correct a misconception that Mr Ritz has about the reason for increases in radiologists incomes over the last several years. Firstly radiologist fees have not increased appreciably for as long as I can remember. They are not billing more per case. The only cause of any income increase has been as a direct result of a larger volume of studies interpreted and procedures performed. Some of this increase is as a direct result of the increase in MR hours provided by the wait-time initiative. The government funded longer operating hours for many MRI machines in the province as part of this program, and more patients were scanned as a result. Radiologists are now seemingly being blamed for this.

As Dr Dhanoa correctly points out, while there has no doubt been increases in efficiency with the advent of PACS, there has also been an increase in complexity of cases and number of images to interpret, due to improvements in the quality of medial imaging machines. This has counter-balanced the increase in productivity due to PACS. Contrary to what Mr Ritz believes, it now, in many cases, actually takes longer to read a study (especially for CT, MRI and ultrasound) than it did 10 years ago. Take ultrasound as a perfect example: The improvement in technology has drastically increased the the ability to "view" human anatomy and pathology. The radiologist can see much more detail, and therefore is now responsible (in conjunction with the ultrasound technologist) for evaluating all that anatomy and finding any abnormalities present. This takes time.

Radiologists are most certainly working harder and longer than ever before. I know because I have been one for the past 19 years. We are much busier on any given day. As well at the hospital where I practice there is now at least one radiologist on site in the hospital until at least 9 pm daily to provide rapid reporting for emergency and inpatients, and the on call radiologist is not infrequently awake during the night providing interpretations for our emergency physicians.

 

Jane Sauder wrote:

Posted 2012/05/29 at 10:40 PM EDT

PACS, introduced in the 1990's, arguably improved radiologist efficiency back then. There have been numerous studies on this, most show efficiency improvements of around 10% when PACS is first introduced. However, some have demonstrated efficiency decreases. Will Falk choses to cite the same single paper showing a 30% improvement in effiicieny, but there are numerous other papers with variable numbers. It also depends how you define efficiency. True efficiency is the time to produce one product (in this case one interpretation). PACS has arguably improved the radiologist ability to look at a single image, but since the implementation of PACS the number of images per study has increased by 500 to 700%. The actual time to interpret a study has increased and therefore efficiency per study has decreased. The real reason radiologist billing (and billing don't equal income) is the massive increase in utilization.
If one has wants to look at physician compensation, don't just look at the radiologist. Radiology has made other physicians jobs easier. The professional fees for other physicians were based on taking a history and performing a physical exam. Now, as a result of radiology, the physical exam is truncated and imaging is ordered instead. I have not heard Mr. Falk suggest that other physicians should have their fees reduced because they no longer perform physical exams, just order a CT or MR. Every day a physician walks into my office to review images. I will ask "What is the patient like". The usual response is "I haven't seen them yet". Imaging has now replaced the physical exam.

 

K Wong wrote:

Posted 2012/05/29 at 11:25 PM EDT

Mr. Ritz, the "elephant in the room", of which you speak of, does not exist. There is a gross misconception with respect to how technology has made a radiologist’s job easier, not only in the public’s eye but also within the medical profession. The improvements in technology have no doubt resulted in dramatic improvements in image quality, the time it takes to acquire an image and the efficiency at which a radiologist is able to work. It, however, has not decreased the time it takes a radiologist to view and interpret those images. Most will argue it has actually lengthened the time. Not only are we reviewing hundreds of more images now, but the images also are more detailed and contain more information. The images acquired by the machines today would be equivalent to a 20 megapixel camera vs a 1 megapixel camera of the past. Intuitively one would think that it would take less time to review a study since the images are more detailed and sharper. However, the opposite is true. Let’s say for example I gave you a photograph of a crowd of a few hundred people in Time Square and I asked you to find the person in the image who is wearing a hat with a feather in it. Which picture would you spend more time looking at, the somewhat blurry image where your chances of finding that hat are low (since the hat blends in with other objects in the image), or the sharper image where you can not only distinguish which individuals in the crowd are wearing a hat but what type of hat they are wearing? I suspect that you would spend more time on the sharper image since there is actually a reasonable chance that you could find that hat. I do the same exercise on a daily basis looking for pulmonary nodules, liver lesions etc. Technology has not made my life easier.

While is true that a PACS systems allows me to be more efficient at work, technology has not assisted me in interpreting the images any faster. Radiologists are renumerated for their time, skill and ability to interpret the images. They are not renumerated based on the time it takes to acquire the image.

The analogy of the pilot is an erroneous one, and cannot be translated to a radiologist. Yes, we have new machines which are faster (twin props vs jets). Yes, the machines are more technologically advanced. Where the analogy is flawed is that the time it takes to get from point A to point B is not any faster for the radiologist (the time required to interpret the study). The best analogy I can think of is a Blackberry device. A Blackberry is a great piece of technology which allows you to do office work on the go. You can send emails anytime of the day and from anywhere. Even when you leave work you can continue responding to work emails. You are much more efficient at your job because of this device but are you working any less? In reality you are either working longer hours or you are more efficient while you are working. Not only are you able to do work outside your office, you are likely receiving more emails than ever before. The same analogy holds true for a radiologist. Because of technology, I can now access images effortlessly in my office and from home. Other physicians can now reach me anytime of the day or night to request a CT or MRI, and the subsequent report. What technology has not allowed me to do however, is interpret the images any faster. That would be equivalent to saying that a Blackberry device has not only made a worker more efficient by being able to respond to emails anytime of the day, but the content of the emails has become less complex and shorter due to improvements in technology! Clearly this logic is flawed.

While most radiologists agree that fiscal restraint is required in difficult economic times, what we do not agree with is that technology has made our lives easier. To improve heathcare delivery in Ontario while maintaining costs, Deb Matthews should work with physicians, not against them, to develop long term solutions for sustainable healthcare in Ontario.

 

David Jacobs wrote:

Posted 2012/05/30 at 12:52 PM EDT

We run our practiced based on an relative value unit system. When we converted from analog to digital mammgraphy, we had to double the units allocated to mammography as the time to read the studies had doubled. So much for Moore's law!

 

Solaiman Talut wrote:

Posted 2012/05/30 at 03:41 PM EDT

Mr. Ritz, Radiologists are not the ones driving physician utilization. The fact of the matter is that more and more imaging studies are being performed than ever before. We can argue what is driving this (medicolegal liability, overworked physicians under pressures to see more patients ordering more imaging studies, pressure by patients). Referrals are what is driving radiology costs. Radiologists are human and can only work so fast. They read more studies because they work long hours providing care for Canadians. How much faster are ER docs at seeing patients or surgeons at operating because of newer technologies?

 

Mark Fruitman wrote:

Posted 2012/05/30 at 05:26 PM EDT

Mr. Falk, the problem is that while you may intend to initiate a conversation, the MOHLTC is already implementing your ideas, to the detriment of patients and physicians alike.

You may be aware that the MOHLTC has proposed tendering radiology to competitive bids in 2014, an idea that seems to be taken directly from your essay. This will undoubtedly lead to the corporatisation of radiology. In Australia, this has resulted in a consolidation of radiology groups into a few publicly-traded radiology providers providing the vast majority of the imaging services in that country. Radiologist remuneration initially decreased, but then dramatically increased as poor compensation created a radiologist shortage. The middle managers and shareholders do not disappear however, and still need to be paid. It is not clear that this will save money in the long run. In fact, the lack of corporate middle men is often cited as one of the great efficiencies of the single-payer system. There have also been numerous complaints that the corporate service providers compromise quality of care for profits.

I further disagree with your suggestion that subspecialty clinical expertise translates into expertise in imaging. In my experience, non-radiologist physicians overestimate their ability to interpret images, even within their subspecialty. I have seen countless examples of errors that occurred because radiologists were not consulted prior to a clinical decision; or worse, because the radiologist was ignored. If non-radiologists are now to be compensated for interpreting these studies, you can be assured that this overconfidence will increase. Furthermore, there are often incidental findings that subspecialist physicians are not trained to detect. A heptaobiliary surgeon may not identify an incidental renal cell carcincoma; a cardiologist may not detect interstitial lung disease on the coronary CT angiogram.

I would also like to address the "pilot and jet plane" analogy, an analogy that I consider deeply flawed. It is the efficiency of the machines that has increased. So more scans can be performed per unit time. This benefit accrues to patients (who have increased access) and hospitals (who can perform a greater number of studies at a fixed cost) but not the radiologist. The radiologist's brain is forever a "turboprop", and cannot work any faster.

The increase in radiologist remuneration began when the government mandated increased access to imaging through their Wait Time Initiative. The government mandated that radiologists perform more imaging studies and therefore work harder. Radiologist remuneration increased. The latter is an anticipated and logical consequence of the former. There is no question that our working hours have increased. I routinely do two hours of work at home a night that I never did five years ago. We are offering coverage longer into the evening. Our call is busier. You do not appear to even have attempted to determine whether increased radiologist working hours could be the cause of increased remuneration; you have assumed that because the efficiency of generating the studies has increased, the rate of interpretation has also increased. Where is your evidence?

By all means, let's have a conversation. But please let's make it clear that the conversation is in the early stages. The government is acting as though the conversation is over and we are ready to act. People are going to be hurt by this. I urge you to to clarify your position.

 

D Durant wrote:

Posted 2012/05/30 at 06:16 PM EDT

The interpretive and patient management skills of radiologists are acquired in the same manner as those of physicians practicing any other specialty: through hard work, sound teaching, repetition and examination. It is therefore unfair, untrue and dangerous to assume that one can acquire sound image-interpretation skills by simply looking at a lot of pictures without the knowledge obtained through an accredited DI training program. The same applies to imaging guided procedures: I have seen seasoned surgeons fail to place a percutaneous drain under ultrasound guidance, a skill every radiology resident possesses on completion of training.


Further, as a fairly recent graduate of an Ontario DI program, I can vouch for the fact that the workload of the radiologist has steadily increased over the last few years, due to increased demand by referring physicians and the public. There is also more pressure on radiology clinics and hospital DI departments to get finalized reports to referring physicians within shorter time periods, and I must say that in most cases this is achieved while maintaining an extremely high quality of reporting.


It is also important to bear in mind that although imaging equipment has certainly become faster, it is no 'smarter' than it was in the early days of radiology and is no more capable of producing actual reports on images than it was back then: so now as hundreds of images come through at light speed, the task of the radiologist is to report hundreds of these images at light speed. The machines are not doing the work for us.


In light of the above, I am not sure how one can conclude that the amount of work done by the average radiologist has somehow remained static or that all physicians, regardless of their specialty are equipped with the skills to interpret even the most complex studies. Radiologists and the practice of radiology form an integral part of the infrastructure of any medical organization and their value should not be discounted.

 

Tarang Sheth wrote:

Posted 2012/05/31 at 08:27 AM EDT

The above essay cogently argues against many of the misconceptions advanced thus far in the policy debate regarding technology aiding physician productivity in diagnostic imaging. I believe it provides a very effective rebuttal to Mr. Falk's views relating to turboprops and jet planes. I would like to add a few points.

The fee schedule has not been adjusted to account for the implementation of voice recognition. This technology allows the radiologist to immediately generate a final report after interpreting the images. As there is no transcriptionist involved, each report must be read and corrected by the radiologist before entering the electronic medical record, generally by taking time after each case to edit the report. This technology substantially decreases the productivity of a radiologist, adding considerable drag to the radiologist's turboprop brain. It does, however, provide tremendous value in the delivery of health care. Final, signed reports can be viewed by ER and other hospital physicians within minutes of an exam being completed. Radiologists at hospitals throughout Ontario have adopted this technology and now provide real-time reporting turn-around, helping immensely to expedite patient throughput in overcrowded emergency rooms as well as to improve hospital bed management. Ontarians have received the benefits of this very substantial clinical value addition for free.

Taking into account the Bank of Canada's inflation target of 2% per annum, the action plan undergoing implementation by the MOHLTC will result in a 25% reduction in per unit reimbursement for radiology services in real terms by the year 2016. Ontarians have already realized great value by paying the same price for years for increasingly more complex interpretation of more numerous images delivered in real-time. Unilaterally reducing the price by 25% due to a flawed understanding of the practice of radiology is abominable. To radiologists, this attack is deeply demoralizing and will sap any willingness to work constructively with government. Over time it will likely result in manpower shortages, perhaps due to lack of faith in the fairness of policy administration in Ontario as much as due to financial issues.

Advocating price competition by opening provision of imaging services to clinical specialists (who would presumably undercut the price of radiologist providers) will be a rapidly self-defeating cost-saving strategy. There is a strong temptation for the clinician to alter his judgement when there is a financial reward for performing a non-invasive test that is seemingly innocuous for the patient. As Dr. Dhanoa cites above, it has been well documented that physicians in a position to order and interpret the same test generate substantially more exam volume. The added danger related to CT scanning as compared to echocardiography for example, is that CT scans administer ionizing radiation to patients.

Non-radiologists generally have no knowledge of the radiation doses administered in CT scans, methods to minimize dose, or the potential harm to patients. Allowing clinical specialists to become self-referring providers of advanced imaging is a terrible idea, one that is very likely to cost more money due to increased utilization and equipment demand and one that has the potential to cause real harm to patients.

I agree with Dr. Dhanoa, that the way forward is to implement better controls on utilization of imaging services by clinicians. This may be the the most effective method to bend the health care cost curve in diagnostic imaging. While radiologists already play the role of advisor in helping the clinician select the most appropriate test, more can be done in this area. I believe the MOHLTC's attempt to define appropriate indications in the fee schedule for lumbar spine imaging was sorely mismanaged due to lack of consultation and involvement of physicians, but in general terms may be the correct way forward and will help to ensure our expensive imaging resources and our radiologists are utilized for the maximum benefit of Ontarians. Slashing the value of a radiologist's services is a misinformed and demoralizing approach to cost containment and makes radiologists, who have consistently provided improved value for health care dollar, personally pay for the growing health care demands of the population.

 

Debra Wingfield wrote:

Posted 2012/03/07 at 12:08 PM EST

I am not a radiologist, but another physician whose specialty is primarily on a salaried model (because my ilk were too short-sighted to see the nagging conflicts-of-interest inherent in being an employee).

With all due respect to Mr. Falk, I see no harm in people, radiologists included, being paid for their work. As professionals they are paid for their expertise, not their time. If a technology makes an examination more efficient, they should not be paid less for the expertise needed to interpret those studies. That is like paying a bookpublisher less upon the advent of the photocopier. It's not the technology that is important but the content.

Furthermore, radiology is a demanding field that requires people of high intellect to practice it. Reduce the income of radiologists and you will invariably reduce the quality. Look to the field of pathology as an example: their income has been dismal for years yet the work is similar to radiology, and the field has been having trouble attracting quality people to it with the intellect and attitude required to practice it competently, as evidenced by the frequent news stories about pathology misdiagnostic disasters. The same cannot be said for radiology, because radiology rewards people well enough to attract the brightest.

The real policy change has to come from sources outside of medicine. We should leave the medical profession alone and instead concentrate on unnecessary wars and sycophancy to the British monarcy: both more expensive and far less useful.

 

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