by an anonymous radiologist
I recently read the article and comments on this link from this post, concerning radiologists, from Musings of a Dinosaur.
I was disturbed to discover the animosity with which this topic is covered. The tenor of the blog is that radiologists are greedy, self-serving and are out to erode the doctor-patient relationship. The suggestion that radiologists would schedule percutaneous breast biopsies for their financial enhancement is both laughable and insulting.
Percutaneous biopsy has become standard of care for all breast lesions that are visible by imaging. Involving a surgeon in the decision-making process typically adds more than a week to the process of diagnosis, and as the writer of the blog suggests, this is not a pleasant interlude for any patient. Even though it took the general surgical community about a decade to come to it, the diagnosis of breast cancer is best done outside of the operating room whenever possible. Blind biopsies by surgeons in their offices are far less accurate, and are rarely tracked statistically for accuracy.
The diagnosis of breast cancer prior to surgery allows a surgeon to plan a definitive procedure; sentinel lymph node biopsy is far more likely to be successful if performed with the first surgical intervention. Since the accepted positive biopsy ratio was 20% both before and after the advent of widespread use of percutaneous biopsy, almost 80% of biopsy patients are spared a trip to the OR. Of the 20% of patients who have a positive biopsy, most are spared a second surgical procedure for the retrieval of lymph nodes and wide margins.
Breast care is the most regulated area of medicine. Not only are we subjected to inspections and careful evaluation by the FDA on a three year cycle, we are frequently required to justify our existence on random additional inspections. The required statistics of our practice are complex, time-consuming and uncompensated, but serve to keep the standard of care high. If we were to self-refer unnecessary cases to biopsy on a regular basis, our positive biopsy ratio would be too low. If we under-refer, we risk missing many breast cancers. The consequences of this are borne by the patients, but it deserves mention that the failure to diagnose breast cancer is the most common cause of medical malpractice lawsuits.
The liability of patients lost to follow-up often lies squarely on the shoulders of the radiologist reading a mammogram. Since it is not required for patients to have a referring physician to have a screening mammogram, and since relying on busy primary care doctors to see and act on abnormal studies is an exercise in roulette, the American College of Radiology and the FDA have very strict rules on the follow up of abnormal studies.
We are obligated by law to have a means of ensuring patients either show up for recommended biopsies or receive several communications, including certified letters, if they choose not to have their abnormality pursued. Given this obligation, most good breast centers expedite the follow-up by scheduling biopsies when they are recommended.
Is there poor communication between radiologists and primary care docs? Absolutely. Are there some radiologists who do part of the job but don’t follow up with giving the patients the biopsy results? Yes, and I think that is very regrettable.
But are there patients who have never even met their primary care physician (PCP) and can’t get into their offices for a breast lump in less than 4 weeks? Are there PCPs who leave calling their patients with abnormal mammograms to office staff and offer little knowledge as to the severity of the suspicion, nor any information about biopsy procedures, positive biopsy rates, or treatment possibilities? I’ll leave it to primary care doctors themselves to answer those questions.
I have been asked by individual physicians to modify our procedures to fit their style and their involvement in patient care, and I am always happy to do so. Most physicians with whom we share patients ask us to be more involved, not less.
I regret that many radiologists eschew involvement in patient care, but I tend to think that more communication with patients is better than less. The role of an involved PCP cannot be over-emphasized, but the regrettable trend in medicine is an erosion of the doctor-patient relationship. This necessitates my increased involvement in patient communication, a role that I embrace and value immensely.
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Related posts:
- Who is responsible for an abnormality on pre-operative testing, or, aren’t radiologists doctors too?
- "Radiologists are sabotaging the practice of medicine"
- Mammogram accuracy and computers
- Should patients bear some responsibility when doctors miss a diagnosis?
- Communicating with your doctor
- Waiting for the biopsy result is as stressful as being told you have cancer
- More medicine isn’t better
{ 8 comments }
I welcome radiologists into ordering mammograms and managing breast cancer care.
My concern is the radiologist ordering tests on patients and sending me the results when I haven’t seen the patient for years or at all. They list me as the doctor. This puts ME at significant risk from a liability standpoint. They need to list as the ordering doctor and then either manage things themselves, if they choose, or refer the patient to the appropriate person. It can be me or a surgeon. But the radiologists here get the test, send me the results, and then expect me to follow up based on their report. On occasion the report is on a patient that I have never seen and cannot contact. The radiology department put my name on the order since the patient needed to list a doctor and randomly? picked my name.
It simply needs to be a coordinated effort where the responsibilities are clear.
I am a proponent of the patient-centered medical home. Thus, if a mammogram indicates a mass needing a biopsy then the PCP should be involved in the process of advising and educating the patient. A PCP with a good relationship with his or her patients can make navigating the health care system much easier. There need not be a week’s delay in seeing the PCP, especially if the PCP site has open scheduling, which my physician does.
Radiologists never order the initial mammogram which is either screening or due to some symptom. Every patient who visits a mammography facility has a referring physician or else they would not have a script for the procedure. That referring physician is the point person for all communication. Your concerns confuse me. If you haven’t seen the patient how are you referring them for mammography? I’m missing something.
BTW, the above comment was directed to stargirl65, not Tex or the original poster.
“Since it is not required for patients to have a referring physician to have a screening mammogram”
from the original post
stargirl65,
Patients are allowed to schedule their own screening mammograms without a physician’s order ONLY if they provide the name of a physician to whom the report can be sent to. Radiology departments don’t just pick PCP names at random and assign patients to them. I understand your concern if a patient lists you as her physician and you don’t know who she is or haven’t seen her in years. This is the downside of allowing patients to schedule their own exams. This law was designed to encourage women to get a screening mammogram by reducing the steps needed to schedule one. It is not some rule created by radiologists.
Diagnostic mammograms on the other hand must have a physician’s order.
I was actually unaware of the law as all of the places I have worked have required a prescription for screening mammograms. It’s at the discretion of the facility whether to require it – it’s just not necessary to receive payment. A quick Google search of radiology facilities found a number of facilities which still require a script despite not needing it for payment . Personally, I feel all medical care should be initiated by a clinician, if only to avoid the situations described above. While I understand the sentiment driving the law, screening should not occur in a vacuum.
In order to facilitate patient screening, we do not require orders for screens. We do, however require patients to name their PCP. Understanding that there is often a very tenous patient-PCP relationship, we do not rely on PCPs to communicate results or initiate necessary work-ups for abnormal studies. This protects PCPs from being held responsible for patients they don’t know, protects us from the liability of “dropped balls,” and MOST importantly, gives the patients some responsibility for their own care.
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