Go ahead and let teens read x-rays

Costs are spiraling out of control, access is declining, and our quality of care doesn’t match what other developed nations are delivering at half the cost.

In the search to reduce costs and bring our ever inflating health care budget under control, the powers that be (insurers, government, health policy wonks (and maybe a few doctors) have looked to individuals with less formal education to perform medical services that were once the sole purview of physicians.

The rationale is that physicians are immensely overqualified for some of the tasks they perform.  If you can use someone who was trained in half the time and for half the cost to perform a service, then the service should become cheaper and more widely available.

This is already happening in my specialty.  The American Association of Colleges of Nurses (AACN) and the American Nurses Association (ANA) tell me and my patients that virtually all of the services I perform can be done as well, or better, by a nurse practitioner.  And they have decades of sponsored studies to prove it.  Some are well controlled and widely applicable.  Others aren’t.  But they exist.

And primary care hasn’t been the only target for disruption.  CRNAs, whose training is half that of anesthesiologists, have been administering anesthesia independently for years.   Non-physicians have been performing sigmoidoscopy since the 1970s, and studies of nurses in the United Kingdom have shown they can perform upper endoscopy as safely and effectively as physicians.  And while not as essential to a person’s health as the previously mentioned examples, many types of non-physicians can administer botox and laser skin treatments.

But why should primary care, anesthesia, gastroenterology and dermatology have all the fun?  I wish to offer my own disruptive solution to the health care crisis.

Let non-physicians try their hand at radiology.

I propose a study where you take a couple of 18-19 year olds (high school graduates, of course) with an affinity toward science and put them through a 6 month “boot camp” where they are trained by radiologists to read knee films.  At the end of their “boot camp,” put them head to head with board certified radiologists in diagnosing things like fractures and osteoarthritis.

Teenagers would make a great initial test group.  Their vision is probably the best it’ll ever be, and they’re really used to sitting in a dark room staring at a computer screen.  They can be paid minimum wage, aren’t prone to forming unions, and because they’re not doctors, wouldn’t be fearful of malpractice suits or other disciplinary actions by credentialing boards (unless you count getting grounded by their parents).

I’d wager you could do some pretty convincing randomized controlled trials showing teenagers can be trained to read certain types of x-rays as effectively as radiologists.  Then we can do the same for other imaging tests with limited anatomy like shoulders, elbows … maybe even mammograms.

Of course, even if we do show equivalency (or superiority) in large scale studies, would I really want a teenager reading my knee films or my mother’s mammogram?  I guess if I came up with the idea and I’m suggesting other people do it, I’d have to be okay with having it for myself.  I’m sure most politicians who support expanding the roles of nurse practitioners and CRNAs would choose them over a physician if they or their loved one needed care.  You’d be nuts not to choose the thing that’s just as good but half the price.  Politicians aren’t nuts, are they?

So let’s go for it and train the new workforce of teenage radiologists.  It may make people a little nervous, but all we have to do is show them the equivalency data and the massive savings they’ll see on their medical bills, and they’ll soon be on board.  It sounds crazy, but no one ever said health care policy was rational.  Let’s add a little disruption.  My kid cousin needs a summer job and those x-rays aren’t going to read themselves.

Keegan Duchicela is a family physician who blogs at Primary Care Next.

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  • http://www.facebook.com/serendipity0712 Allie Oop

    Wow… could you possibly be any more pompous AND unprofessional at the same time? I’ll play the world’s smallest violin just for you because you’re so upset that Nurse Practitioners and CRNAs get to play in the same sandbox as you.

    • Cathikins

      I think there’s really no need for name calling in response to this post or on this forum. Maybe just something I picked up in medical school..,

      • http://www.facebook.com/serendipity0712 Allie Oop

        It’s not about name calling, it’s about the arrogant tone of the article, comparing CRNAs & NPs to scientifically inclined teenagers and “my kid cousin”.

        • Cathikins

          I see your point.. I think he was trying to draw out the trend to an extreme to illustrate our potential discomfort

          • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

            Whether or not he is being arrogant, he makes a very interesting point. Why do we need people with over 12 years of post high school education doing work that 90% of could be done by someone with six months of training? Why not consider having radiologist only do the work that that such education requires and paying them well for it. We as a society could certainly afford it with all the money saved in the reading of the routine cases by lesser trained people.

          • http://twitter.com/MDaware Seth Trueger

            the 90% is easy. it’s that tricky 10% that makes all the difference

  • http://twitter.com/ChrisJohnsonMD Christopher Johnson

    Mid-level providers in many specialties do well at many tasks. Most of the time you don’t really need an expert . . . until you really need an expert, sometimes quickly. And that need is unpredictable. So what’s the best mechanism to make that happen? Turf squabbles obscure the question, but it is a real one: how should we decide which things are appropriate for mid-level providers and which are not?

  • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

    Well, there is already a mid-level called a radiologist associate…..there is a program at Wayne State and another one in North Carolina that are master’s programs, and they do preliminary interpretations and quite a few interventional procedures. And plenty of PAs and NPs in EDs read radiographs for the initial interpretation, and many PAs work in radiology as proceduralists. But, they aren’t teenagers; having prior career experience and master’s degrees and usually substantial career progression to reach those goals.

    Now, the physician intern looking at an x-ray at 3:00 am might be closer in age to a teenager and with less radiology training than your pilot program describes to boot! Everyone starts somewhere, and we work our way up depending on our capabilities and training, No need to fight, there will be enough patients for everyone in the coming years.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Is there a reason why computers can’t do this? I bet in a few years most images will be read electronically anyway, at least for those who can’t afford to pay for a real radiologist, which does not include “policy makers”. Maybe there will be an “app” for that too, so you could consult Siri….

    • Keegan Duchicela

      Interesting you brought that up!

      The recent winner of the 2012 Google Science Fair came up with a cloud based computer algorithm that can determine whether a FNA (fine needle aspiration) of a breast biopsy is benign or malignant based on certain characteristics. Her program has amazingly high sensitivity and specificity for detection (tested against a massive data set), AND she’s only 17 years old!

      There’ll be a lot more computer aided diagnostic/detection systems developed in the coming years – its already happening in radiology. Now I guess they’re doing it in pathology too.

  • Keegan Duchicela

    Allie Oop – thanks for your comments!
    No need to take offense, though. There are some very smart teenagers out there! And at the very least, I was comparing them with radiologists =)

    I’d argue there are a lot of things that non physicians could do instead of nurses and physicians. I mentioned some examples of certain physician services. I’d wager that it’s true in the nursing field as well. For an outpatient clinic, a well trained MA can perform many of the tasks nurses traditionally perform AND at a lower cost. The regulations vary state by state, and just as physician groups lobby for scope of practice restrictions, nursing associations do so as well.

  • Angelea Bruce

    In my experience as a patient and a clinician, the physician’s fees are the least of the problem. Healthcare costs are ridiculous for at least 3 of the following reasons:

    1. High tech tests requiring expensive equipment and supplies.
    2. Unnecessary testing, treatment, and medications used/prescribed due to physicians having less than 15 minutes to gather information, make a diagnosis, and treat a problem before moving on to the next patient. If doctors had more time to listen to, and get to know, their patients, as well as having time to discuss noninvasive treatment options, i.e. diet, exercise, stress reduction, etc., I am convinced their hourly rate would cost far less to the healthcare machine than the tests, invasive procedures, and medications often prescribed to treat the same problems.
    3. And the Number 1 reason healthcare costs so much is insurance companies. The fact is that any given provider must deal with dozens of different companies and policies within companies which takes hours upon hours of support staff to communicate with and bill is what is really behind the outrageous cost of healthcare.

    I am happy to pay an experienced, well-educated physician, including a radiologist, for his or her services. On the other hand, when I have a sinus infection or other mild illness or injury, I don’t feel I need to waste the time of my doctor, or my/our money, when a PA or NP will do just fine.

  • Close Call

    The author proposes an interesting thought experiment (and one that’s been brought up before) – of course we’re never going to have teenagers reading xrays, but what if we had data that showed they COULD be trained to read xrays just as well as radiologists? How big would an RCT or observational trial need to be before we as a society would be comfortable with it? Similarly, how much data do we need before we are absolutely convinced CRNAs can give anesthesia safely without supervision?

    Scope of practice issues are always hot-button topics. While physician fees certainly aren’t the main cause of our healthcare financial problems, scope of practice restrictions certainly do limit access to care.

    We should be open minded to finding new ways of providing and paying for care- and it shouldn’t just include nurses and physicians. If we believe and put faith in data that shows a non-physician can give a medicine to make a person unconscious and bring them back again safely, we should also take seriously data showing a teenager can read a mammogram… if that’s indeed what the data shows.

  • http://www.facebook.com/tommy.y.fu Tommy Fu

    Haha I like the outside-the-box thinking here. The Aravind eye clinic in India is actually doing something similar. They break up an eye surgery procedure into 15-17 different slices/tasks, and entrust a high school level teenager to become proficient at their own specific task through heavy repetition and doing high volumes. Collectively, they’re able to do eye procedures with complication rates even slightly lower than the U.S. and prices that are about 1/10th. I’m not saying they are overall better, but an interesting example.

    I would be in favor of seeing such a study. The silicon valley folk would probably really accept it. Down the road, one of the potential issues I could see is with the lack of fear of malpractice as a teenager. We would need to substitute that with another incentive for them to still do a good job. But I agree, a 6-month intensive camp would probably teach someone to be both pretty sensitive an specific at reading those films

  • Molly_Rn

    For what they do radiologists are grossly overpaid and family docs or internists are grossly underpaid.

  • http://twitter.com/bbgrayrn bbgrayrn

    Actually, computers and robots have already been shown to do a great job reading x-rays. But I would think they’re not so good at primary care.

    There’s much that advanced practice nurses can do in the average medical practice, especially with chronic care patients, helping them manage their treatment regimen, educating them and assessing them for problems. With the coming physician shortage, we’re going to need to figure out just what we really need from physicians and what can be done as well or yes, even better, by others. Full disclosure: I’m a cardiovascular clinical nurse specialist.

    When the sphygmomenometer first came out in the beginning of the 20th century, physicians insisted only they had the skill it took to get a reading. Gradually we learn what requires a certain level of expertise and what does not.

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