Isolation threatens the practice of diagnostic radiology

During breakfast with my father over the holidays, a friend of his asked me what kind of doctor I am. “I’m a radiologist,” I answered.

I was met with a puzzled expression and a reply of “Oh, I thought you were a doctor doctor.” I smiled and returned to my banana.

Most radiologists, especially those like me who are not physician offspring, are faced with this sort of discourse at least once. I even once had to explain my credentials to a nurse who almost called security on me when I went to check on a patient in the middle of the night who had previously undergone an interventional radiology procedure.

Medicine is filled with radiologists who chose the specialty because it allowed them a degree of separation from patients, not despite this trait. Radiologists are physicians who interpret radiologic exams (MRIs, CT scans, X-rays, ultrasounds, etc.). Most patients will never meet us even though we regularly make life-saving diagnoses. Given the relative isolation, diagnostic radiologists spend most of their time on the art and science of their specialty and are more buffered from tasks that don’t result in monetary reimbursement. With the advent of advanced computing resources, robust networking equipment, and faster scanners, radiologists commanded salaries rivaled only by highly specialized surgeons for most of the previous decade. During the radiology boom of the 2000s, medical school graduates applying for radiology residency needed medical licensing exam scores higher than almost every other specialty to earn a seat at this exclusive table (with dermatology, orthopedic surgery, plastic surgery, neurosurgery, and otolaryngology in a similar class). This is why most radiologists merely smile when challenged by the “not a real doctor” accusation.

Many anesthesiologists I know have similar laidback reactions when asked why they would prefer anesthesiology to surgery. An anesthesiologist friend of mine refers to the sheet between himself and the surgeons in the operating room as the “blood-brain barrier,” i.e. he is the “brain” for choosing the field that lets him bill per unit time while the blood (messy part) is on the other side of the sheet. We don’t let the small stuff sweat us.

Too much isolation from patients and other doctors has hurt radiologists in recent years. The ability to interpret images remotely has turned the field into a commodity that can be sold to large consolidative practices often not stationed near the scanners, and a health care payment system that favors quantity over quality emphasizes speed over detail. While radiology salaries and job opportunities for new graduates have taken a significant hit, many doctors continue to label radiologists as master systematic vampires (and not just because we sit in the dark all day). When a radiologist like myself speaks of cutting back on unnecessary exams to improve system efficiency, I don’t have to wait long until a specialist points out how my practice is predicated on unnecessary testing and that I supposedly benefit from this. At the same time, we are slighted for recommending clinical correlation regarding equivocal findings when the reality is that we are merely not given enough clinical information to comment on significance.

Truth be told, insurance companies would make a lot of money if they employed radiologists to deny inappropriate orders. I am not referencing radiologic studies that are not likely to result in a diagnosis. I am referring to studies ordered that are incapable of answering the clinical question asked. It’s an epidemic.

Many radiology practices, drunk from the prosperity garnered by large workloads, are happy to perform all studies that walk in the door. Calling the ordering provider to recommend a better test takes time and may cut into productivity. The system is even fundamentally designed to prevent radiologists from improving the system. Rather than attributing us the status of experts capable of controlling unnecessary radiation and cost, we are not legally allowed to order studies for fear of predatory over-ordering.

As a resident, I learned that when a pulmonologist (lung specialist) is asked to drain fluid from the thoracic cavity of a patient (thoracentesis), he or she evaluates the necessity of the procedure, bills for a consultation, and then drains the fluid. Radiologists, on the other hand, generally can’t bill for consultative services for simple procedures. Other doctors merely write orders for us to do things to their patients, often without the courtesy of a phone call or a proper explanation to the patient as to what will transpire. I can’t count how many biopsies I have done on people who didn’t even know that they had a concerning imaging finding. Again, this is our fault. We embrace that isolation.

Part of the radiologist oversupply stems from a lack of retirement due to a fear that health care reform would slash radiology ordering practices. From my perspective, this has not materialized. Americans have a thirst for knowing as much as possible just as much as emergency providers have a need to limit liability while maximizing patient throughput. For every conversation I have with a parent worried that his or her child was exposed to excess radiation during a CT scan, there are many more patients pushing to be scanned despite the large cost that comes with it. The health care system is driven by the pressure of its constituents. We have proven that we can work faster and harder for the same payment, so this has become our new expected baseline.

Clinicians bring many studies to my hospital for uncompensated re-interpretation, a practice that my superiors embrace because it makes us look valuable when we are instead creating more systematic waste. I find myself asking what other doctors out there are told to re-evaluate a patient for free. The practice is tantamount to accepting liability for a physical exam performed by someone else, yet radiologists are subject to this all the time because we rely on hospitals to provide a workplace. Our quality practices also require that radiologists constantly evaluate each other, a standard that few other physicians are subject to.

Even more damaging to the profession is the fact that studies that are not indicated are often merely unreimbursed (which incentivizes radiologists to find abnormalities). Are emergency physicians denied payment when the patient doesn’t have an actual emergency? Obviously not.

There is no other field of medicine that I would rather do, but working among radiology colleagues who refuse to step up and become more integrated into their local clinical services risks turning radiologists into technicians. We must get out of the dark, in more ways than one. If we are not at the table, we are on the table.

Cory Michael is a radiologist.

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