Turf Wars?

[snowday]

Hi guys,

 

I have quite an interest in radiology, and so I have read through this forum and came across what may or may not be challenges for the field of radiology to overcome in the future (e.g. outsourcing, reimbursement cutbacks). Though I personally don't think outsourcing is an imminent threat due to medicolegal issues, and I don't have too much interest in reimbursements, what seems to be a somewhat legitimate threat is turf wars. I may be completely misinformed, as I don't have much radiology exposure as of yet, so I am just wondering--do turf wars exist in hospital settings to a significant degree, with other specialists such as neuro/cardio/gastro wanting to read their own imaging? I am particularly interested in potential neuro turf wars, as I find neuroimaging quite fascinating, and I am wondering which direction you see this 'turf war' (if one exists) going in the future? Will neurologists (or other specialties such as cardio/gastro) be reading more images, or will radiology be able to 'protect its turf', so to speak?

 

I appreciate any insights you may have!

 

All the best,

snowday

[TheCat'sMeow]

I'm not sure about the turf war aspect of this but I know cardio reads their own echos and caths, cardiac MRI and ct goes to rads (at least at the institution I'm familiar with).

[NLengr]

In some centers, radiologists read intra-op flouroscopy a few days after it is taken. This, despite the fact that the patient is closed and has been home for a few days prior to them being read.

 

I guess it's the benefit of having a second set of eyes.

[A-Stark]

Really? Seems more like an absurdly poor excuse to bill for something that almost by nature does not "change the management".

 

In any case, I don't know if there are many - if any - neurologists reading (and billing for) CTs, MRIs.

[Lactic Folly]

From the neuro perspective, neurointerventional is more likely to go to neurosurg/neurology than image interpretation is.

[NLengr]

Really? Seems more like an absurdly poor excuse to bill for something that almost by nature does not "change the management".

 

That's the other side of the argument that you hear.

 

I won't reveal what side I fall in.

[Ian Wong]

My suspicion is that turf wars will continue indefinitely. It's the nature of medicine that there never will be a completely fair way to delineate exactly what specialties can do which procedures. This isn't limited to radiology however.

 

Clinical specialties butt heads all the time.

 

Derm, Plastics, and ENT all compete for cosmetic cases. Interventional Cardiology nearly made Cardiac Surgery extinct in the last 2 decades. Ophthalmologists want to make sure they protect their turf from optometrists. Traditional family doctors are threatened by walk-in clinics, who skim off all the fast, high-paying patients, while dumping complex patients to the ER or back to the primary care provider. Pharmacists, and mid-level providers are always fighting for increased practice rights, which ultimately decrease the need for physicians to supply those functions.

 

Radiology is at an interesting junction, because imaging is becoming more prevalent in both the management and treatment of diseases. It's only natural that specialists who make use of this imaging may be interested in reading it formally, particularly if it pays better than whatever they are currently doing.

 

A good example in the US, where I did my residency, is musculoskeletal (MSK) ultrasound (U/S). It pays poorly from the radiology perspective, particularly compared to its closest counterpart, which is MRI. Both of these modalities are used primarily to examine soft tissues, such as tendons, muscles, and ligaments.

 

For the average radiologist, there's little incentive to transfer time spent reading MSK MRI's into performing and reading U/S. Reading MSK U/S is a money-loser for a radiologist. However, for a rheumatologist or a physiatrist, who might make half of what a radiologist makes, incorporating MSK U/S into their practice could be a substantial income boost. If you can make more money doing radiology-type work rather than seeing patients (and you often can), that's one reason you see clinicians moving into imaging.

 

It's significantly more rampant in the US than in Canada, as there's significantly greater control exerted by the Canadian government to restrict the explosion of imaging here than in the US.

 

In the US, you often have the following:

- OB/GYN doing the majority of OB imaging.

- Neurologists doing carotid U/S, and possibly CT and MR imaing.

- Orthopods doing MSK CT and MR.

- ENT doing sinus CT.

- Physiatry and Rheumatology doing MSK U/S.

- Emerg doing focussed ER U/S.

- Neurosurgery doing fluoro-guided neurointerventional procedures.

- Cardiology doing essentially all heart related diagnostic and therapeutic imaging, with some really aggressive guys doing peripheral vascular intervention as well.

- Vascular surgery doing vascular imaging (Doppler studies), and peripheral vascular intervention.

- Pain physicians (from anesthesiology and physiatry) doing fluoro-guided steroid and anesthetic injections.

- Surgeons doing imaging guided biopsies (such as U/S or stereotactic guided breast biopsies).

 

There's probably a lot more, but that's what I can think of in 10 minutes.

 

Having said all this, I think the majority of imaging will continue to lie in the hands of radiologists. In Canada, this is due to a lot of limitations regarding the purchase and installation of CT and MR scanners, and whether you can bill for image-guided procedures (which I believe is more restricted here).

 

As well, we typically retain more imaging expertise in that particular subspecialty, especially since the majority of radiology graduates in Canada and the US are going on to do fellowships after residency. We are also in charge of the quality assurance processes, which are supposed to ensure that the proper exam is being done (as an example, a CT exam can be tailored tons of different ways as far as the presence, absence, and timing of oral or IV contrast, as well as radiation dose and types of reconstructions performed, all of which will affect the diagnostic accuracy of the exam). These are things that the average clinician has no training in.

 

For neuro-imaging, I believe that CT and MRI will continue to lie firmly in the hands of radiologists in Canada. Neuro-interventional will continue to be a very niche specialty, as it can only exist in large centers. I would predict that it will have more and more neurosurgery representation in the future, but if you are a radiology resident and want to do neuro-interventional, there will be a training spot for you. Most radiologists value lifestyle too much to do neuro-interventional, which can have pretty brutal call.

 

Ian

[rmorelan]

So out of curiousity what can a radiologist do without a fellowship - are those sorts of things more core and less open to the entire "turf war"?

[Lactic Folly]

Another great post Ian, thanks for sharing your thoughts.

[feversugar]

Another great post Ian, thanks for sharing your thoughts.

 

I agree, very interesting read thanks

[Ian Wong]

In theory, a radiologist who has finished residency is capable of reading all imaging modalities and doing light interventional radiology procedures (ie. lines, drains, biopsies).

 

Many people say that interventional radiology is the only true fellowship, because you are acquiring skills in an area that is not traditionally open to residents. The average resident is not going to be able to do a TIPSS or an aortic stent-graft without that fellowship training. Neuro-interventional fits in the same category (no resident is going to coil a cerebral aneurysm or glue a cerebral AVM).

 

Most of the other fellowships, such as MSK, Peds, Body, Neuro, simply build on the diagnostic interpretation skills you already learned in residency. In theory, an MSK fellow is going to interpret MSK MRI faster, and at a higher level than a non-fellowship trained radiologist. However, if the general radiologist is diligent, and does a high volume of MSK imaging in practice, there's no reason that they cannot acquire those skills over time.

 

It's not really any different than an internist with an interest in cardiology, or a family physician with a CCFP EM going up against a graduate of a 5 year emergency medicine residency. If that individual spends a lot of time working in that area, they eventually end up performing at a high level. Of course, having the MSK imaging fellowship, or the cardiology fellowship, or the 5 year EM residency is great for marketing reasons, and tends to help build up the local referral patterns.

 

It is for these latter reasons that most radiology graduates are doing fellowships. It increases your marketability for getting the competitive desirable jobs.

 

Ian

[coastalslacker]

deleted

[Ian Wong]

Honestly, I would love to hear things from your perspective as an orthopod. I have a few friends who are orthopods and they are pretty adamant that radiology input on plain films, fluoro, and CT are not necessary. I do believe that radiologists can contribute when it comes to MR.

 

I'm new to the attending game. The places I've worked for all do group billing and I am not privy to those details as a non-partner. I'm not sure what fraction of the income of the practice comes from reading ER ortho films, or post-op/post-reduction ortho films, but I have to believe that it is a relatively low percentage. Most radiologists find that particularly on the post-treatment films, that there's little to add, other than screening for incidental findings, like a lung cancer tucked away on the edge of the film. I can say that I've seen at least 3-4 such lung cancers on shoulder x-rays thus far, as well as at least 1 previously unknown pneumothorax. I've definitely picked up previously unknown metastatic disease on pelvis radiographs for hip replacement templating.

 

However, I would add that this is all in the setting of having read many, many thousands of these studies. Is this a good use of resources? These studies are also typically not fun to read; a whole rack of these on an ortho clinic day is a pretty mundane time.

 

Ian