As costs of health care begin to escalate again, evidenced by the national rise in insurance premiums, it is expected that the national debate over health care will re-emerge. With the patient’s bill of rights being advocated and adopted, attention has been focused on the obligations that patients should expect from “the system.” Due to the limited financial resources dedicated to health care, difficult decisions will have to be made in the future. Central to this discussion should be a debate over whether money is better spent in diagnosing disease once symptoms develop or trying to identify early disease through screening programs.

Edward I. Bluth, MD

Radiologists traditionally have been observers in this debate. Our training and resources have in the past been dedicated to developing more sophisticated instruments capable of diagnosing abnormalities at early stages, but primarily only after symptoms have developed. Special attention and care have been given to developing interventional therapies that radiologists can apply to many critical situations. The field of radiology has been changing from one of simple observation and diagnosis after symptoms have developed to now playing a major role in diagnosing and treating patients. This increase in resource utilization has been accepted by the medical community and the general public.
With the exception of mammography, radiologists have paid little attention to the large number of asymptomatic patients who may harbor disease or who are at great risk for its development. In fact, it has been generally accepted that imaging should be ordered only if a valid symptom or critical sign is present and an appropriate ICD-9 code can be established. Only then can imaging studies be reimbursed.

Those of us in radiology have accepted this state of affairs. Perhaps it is time for radiologists to reassess this view and actively become involved in changing their role and responsibility. As imaging becomes more sophisticated, we can identify early signs of disease before they become clinically evident. For example, intimal thickening of the carotid arteries can be noted as can asymptomatic, carotid arteries stenosis with high resolution ultrasound. CT assessment of the coronary arteries can suggest a risk of asymptomatic disease. CT of the lungs can detect small cancers at early stages. CT colonography appears promising as a way to evaluate cancer of the colon.
We as radiologists should be in the lead of those evaluating screening tests for scientific validity. It is time for radiologists, as advocates for our patients, to actively become involved in the policy decisions of how the health care dollar is spent. It may be as important for us to spend resources on the prediagnosis of disease as it is to develop new interventional techniques once disease is present. The early diagnosis and curtailing of disease progression is certainly a more efficient utilization of our financial resources. If we, as radiologists, do not become involved in the debate on the value of screening, we will leave the important decisions of how radiologists should function to others.
I believe that we have an ethical obligation to our patients, to become actively involved in identifying disease at an earlier stage than we do presently. Patients will be better off if they come directly to the radiologists for evaluation of early diseases prior to symptoms or to determine their risk of developing future problems using screening programs. We can identify these potential problems, suggest alternate behavior or lifestyles, identify lesions at an early treatable stage, and take a more dominant role in the health of our patients. In this new century, as radiologists, we must be not only a physicians’ physician, but also a patients’ physician.

Edward I. Bluth, MD
Chairman, Department of Radiology
Ochsner Clinic, New Orleans