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Radiologists say that obstetricians have taken over much of the fetal ultrasound imaging that was once done in radiology suites. Some fear that a similar assault on radiology’s traditional dominance is taking place in ultrasound gynecological imaging. Others see these practice shifts as nothing alarming. They argue that those who know ultrasound, no matter their discipline or subspecialty, are the ones who best serve patients.
“The problem with all medicine now is that there is so much to learnand there is not enough time to learn it,” says Beryl R. Benacerraf, MD.
Benacerraf is a partner in Diagnostic Ultrasound Associates in Boston and a professor of radiology and obstetrics/gynecology (OB-GYN) at Harvard Medical School. She is a specialist in ultrasound imaging. She also practices at Brigham and Women’s Hospital in Boston.
Asked if there is a “turf war” between radiologists and OB/GYN specialists for ultrasonic imaging business, Benacerraf says, “Yes, it does existvery much so.” Unlike many radiologists, however, Benacerraf thinks there is no turning back the clock to a time when radiologists performed the lion’s share of OB/GYN ultrasound imaging. “Radiology departments that refuse to share are asking for trouble, because the obstetricians control the patients, and they can stop the pipeline of patients anytime they want to,” she says.
Benacerraf also makes the case for expertise in ultrasonography as the critical factor, not whether the imaging doctor is a radiologist or an OB/GYN specialist. This is at the heart of her comment about doctors these days having too much to learn. “Both disciplines are equally good if they are trained for it,” she says. “They work together very well because they understand the contributions they can make to each otherradiologists on the imaging side and obstetricians on the clinical side. They do learn from each other, and at the end of the road they can be interchangeable.”
At Brigham, says Benacerraf, the obstetrical ultrasound is shared equally between the radiology department and the obstetrics department. “If you have 10 [imaging] sessions, five are assigned to the obstetricians and five are assigned to the radiologists. The revenues are shared and the slots are shared. The best situation is that there is input from both subspecialties,” she says.
But the sharing of ultrasound duties in an academic setting may be a far cry from what happens in obstetricians’ private offices where ultrasound imaging may be less expert. There may also be a deleterious effect on radiology training as a whole from having ultrasound increasingly divided among many subspecialists.
Carol B. Benson, MD, is a colleague of Benacerraf’s. She too is a professor of radiology at Harvard. She is also director of ultrasound and codirector of high-risk ultrasound at Brigham and Women’s.
“The imaging procedures do tend to reimburse very well, and many medical specialties have tried to find themselves imaging niches,” Benson says. “It’s not just in ultrasound, but in ultrasound it’s becoming more and more that way. You can buy an ultrasound machine for $20,000. If you’re looking only at one organ, you can probably get pretty good at looking at that organ.”
While Benson, like Benacerraf, gives high marks to Brigham’s ultrasound sharing approach, she argues that the shift in imaging to nonradiologists has exacted a price on patients and institutions. “They are sucking the business from one part of the hospital to another,” she says. “The specialties are cherry picking the studies, and they’re cherry picking in the daytime hours. If you don’t use your radiologists all the time, the hospital is not going to buy them the new machines.”
Like others, Benson makes the argument that shifting ultrasound imaging away from radiologists also weakens radiologists’ abilities to stay professionally ahead of the ultrasonographic curve. “The radiologists are diluting their practices with other modalities, and they’re not staying up with ultrasound,” she says. “It undercuts the imaging infrastructure in the hospital.”
Benson says in her view the shift in ultrasound imaging to OB/GYN and other specialists, along with the proliferation of inexpensive ultrasound machines, has diminished the quality of ultrasonography overall. “In the real world, the quality of ultrasound has been decreasing. Ultrasound is being practiced less well across the board. The radiologists are not as good, and the OB/GYN specialists are not as good.”
To the degree it exists, this decrease in ultrasound quality also has a spin-off effect on patient care, on other imaging modalities, and on health care costs, Benson argues. “Instead of having 1,000 ultrasound specialists, now you have 100,000,” she says, “so everybody is sticking an ultrasound probe on patients. Then, if they don’t know what they’re seeing, they order up other studies, like CT. They’re not as good at recognizing variance of normal or insignificant findings, so there’s a lot more imaging being done that costs a lot of money.” She does note that inexpensive ultrasound equipment may mean that in rural areas more imaging is getting done, which may be beneficial to patients.
The OB/GYN View
Ilan E. Timor, MD, is an obstetrician/gynecologist who has devoted his practice to OB/GYN ultrasound. He is an expert’s expert, the author of several books on the subject. Timor is a professor of OB/GYN and director of OB/GYN ultrasound at New York University Medical Center. Like Benacerraf, Timor believes strongly that it is the training in ultrasound, not the subspecialty, that makes the difference in creating the ultrasound doctor.
“What I claim is that there is not too much difference in who does the scans, if the person is highly qualified, has the experience, is well read, and has continuing medical education,” he says. “The obstetrician/gynecologists, if they understand what they’re doing, are probably more qualified. We look at the patient as a whole, and we can dig out the correct diagnosis by taking a history, by understanding complaints, and by integrating this information with the sonographic picture.”
Timor is looking through the same window as many radiology-trained ultrasound specialists, but he is looking from the other direction. Timor meticulously and exhaustively trains OB/GYN specialists to know what they are seeing, something he says many radiologists are not trained to do when it comes to ultrasound.
What happens most often when generalist radiologists read the ultrasound images, Timor says, is that they put in their reports a long and confusing list of all the diagnoses that the image information might lead to. Too often, they do not narrow the range of possibilities. “So, when the obstetrician/gynecologist gets back that report, he’s back to square one, because he doesn’t understand what those reports mean,” Timor says. “On the other hand, I will narrow that down to one, or maybe two, or at most three possibilities. I am sticking my neck out so to speak. I understand the patient, and I put that together with the picture. That is what the obstetrician/gynecologist really needs.”
Timor says many obstetrical practitioners have turned successfully to doing their own ultrasound interpretations but that few gynecologists have. The gynecologists are particularly needful of interpretations that reduce the number of probable diagnoses. “In many cases, the gynecologist will have to do an invasive procedure, because the radiologist has said that malignancy can’t be ruled out. But I will try to say&this is a benign lesion. So the gynecologist can say, OK, let’s do a blood test and watch it for another half year.'”
Timor says the typical OB/GYN student spends less than a month on pelvic or obstetrical ultrasound scanning. In Europe, the same student gets 4 to 6 months of training, he adds. While radiologists in the United States get much better training, Timor thinks OB/GYN doctors need more training. “Many of them get a sonographer to interpret the pictures and then they sign the report. This is not good. Today, OB/GYN ultrasound is considered the right hand of the OB/GYN specialist.”
Goodbye Obstetrical?
Many practitioners, radiologists and OB/GYN specialists alike, seem to agree that obstetrical ultrasound is shifting away from radiologists and over to obstetricians.
“We have the loss of obstetrical for sure, and in many areas gynecological imaging is also decreasing for radiologists,” says Ellen B. Mendelson, MD. Mendelson is a professor of radiology at Northwestern Medical School and chief of the Breast Imaging Section at Northwestern Memorial Hospital and the Lynn Sage Comprehensive Breast Center in Chicago. “Suppose you polled 25 university hospitals where residents are trained,” she adds. “You would probably find that in two thirds of them the OB/GYN ultrasound has been lost. It’s a lotand it’s awful.”
It is more than just a loss of income for radiologists, Mendelson adds. It is an assault on the ultrasound training of radiologists too. “At Northwestern now, the radiology residents get very weak training in OB/GYN ultrasound. They are regarded as onlookers rather than participants. It’s a shame because radiologists learn to do imaging, and with ultrasound the technical part of it is absolutely crucial.”
The other side of the coin, according to Mendelson, is that OB/GYN specialists are not getting the training they need in ultrasound either. “They aren’t trained as imagers,” Mendelson says, “they’re trained as clinicians. I will tell you what I see, which is the hiring of sonographers to do the studies and report to the physician what they see. There may be some superb ultrasonographers, but for the most part, what the sonographers see is what’s billed for.”
Asked if radiology can take a stand against this imaging shift, Mendelson says, “What kind of stand can you take? There is no way to take a stand. The last thing we want is more federal regulation like we have for mammography. The American College of Radiology (ACR) standard is quality, and we stand for that, but the ACR has no teeth. We can lobby but there’s not much the ACR can do.”
The proliferation of inexpensive ultrasound equipment has not helped either, Mendelson adds. “The other part of this is that the [manufacturing] corporations can affect things. They are developing widespread and diverse inventories. They saturate markets, and when they have one, they go after another.”
Standards Needed
Anna S. Lev-Toaff, MD, is professor of radiology at Thomas Jefferson University (TJU) in Philadelphia. She heads the 3D ultrasound group at TJU. She confirms what others have said concerning the loss of obstetrical ultrasound for radiologists. “Officially, at TJU we have an agreement with the OB/GYN department that we in radiology do all the gynecology ultrasound and they do all the obstetrical.” Looking at the same picture on a broader scale, she adds, “It’s a power thing, it’s a control thing, it’s a money thing, but many OB/GYN specialists are highly trained and can do it.”
Then there are those who are not so highly trained, or who cannot afford or do not have the best equipment. “In the private practice sphere, anybody can buy an ultrasound machine, and even if they have no training, they can hire a technician and do the billing themselves. The FDA (Food and Drug Administration) doesn’t monitor it. Basically, the tech does the diagnosis,” Lev-Toaff says. She says some insurance companies have started demanding that obstetricians and other specialists refer ultrasound examinations to a third party to prevent situations where “every time the patient comes in, the ultrasound machine is turned on.”
Lev-Toaff also notes that while there are major differences in the quality of ultrasound machines and their capabilities, the payor gets billed the same no matter how good or how bad the machine is. “There are no codes for good equipment and bad equipment,” she says.
Lev-Toaff says patients need to be aware of the big differences in the qualifications of those doing ultrasonography. She is an advocate of accreditation to protect patients. “We’ve taken care of this problem in mammography, where the government requires certification. We’re only starting to see accreditation in ultrasound, and right now it’s voluntary. Certainly, one of the motives is concern for turf, but radiology welcomes rules and regulations based on qualifications. If you have the right skills, you want to be accredited. If you’re using a 15-year-old machine and cranking out lousy images, you’re not going to get accredited. Hopefully, we will get to the point where there will be formal requirements in ultrasound.”
She says TJU is asked to perform a lot of imaging simply because its radiologists are trusted and it is recognized as having top-of-the-line equipment. “It’s common for us to see the second opinion kinds of cases.”
AIUM Position
Paula Woletz, RDMS, RDCS, MPH, is director of accreditation for the American Institute of Ultrasound in Medicine (AIUM). The AIUM is composed of physicians and institutions that specialize in ultrasound treatments, regardless of their discipline. “Our concern is that the ultrasound be done well, not who it is done by,” says Woletz.
She says the AIUM works with the ACR and the American College of Obstetricians and Gynecologists (ACOG) to develop voluntary accreditation standards for ultrasound treatment. AIUM and the ACR both offer voluntary ultrasound accreditation. Woletz says accreditation is needed because there are “few to no regulations regarding the practice of diagnostic ultrasound.
“With very few exceptions, any licensed physician is able to interpret a sonogram with or without training,” she adds. “The exceptions are that with Medicare and Medicaid there are stricter guidelines for vascular ultrasound, and in California to qualify as a prenatal practice you must be accredited by the AIUM or the ACR.” Woletz says nonradiologist AIUM members doing ultrasound make up a long list of specialties including OB/GYN, vascular surgeons, breast surgeons, pediatricians, family practitioners, emergency doctors, nephrologists, and urologists.
A particular headache for the AIUM, says Woletz, are the so-called fetal keepsake video providers who use ultrasound to make pictures for parents of their babies-to-be in the womb (see story, page 34). But fetal keepsakes are not the only concern. Woletz calls it “buyer beware” for ultrasound imaging in general. “Given the absence of mandatory regulations, it’s up to the patient and the referring physician to look into the facilities the patient goes to,” she says. “If they’re not accredited, they should find out how experienced they are, because the vast majority of those who do ultrasound are not accredited.”
Woletz says the AIUM has not involved itself in seeking regulations on the practice of ultrasound. But she disagrees with those who argue that the overall quality has gone down. “Particularly in obstetrics,” she says, “the advances have made it possible to see things sooner and see them better. If we saw an embryo with the naked eye, we would not be able to see as much detail as we can with a sonogram now.”
Malpractice Issues
Because ultrasound is unregulated and inexpensive compared to other imaging modalities, the question arises whether poor ultrasound interpretation contributes to the number of obstetrical or gynecological malpractice cases. If it does, then does that put upward pressure on all malpractice rates?
Neither question, it seems, can be answered in a decisive way. If the data is there, nobody appears to have it in hand. At the Physician Insurers Association of America (PIAA), which is made up of malpractice carriers, insurance rates are not tracked, according to Lori Bartholomew, MPA, who is PIAA’s director of research.
Bartholomew says none of her data suggests that the proliferation of ultrasound imaging has had an effect on the number of malpractice claims. A PIAA study of radiology practice standards did demonstrate that, for certain procedures, meeting ACR and other accrediting standards did tend to reduce the number of claims filed, Bartholomew says, but hard numbers were lacking. “The standards of ACR have helped,” she says. “If [ultrasound practitioners] can document that they have met the standards of care, they can prevent claims.” She says PIAA is now conducting a study to see how much communication problems between doctors and patients contribute to malpractice claims being filed.
Steven R. Goldstein, MD, is an obstetrician/gynecologist and director of gynecological ultrasound at New York University Medical Center. He is also a professor at the NYU medical school. Goldstein does legal consulting in ultrasound malpractice cases, as he puts it, “on both sides of the fence.”
Like his colleague Ilan Timor, Goldstein says the important factor in ultrasound interpretation is expertise, not one’s specialty. “There are plenty of radiologists who have sonographers making the diagnosis, and they’re signing off on it,” he says. “I see the culpability split between practices. Those who limit themselves to ultrasound tend to be better at it, whether it’s the OB/GYN or the radiologist.”
Goldstein says most malpractice cases he sees have to do with fetal abnormalities. “But in the last couple of years, I’ve started to see cases involving gynecological ultrasound.”
Contrary to what some are saying, Goldstein maintains that the AIUM standards and others have made ultrasound more professional and of higher quality than in the past. “Now that there are standards that are more developed, the people doing the [substandard] work are much less in number than they were 10 or 20 years ago,” he says. “We have raised the bar in order to get people out of the business who think this is a cash cow and who are going to work the procedures. I give a lot of credit to the AIUM.”
Carol Rumack, MD, is a professor of radiology and pediatrics at the University of Colorado Health Sciences Center in Denver. Rumack is also a member of the ACR’s panel of governors and chair of the ACR ultrasound commission. Like Goldstein, she says most ultrasound malpractice cases occur in obstetrics. “They [obstetricians] get sued for wrongful death and wrongful lifepeople saying Now I’m stuck with this baby I don’t want.'”
While it does not relate necessarily to malpractice, Rumack says that one area that concerns her is abdominal ultrasound images being read by emergency department doctors. It is easy for them to miss ectopic pregnancies, she says. “They are really hard to diagnose. It takes about 300 obstetrical ultrasound cases to learn how to do them right. That’s what we require of our residents.”
Conclusion
“A lot of obstetricians keep an ultrasound machine in their offices just to check pregnancies. Most of them don’t even bill out for it, because many managed care plans will not pay for ultrasound done in an OB/GYN office,” says Steven L. Edell, DO, FACR, FAIUM, who is medical director of the Women’s Imaging Center of Delaware in Wilmington. “I don’t have a problem if they just want to see if there is a pregnancy or a demise.
“I do see radiologists losing business when I hear from my colleagues around the country,” Edell adds, but he gives perinatologists high marks for their ultrasound ability generally. “The perinatology [use] is high quality.”
Edell says radiologists have the edge when it comes to the latest equipment and the detailed interpretations available with color and Doppler ultrasound machines. “I’m buying one now for $180,000 that is color flow, Doppler, and very high resolution, because I do vascular and other high-end imaging.” For Edell, the best response to the proliferation of ultrasound imaging seems to be to go with the flow. He says radiologists still have the edge in research as well as the edge in using contrasts that allow them to interpret minute structures. “We have a nice rapport with our area obstetricians and gynecologists,” he says. “If they don’t know what they’re seeing, they send it to us to interpret.”
Sharing, cooperation, and recognition of expertise no matter the specialty are a theme voiced by many OB/GYN and radiologists, despite the problems of admitted turf wars.
Arthur C. Fleischer, MD, is chief of diagnostic sonography and a professor of radiology and OB/GYN at Vanderbilt University in Nashville. He agrees with Edell that radiologists continue to have the edge in high-end ultrasound interpretations. “Basically, the 3D reconstruction algorithms in ultrasound are the same ones used in CT and MR,” he says. “Radiologists understand the 3D process and evaluating contrast, which are areas OB/GYNs are not real accustomed to.”
Like others, Fleischer champions sharing between disciplines. At Vanderbilt, he says, radiologists and obstetrician/gynecologists have joint appointments and cooperate in training, technical staffing, and equipment purchasing decisions. “In November, we will be in one location for everything,” he adds. He says the combined program has worked well for doctors and patients. “If you don’t provide good service and expertise, I’m sure there are all kinds of competition. That hasn’t been the case here.”
But as Carol Benson argues in describing a similar radiology and OB/GYN alliance at Brigham and Women’s Hospital, ultrasound in academic medical settings “has nothing to do with the real world.”
George Wiley is a contributing writer for Decisions in Axis Imaging News.
