The Readers Respond

Our coverage of recent self-referral topics generated some feedback. Here are a couple of examples. We encourage readers’ letters.

Tending to the Taint of Dubious Exams

You have really missed the hidden point (“Study Offers a Gut Check on Self-Referral,” August 2008).

Radiologists are an important part of the self-referral problem and a 300+ percentage increase in abdomen CT due to radiologists is something to lament, not praise.

As much as two-thirds of all inappropriate CT is done in hospital where radiologists can, but often avoid interacting to reduce the number of questionable exams. Anyone believing that a captive, hospital-based radiology practice is not influenced by the fear of retribution from the front office or ignorant of the millions of dollars generated by imaging of dubious clinical value is naive.

We are equally well paid for interpreting clinically inappropriate studies, especially the millions of exams done for marginal reasons through the emergency department. All excuses aside, this has the same taint and same odor as equally dubious exams done in a private office building.

As the old saying goes, these are distinctions without a difference and the American College of Radiology and radiologists should acknowledge the problem rather than point fingers at others.

Craig Clark, MD, JD
Cedar Rapids, Iowa

Evolving Health Care Services Not the Same as Improper Utilization

Your article (“Self-Referral Reform,” July 2008) does not present a balanced view of imaging utilization. As a matter of practice in medicine, physicians (including radiologists) routinely practice self-referral as they diagnose and treat their patients. For example, if a surgeon evaluates a patient, determines that they have appendicitis, and performs a curative surgical procedure, that is self-referral, and it is widely accepted as a normal part of medical practice.

“Improper utilization” of medical resources, imaging included, is an undesirable outcome with many causes. Misallocation in imaging utilization has myriad facets, stemming from varied intentions on the part of all those that control and direct medical assets. It can result from a referral for inappropriate or redundant imaging procedures by an uninformed generalist clinician. It can occur when a radiologist, in a radiology-owned outpatient facility or hospital, suggests additional studies to be performed at that facility that may not actually be required for the diagnosis and treatment of a patient’s condition. It can also come from a specialty clinician in-office imaging facility as the article suggests. Members of the American Society of Neuroimaging (ASN), a professional organization representing neurologists, neurosurgeons, neuroradiologists, and neuroscientists, are opposed to the overutilization of imaging services. However, growth in the use of an imaging modality within a specific specialty by itself, without a review of patient outcome data, does not necessarily represent improper utilization. It represents a change in the types of health care services delivered to patients with a specific category of conditions.

Lawrence R. Wechsler, MD
Vice President, American Society of Neuroimaging, Minneapolis