By definition, specialists are devoted to a specific area of medicine. Yet that does not mean there is no crossover. Leukemia falls under the purview of hematologists and oncologists. Certain spine conditions can be treated by an orthopedist or a neurosurgeon. Cardiac imaging exams may be read by a cardiologist or a radiologist.

Naturally, some competition can develop in these overlapping areas, particularly when billing is at stake, but collaboration is always the best choice—for both the patient and the physicians. Each specialist offers a unique perspective and expert knowledge. Where they start to overlap is often where they must work together.

“Obviously, cardiologists and radiologists are not going to work together to manage a patient with heart failure or read a brain MR. Those are two areas that are clearly separate. But as you get closer and closer, like reading an echocardiogram or a chest radiograph, the divisions begin to blur. The focus of overlap right now is on CT and MR,” said Geoffrey Rubin, MD, professor of radiology and chief of cardiovascular imaging in the department of radiology at Stanford University School of Medicine, Stanford, Calif, and chair of the ACR Cardiovascular Imaging Committee of the American College of Radiology (ACR), Reston, Va.

Time has helped to work out past workflow and responsibility issues, such as those surrounding echocardiography and cardiac catheterization. But newer modalities, in particular cardiac CT, are in a current tug of war. Billing and reimbursement issues further aggravate collaborative efforts, but there are many creative solutions.

Allen Taylor, MD, chief of cardiology service at Walter Reed Army Medical Center, Washington, DC, suggests that these arrangements depend very much on the strengths and weaknesses of the groups and the individuals. “In one center, one of the groups may not have an interest in cardiac imaging so the other takes the lead. In another center, both groups are interested and they divide the work evenly. I don’t think that one way is better than another, but a contentious approach is not productive. It’s better that people work together,” Taylor said.

Which Modality

Rubin concurs. “The tendency for cardiac CT to be performed by a certain group is dependent on the level of interest. In centers where they both have a strong interest, they will either work together or there will be a battle,” Rubin said.

Rubin attributes the potential volatility to the modality’s infancy. “CT has focused on vascular imaging for about 15 years now. The cardiac segment was first introduced in 1998 and has been maturing over the last 4 years. So there is a more volatile circumstance because it is a situation where there are fewer individuals who are highly experienced with it,” Rubin said.

Experience may play into the selection of a modality if there are options, but often the situation (eg, symptoms, patient medical history, etc) dictates which particular exam should be ordered. “To a certain extent, MR and CT do have overlap capabilities, but if the physician really thinks about it, he can identify the preferred exam,” Rubin said.

If there is more than one way to arrive at an answer, the physician ordering the test will often choose an exam with which he or she is more experienced. “I don’t think that one favors one exam over the other, but it is based on experience,” said John A. Rumberger, PhD, MD, FACC, director of cardiac imaging at the Princeton Longevity Center, Princeton, NJ.

The differences then depend more upon the physician than his or her specialty. Rubin cites determination of the impact of ischemia in the myocardium as an example. “There are three competing modalities—stress echo, nuclear perfusion imaging, and MR perfusion—which have very different representative usage based on the practice of cardiology,” Rubin said. But the choice is individualized rather than disciplinary.

Similarly, some practices may be more MR-focused while others are CT-oriented, but even this dichotomy is muted. “In the instances in which there are lots of ways to get the same answer, you do what you are best at,” Taylor said.

One benefit of a collaborative effort, however, is the ability to broaden a testing menu. More people, particularly with a different background, mean more skills and subsequently more options. “Say the cardiologist can do everything but cardiac MR, but it is the right test for the patient? If the radiologist can perform the exam, then because of that collaboration, the patient has more options,” Taylor said.

Who Interprets It

Of course, battle lines are not drawn over which modality to use as much as over which physician gets to interpret the image. “When a battle occurs, they are most likely to battle about one group having the opportunity to interpret and perform the imaging study,” Rubin said.

Some of the disagreement is centered on who is the most experienced, qualified, and/or better equipped. Cardiologists tend to believe that their unique knowledge of the cardiac system and their clinical perspective make them well equipped to read these exams. Radiologists believe their understanding of the physics and technology, as well as vast image reading experience, make them uniquely qualified to read.

“These can both move toward the middle. Cardiologists can learn about the workstation, and radiologists can learn about alternate imaging procedures and cardiac medicine. But it’s unlikely that without tons of experience one will know everything the other knows. So there will always be, to some degree, a gap in what each discipline knows and the way they approach things,” Taylor said.

Some, like Taylor, believe these differences can be capitalized on, but others are wary of relying too much on them, particularly when they extend to philosophy. Radiologists and cardiologists differ not only in technical background and knowledge but also in approach and perspective.

Cardiologists may be more likely to interpret readings with the clinical circumstances in mind, whereas radiologists often take a more objective approach. “There is value in putting the exam in clinical context,” Taylor said, suggesting the better a physician knows the patient, the better the clinical context.

Others believe image interpretation should occur independently of the clinical report. “A cardiologist is more familiar with the overall function of the heart, not just its anatomy, which may bring something special to the interpretation, but I think you can go too far. If you allow your perception of the clinical circumstances to color your interpretation of the images too strongly, then you are not performing an independent interpretation,” Rubin said. If the objective interpretation is overly influenced by the subjective symptoms, the resulting diagnosis may be inaccurate.

Another philosophical difference centers on the need to read outside the area of the heart on images taken for cardiac purposes. “The importance of reading all parts of the film to not miss a finding that might otherwise go undetected is a basic fundamental credo of radiologists,” Rubin said.

However, cardiologists do not necessarily agree with this philosophy. Some believe the potential risk that can result from false positives is not worth the benefits of diagnosing an unexpected condition. Rubin acknowledges that there are valid concerns. He contrasts two situations.

The first is the patient whose image reveals a suspicious lung nodule that turns out to be cancer. The malignancy, however, has been discovered before it has spread, much earlier than may have otherwise occurred, and the patient undergoes surgery and treatment and extends survival. On the other hand, there is the patient who undergoes a biopsy for a suspicious lung nodule, and although the biopsy is negative for cancer, develops pneumothorax, which causes the lung to collapse. A subsequent hospital admission precedes a cavalcade of events that eventually result in the patient’s death.

These cases represent extreme ends of the spectrum but provide valid arguments for both sides. Some suggest more studies are needed to determine the clinical value of peripheral findings.

Yet, however one feels about the need for complete image interpretation, this peripheral portion of the read presents an excellent opportunity for collaboration. Imaging modalities commonly read by cardiologists—echocardiography, cardiac catheterization, and nuclear stress testing—capture only the heart, whereas MR and CT also image surrounding areas. “Radiologists are qualified to read the lungs and surrounding tissues, even the pulmonary arteries, while cardiologists are experts of the heart only,” Rumberger said.

A collaborative effort can provide a reading of the entire image and use the expertise of each: in some institutions, the cardiologist interprets the heart and the radiologist reads the surrounding area. In other institutions, such as the Stanford University School of Medicine, the two disciplines read together. “We interpret MR jointly, with the cardiologist and radiologist reading together and forming a consensus opinion,” Rubin said. At the Walter Reed Army Medical Center, the two groups alternate reads.

These processes avoid having to merge two separate reports that may have different opinions. Rumberger suggests there should be few differences in interpretation if both readers have been trained competently, though there can be disagreements related to the severity of a narrowing in the heart artery, for instance. Taylor thinks disagreements can actually be quite common.

“Interpretive skills have a subjective nature and experience definitely plays a role, so two people can easily disagree. It has been well documented. But it is not a radiology-cardiology issue. It’s just two different individuals looking at the same thing and interpreting it two different ways,” Taylor said.

In these instances, one physician has to convince the other of his interpretation, and the two must come to some sort of agreement. “This is where a second test can prove valuable or where uncertainty can be framed in a clinically appropriate way,” Taylor said. Ultimately, it is the clinician who will decide the impact of that information on treatment.

Who Bills It

The interpretation of the exam is the item for which a physician can bill, however, and limited reimbursement presents challenges for any discipline. “Right now, cardiac CT in particular is in a volatile state of reimbursement, particularly from CMS [Centers for Medicare and Medicaid Services], so there is not a lot of financial gain to be had right now in performing these studies,” Rubin said.

Joint work presents a particular economic challenge as reimbursing agencies will not pay for a duplication of effort. Peripheral reads can be claimed, but double reads cannot. Few physicians want to sacrifice 50% of the profit through an even split, particularly when they are still performing 100% of the work. However, Rubin suggests they may have to weigh these options against their interest in the program. Rubin has seen some institutions pay an additional interpretation fee out of pocket to the physician performing the double read; but the institution does not receive reimbursement for this fee. “If the activity results in an increase in patients coming into the cath lab and an increase in admissions of patients requiring coronary revascularization, then it is to the hospital’s advantage to see the diagnostic service flourish,” Rubin said.

The future, however, is likely to be different. “There is very little disagreement that these technologies will play an increasingly important role in clinical care, and compensation is just awaiting more refined data and an evolution of thinking on the part of those at CMS,” Rubin said.

It also may require a bit of evolutionary thinking on the part of cardiologists and radiologists. Cardiac MR and CT workflow is likely to eventually settle into a routine, much as previous technologies have, but the two disciplines will have to play nice to get there.

Sandbox Rules

“The fighting in the sandbox has to end,” said one source when discussing cardiac imaging and the relationship between cardiologists and radiologists. Some groups have not yet figured out how to get along. If both want to be involved in cardiac imaging, however, they are going to need to learn how to play together. Following are some tips for achieving a harmonious working relationship.

  • Focus on the patient: “The patient comes first,” said John A. Rumberger, PhD, MD, FACC, director of cardiac imaging at Princeton Longevity Center, Princeton, NJ. With patient care at top of mind, collaboration should be thoughtless.
  • Respect your colleague: “I think the biggest tip, without a doubt, is to respect your colleague,” said Geoffrey Rubin, MD, professor of radiology and chief of cardiovascular imaging in the department of radiology at Stanford University School of Medicine, Stanford, Calif, and chair of the ACR Cardiovascular Imaging Committee of the American College of Radiology (ACR), Reston, Va. Rubin believes respect will influence actions.
  • Work for a win-win: “Solutions can be very tailored to the people, setting, and community. Everyone needs to look for win-win opportunities among what needs to be shared,” said Allen Taylor, MD, chief of cardiology service at the Walter Reed Army Medical Center, Washington, DC.

“Technology won’t take off in a situation where there is disgruntlement or disagreement, particularly when collaboration is not allowed,” Taylor said. Collaboration, however, can result in new and positive achievements, and a positive working environment benefits everyone.

—R. Diiulio

Renee Diiulio is a contributing writer for Medical Imaging. For more information, contact .