Debate over incentives and costs misses important element: Who’s the expert?

A number of articles and letters have been published in the past several years, gaining more momentum of late, regarding self-referral. This has become a major point of discussion for CMS, state and federal legislators and regulators, insurance companies, and medical organizations (including the AMA, ACR, and other specialty societies). Much of the discussion has focused on the perverse incentives and added costs of ownership of equipment and billing for procedures. I have no doubt that there will soon be a solution to the obvious conflict of interest issue. Hopefully, it will be one that preserves the value of radiology, and not one that reduces the value so that only radiologists want to do imaging.

On the other hand, especially should the current trend in other specialists dabbling in imaging continue, there is another perspective to this issue that should not be ignored.

We have a tendency to think that anyone with sufficient academic acumen and several years’ postgraduate training in medicine or surgery could learn to interpret imaging. However, I would state this is not necessarily the case. I’m sure every radiologist reading this article can recall a recent instance of having painstakingly labored to explain the location of, or the surgical approach to, a lesion depicted on two-dimensional films to a clinician who simply cannot conceptualize the finding in the three-dimensional space that we and the patient inhabit. We frequently use workstations and 3D images to attempt to get our point across. Although these images usually are not required for us to interpret a study, they can be very useful, for example, to a surgeon attempting to plan a surgical approach in a manner in which they think.

We have a skill not easily possessed. Some cannot learn it, and some can only superficially learn it. Hopefully, our residencies and our practices have selected those of us who can “see” where things are and their relationship to other structures on two (plain films) to 2,000 (MDCT data sets) two-dimensional images. A weekend course or a week-long externship doesn’t convey this knowledge.

Even if a specialty can learn to interpret images, they generally learn only the salient features in which they have an interest and tend to ignore the other findings and structures on the film.

In addition to specialty tunnel vision, nonradiologists are far more susceptible to satisfaction of search errors. We know and struggle against this error as a result of our training and its constant presence in our literature. Once the nonimager sees the finding confirming diagnosis or the obvious abnormality, search for other findings ceases.

We provide a complete exam evaluation, able to evaluate the multiple structures visible on a host of studies and compare them to other imaging tests, many of these completely unfathomable to the referring doctor. After training, the cardiologist sees the coronary arteries but not the pulmonary embolus. The pulmonary specialist sees the lungs and the mediastinal lymph nodes, but not the aortic dissection.

Even those specialists who do feel they can interpret imaging exams betray themselves without understanding they do so. A neurologist once told me he felt he was as expert as any radiologist at reading MRI. I agreed he might be equivalent to some of my partners who rarely read MRI of the brain, but I doubted he was as good as any of our neuroradiologists. I asked who he showed studies to when he had questions. When he gave two of the neuroradiologists’ names, I asked why neuroradiologists and not his neurologist partners. Unfortunately, it is impossible to know if there are studies that should be referred when the abnormality is not appreciated.

In addition, if a single clinician “owns” the patient, even within a group practice, then they will likely be the only physician reading the patient’s exams and where does quality control and peer review happen? Is a formal written report generated? Can you request the prior study for comparison with a report from the clinician’s office? In my community, the answer to most of these questions is no.

I was once asked by a pulmonologist in our Chest Conference, when looking at the PET data without the CT images on our PACS from a PET/CT, how I knew where I was when pointing out an area of abnormal activity in the right hilum. My reply was simple, “I am the roentgenologist.”

William T. Herrington is a member of Athens Radiology Associates, PC, Athens, Ga, and president of the Georgia Radiology Society. For more information, contact .