RADIOLOGY — THE INEVITABILITY OF CHANGE Before the real debate began, the basic
question of change in the profession of radiology was addressed, together with the subsidiary question of whether actu- ally any change is inevitable or not. Here at least there was a broad consensus — there is no doubt that the profession is changing, but in itself that need not be alarming. After all, change has been part of the development of radiology since the beginning of the profession and the main thing is that the radiologist should be part of the change and not be by-passed by the change. There are even some basic aspects that are not changing at all — such as the ultimate importance of providing optimal care to the patient.
However — and it’s a big however — the changes that are affecting radiol- ogy nowadays are actually much more fundamental than any that have shaped the profession in the past. One obvious development is the veritable explosion of the expertise that is now expected of radiologists, who, thanks to technologi- cal advances, are routinely confronted with images containing much more information than was ever available in the past. The increase in knowledge that a modern radiologist must pos- sess in order to deal professionally with such images is not just a challenge for the individual but also is putting huge strains on the structure and operation of classical radiology departments. For example, the trend toward sub spe- cialization inevitably means that there are now radiologists who have closer professional contacts with other clini- cians in that sub-speciality than with their colleagues in the radiology depart- ment. The creation of centers focussing specifically on sub specialities such as cardiology or neurology, is a huge devel- opment that worries, even scares, a lot of radiologists.
What’s more, the pace of change is itself changing, as are the factors that are driv- ing such changes. Before, it was purely technological developments, such as the move from single slice to 64 slice CT
APRIL/MAY 2012
systems, that drove the evolution. Now, increasingly, economics and financial investment issues are impacting the pro- fession and are frequently operating on a much shorter time-scale. Whereas in the past it was reasonable to have a view of the likely evolution/trends in a depart- ment over the mid-term, if not the long- term, now decisions are often having to be made based on a perception of how things will be budget-wise next year.
REIMBURSEMENT Whenever the issue of budgets and
investment economics arises, inevitably the question of reimbursement emerges at the same time. In this period of eco- nomic
down-turn and ever-greater
pressure on healthcare budgets, not to mention that the new developments
in radiology are almost invariably extremely expensive,
reimbursement
issues are becoming even more impor- tant than they were in the past. Where once the reimbursement authorities would consider technical parameters such as accuracy sensitivity, specific- ity, etc. to decide whether a procedure should be reimbursed or not, nowadays the single factor that is becoming more and more important is quite simply how beneficial is the procedure to the patient. When this concept of “value for money” is applied it is going to be more and more important for radiologists to be able to quantitate the specific benefits that they bring to what is after all only one part of a complex chain of procedures involving the patient and the ultimate clinical outcome.
FigUre 1. A typical pathway that a patient in the UK who presents to his general practitioner or primary care physician with symptoms such as coughing up blood has to go through. The GP would send the patient for a chest X-ray; a report describing the presence of a lesion would then be sent back to the GP, who would then send the patient to the Chest Clinic, where a CT might be taken, confirming the lung lesion. A multi-disciplinary meeting (MDM) would then be held and decide that a biopsy should be taken, which could confirm that the lesion is cancerous. A staging CT might then be taken followed by another MDM, where the decision could be taken to send the patient for surgery. Such a complicated, long-winded procedure could even be more involved, e.g. if a PET/CT is decided upon.
Clearly such a procedure is not only extremely stressful for the patient, but is also very expensive. A simpler procedure would be for the radiologist to be proactive and say organise for the biopsy and CT to be taken before the patient leaves the department and interact directly with the patient and the GP. Ironically the most frequent resistance to implementing such a simplified pathway comes from the radiologist himself, who may feel that his mission is only to interpret images. Additionally, the cost of the radiologist’s time in dealing directly with the patient and organizing the procedures needs to be reimbursed.
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