THE FUTURE ROLE OF RADIOLOGISTS
patients through the diagnostic deci- sion-making pathway) they may not be implemented unless appropriate cost reimbursement are in place. [Figure 1]
THE NEED TO SUB-SPECIALIZE In the past, one of the attractions,
FigUre 2. An “expert” clinician who is used to seeing detailed images in his field can be more skilled than a “general” radiologist in interpreting these images. But there can still be situations where a radiologist can detect anomalies or incidental findings that the special- ist in the other field may fail to interpret. The above case is a young lady presenting with neck pain and referred by an orthopedic surgeon. The MRI shows that there is no problem with the spine but that there is a mass anterior to the upper thoracic spine. The radiologist decided that this merited further investigation and more detailed radiological examinations were undertaken ultimately ending up with the diagnosis of a malignant lymphoma with appropriate treatment initiated. The diagnosis of this potentially more dangerous condition than the rea- son for the original referral was only possible because of the width of experience of the original radiologist
For hospitalized patients, a huge propor- tion of their overall costs arises from the cost of the stay in hospital, so any pro- cedure which can be shown to shorten this (and it is important to be able prove it) will be looked on favorably by the reimbursement authorities. It is how- ever important to distinguish between “expensive” and “cost-effective”. There is no doubt that modern imaging sys- tems are extremely expensive, but if they can be used to establish a diagnosis and initiate treatment quicker than would otherwise be the case, then the increase in cost-effectiveness is clear. There is no need to apologize about expen- sive machines — we just have to use them properly. In the modern world, cost and reim- bursement issues have an impact every- where. Thus, even when it is generally accepted that new procedures (such as more direct interaction by the radiolo- gist in the typical pathways of processing
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even the “fun” of being a radiologist was the broad spectrum of cases that is likely to be met. This is likely to disappear. The reason is that, as modern systems pro- vide more and more detailed informa- tion and about structure and function (and the provision of functional infor- mation is becoming increasingly impor- tant in radiology) there has been a real explosion in the knowledge required to correctly interpret such images. It is sim- ply not possible for any one person to be able to hold the knowledge needed. Hence the need to subspecialize. Other- wise an “expert” clinician in a particular field, e.g. a liver surgeon, who sees such specialized images on a routine basis will be able to interpret the images better than a “general radiologist”.
«.... radiologists need not be
ashamed of the high cost of the machines they use — they just have to use them better....»
Despite this, situations exist, particularly in the identification and interpretation of incidental findings, where the broad expertise of the “general” radiologist can be of more value than a specialist in another field [Figure 2]. In addition, the situation regarding
subspecialization varies considerably from country to country. Even the use of the term subspecialization itself is frowned upon in some countries where it can be interpreted as being “over-spe- cialized” or only familiar with one field and ignoring the rest. For those radiologists who may be afraid of this use of the word sub-specializa- tion an alternative (used in France) is the term “special interest”., which has the advantage of meaning being very good in one field but still good in all others.
view,
DISEASE-ORIENTED CENTERS From the organizational point of radiology departments can be
classified into two main categories. The DI EUROPE
first is the “Factory” type of organization where there are huge reading rooms in which the radiologist reads the images in front of him without knowing where they come from either next door or from the other side of the world. Even the PACS often doesn’t tell the radiologist which machine is being used. In such circumstances, the radiologist will, at the end of the day have done his job by interpreting the quota of images without having seen a patient. Such “radiology factory set-ups” are however still needed simply because of the huge number of images to be interpreted.
«.... in the past the «fun» of being a radiologist was
being confronted with a large spectrum of different cases. Tis will disappear...»
In the context of the huge numbers of images to be read in the “factory model” it shouldn’t however be forgotten that, statistically, by far the largest group of patients whose images have to be inter- preted are basically healthy patients whose radiology images are normal. The other type of organizational set-up is the disease-oriented center where a different organization is required since this is at a higher, more problem-solving level. In such centers frequently certain medical (not radiological)specialities have developed. For example in breast centers the patients don’t come with the question “do I have a problem?” but rather “I have a problem — what is it?”. In some cases e.g. in the interpretation of breast micro-calcification, the radi- ologist can be the principal player, while in other cases, the surgeon is the appro- priate person to advise the patient. The important thing is to have the flexibility to have the necessary specialists avail- able in the disease-oriented centers, an option which is not possible in the “fac- tory” model of radiology. In such disease-oriented centers,
a
question frequently arises, namely who “owns” the radiology machines. Such arguments are futile— what’s important is not so much the “ownership” but the “management” of the scanners and that is the role of the radiologist, who can then play the role of guardian in such areas as safety
APRIL/MAY 2012
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