I recently attended the Neuroimaging convention in New Orleans. Neurologists are poorly compensated nationally with average income being 140K-180K. Any thoughts/information as to how much boost would incorporating Neuroimaging in your practise will provide. Currently...average compensation per patient say is about $110.00 nationally.

Please comment.

What greed! If you think Neurologists are poorly compensated and want to interpret neuroimages, then switch fields and become a neuroradiologist. You chose to go into neurology, no one prevented you from choosin radiology.

What a freakin disservice you will be doing to your patients. You will be married to your clinical diagnosis and then interpreting the images with extreme bias. Not to mention the improper training! Common, you really think a month here and there, a couple of hourly conferences is enough to know the nuances of all neurological disease as well as the technical side of MRI and CT!

Please stick to seeing patients! That is what you are good at and are trained at. Let me read the images. I certainly do not want to see your patients even if I do know neurological disease as well as the treatment for many of the disorders.

Greed is what is ruining the medical establishment.

Let the flames start, but I feel a lot better:D

oldandtired,

If you weren't a radiologist or a radiologist-in-training, I think your post might carry more weight. You seem to be on the defensive (protecting against a turf war?).

Your points are well taken but seem to be made in your classic style. That said, I suggest a new user ID for you:

oldandtiredandbitterandmeanandrude

Cheers,

Frank

My two cents:

If you want to do neuroimaging, please do yourself and your patients a favor by doing a radiology residency.

Think twice before taking on the financial risk of running an outpatient magnet (as you would not get priveledges to do so inside an hospital with a radiology department) as well as the medicolegal risk of interpreting images without proper training. Not only could you declare bankruptcy by not having enough cases to support your magnet, but you will be crusified on the stand by your local neuroloradiology when you do miss that sinus tumor that could have been resected 6 months ago, but now is inoperable and will lead to the patient's death (cause all you were interested in is the brain). And believe me the medical malpractice lawyer will beg and plead to the jury to give their client an especially extra large award to deter others from rendering sub-standard unqualified medical care. And then when your malpractice insurer doubles or triples or quadruples your premium, you will be left pondering "was it really worth it?" Or worse yet, no malpractice insurance will give you coverage. I'm not trying to be mean or rude. Just giving you a dose of reality We all have to make choices in life. Choose wisely.

Yes, I will be going into radiology. So take everything I say with a grain of salt, but these thing do and have occurred.

Come on now...what are you guys smokin? Do you REALLY think you're better at reading neuro than a well trained neurologist?
While you're spending vast amounts of time studying GI, GU, pulm, cardio and ortho rads (not to mention US, mammograms, arteriography etc., etc.), I'm spending every single day studying neuro films. I'm curious...just how much time (exactly) do you spend learning neurorads and who is teaching you? Does EVERY rads program have fellowship trained neuroradiologists?

I am being taught by an amazing group of neuroradiologists, as are our radiology residents. However, even with a good rads program like ours, we still spend so much more time on neurorads that our ER docs routinely have us double check the readings of the radiology residents. I can't imagine the gap in experience will narrow as time goes on.

Don't misunderstand, I have no desire to charge for reading my own films...I have enough liability as it is. However, I have been taught (by every neurologist I have ever worked with) to NEVER rely on general radiologists as they don't usually have sufficient training.

I'll always defer to a good neuroradiologist, but unless you're fellowship trained, don't expect me to trust your readings...I know better.

Come on, cut the crap.

My radiology residency has many fellowship trained neurorads. In fact before the explosion of MRI/CT/US, one of the biggest fellowships in radiology was neuroradiology and thus many practices have a good percentage of neuroradiologists. I have no doubt that a fellowship trained neuroradiologist is better than many general radiologist in terms of neuroimaging. However, a neurologist is not in the same league at reading neuroimaging as general radiologist. ... What are you smoking?....

The problem is you are not properly trained in the physics of MRI to interpret images. If all you know are t1 and t2 and don't understand MRI physics and it's principles then you will not understand what images from other sequences mean. Thus, you cannot interpret Brain MRI images as good as even the general radiologist. And the radiologist will be required to keep up with changes in the MRI technology even when he finishes residency. He sees tons of brain MRIs every day and not just the cases that you personally refer, but ones from the entire community of neurologists in his geographic area. Many private practice neurologists do not even look at the images once in clinical practice, but read the reports. Also, radiologists are not blinded by our clinical diagnosis so that we look at the the whole image not just one particular area.

Lastly, I doubt many neurologists have the time or the energy or desire to keep up with the nuances of the different MRI sequences because these neurologists are busy running a practice. You may be the exception, but I think this is generally true. Radiologists however must and do keep up with the technology. I'll put up my neurorad skills (once I finish residency) against any general neurologist out there. Bring it.

This debate is a non-issue. In the hospital setting, academic or otherwise, the radiologists will read the films formally and the neurologists will glance through them. In the outpatient setting, its pretty much the same. Some neurology groups have CT scanners and I know of one who recently acquired an MRI scanner. These groups pay a radiologist to read the films. The radiologist is employed to read the films - and don't worry, there's more than enough money to be made.

As to the general abilities to read films: its a bell shaped curve isn't it. I trust myself to read CTs and one of our neuro residents seeing something that the radiology resident didn't occurs so frequently its an event not worth mentioning. BTW, for some reason this occurs with posterior fossa lesions and white matter lesions. I feel ahead of the curve in this matter. But I'll never care to know the signal characteristics of the different tumors (perhaps MRS will help with this in the future), or the age of blood on T1/T2 (although I'll know it for the boards), or anything in the spine. Compared with any neuro-rad fellow, I'm probably hitting about 10%ile. But compared to a general radiologist, I feel very confident - after all, I haven't seen a KUB in over 2 years.

But it doesn't at all matter. We have to be experts in our fields. My field is not just looking at films. I don't want to do only that. I want the expert to do that. And even though I might be better at reading some CTs, a jury would never get to hear about it because the case where I - with no radiologist - missed that UBO that bloomed into that GBM will be settled. Would I even be covered?

Voxel,

It doesn't take a physicist to understand the differences between imaging sequences. Also, what makes you think that we aren't required to keep up with changes in MRI technology? It might surprise you to know that neurorads is a big part of our boards.

I guess some of my bias comes from experience. As a student and intern, I did rads rotations (with general radiologists) just to get more experience with neurorads...I was very disappointed. These radiologists did NOT read "tons of brain MRIs everyday". They might have two or three a day, but not "tons". Also, they seemed uncomfortable with unusual pathology. In the end, I learned more from the neurologists who came by to look at their own films (almost always after the radiologists had left for the day...still not sure if that was coincidental).

Call me crazy, but I'd guess there's a good reason for the existence of neurorads fellowships (not everyone goes into interventional). In fact, my department is so distrusting of general radiologists that it has a policy of NEVER treating based on the rads report alone. If a patient doesn't come to their appointment with films in hand, they must return with the films or have them redone by our facility. That's how I'm being trained and that's how I'll practice. Actually, I've never met a neurologist who didn't read their own films. Just because you're not seeing it doesn't mean it's not happening. BTW, only an idiot would stay married to a clinical diagnosis if the imaging pointed to a different type of pathology and only a bigger idiot would focus on one particular area of the films and ignore the rest.

I consider you an intelligent and articulate contributor to these forums, however with respect to this particular topic I do not agree with your comments. Your statements might carry more weight if you actually were a radiology resident, but you're not. Why don't you get back with me in a year or so, when you've had some REAL experience.:rolleyes:

I highly doubt that neurologists are trained in reading head and neck images outside of the brain. You may think you can look at structures other than the brain and find them with the same accuracy as radiologists, but I doubt that this is the case.


The thing is that academics is different than private practice. The neuroradiology department in my medical school was very strong. However, the general rads were no slouches in private practice either. I have also shadowed several private radiology practices. There is a world of difference in the level of competency required in private practice vs academia. In my med school all the neuro imaging was read my neuroradiologists. There were *no* general radiologists. They were all highly subspecialized into MSK, Body, ultrasounds, Peds, Neuro, Neuro IR, etc. In private practice it is different in that most practices have ~2 or neuroradiologists out of 8. However since they were doing about 20 brain MRIs per day on average (1 inpatient magnet and 1 outpatient magnet and not including head CTs and fetal/neonatal head ultrasounds) in one practice I am familiar with. The general radiologists in private practice were more competent than say the subspecialized pedi radiologists in academics (med school) to read brain MRIs because the generalist had to carry the load. They kept up with the different imaging. When there were very difficult cases, they were discussed with the neuroradiologists on staff. This was probably 5-10% of the cases. I have no doubt that it helps to have a fellowship trained neuroradiolgist on staff. They are very appreciated. Also, I'm not sure how strong the non-neurorads are at your program... I think it could be sample bias on your end.

Anyway, I have had plenty of interaction with the neuroradiology department and private practice radiologists. I have spent a lot of time in radiology and getting familiar with the people and the daily workings of a radiology practice. I don't think I have to wait until I finish next year to comment on the matter. I will grant you that I will need to finish my radiology residency, but I will be competent to read most any film the comes my way. If a very difficult case comes up I can always discuss the case with one of my neuroradiologist partners or do a journal search to help solve the problem.

I think you and I have different perspectives given our different experiences at different institutions/practices. I have seen what it's like in both highly subspecialized academics and private practice. I haven't seen many good academic programs with many general rads on staff reading neurorads.

Can there be some institutions/practices that have weak radiologists? ... Of course... but I think that is the exception rather than the rule.

Does anyone here think that neuroimaging may someday become a formal fellowship for board certified neurologists. Seems to me like it would be a logical fellowship for a neurologist.

Voxel,

Some things are true whether you believe them or not. I suspect that it may be you who is forming opinions based on selection bias, not to mention your obvious naivete. While spending time with several radiologists may give you a good understanding of the workings of a radiologists' practice, it is hardly enough interaction for you to form opinions about their expertise.

Also, just because a general radiologist "carries the load" doesn't mean they have the necessary knowledge and experience. It's always embarrassingly obvious when a report has been generated by a general radiologist vs a neuroradiologist. No comparison. The truth is, when speaking of general radiologists, only one thought comes to mind...jack of all trades, master of none!

My opinions have been formed not only by working with general and fellowship trained radiologists and residents, but also by reading the reports of numerous outside radiologists, many of whom hedge their reports so much as to make them completely worthless. It seems the majority are primarily concerned with covering their butts. Either that, or they have no confidence in their reading skills...and they certainly aren't consulting the neurorads people. BTW, I'm at a regional referral center, so I routinely get reports from private radiologists in several different states. Also, the less than impressive general radiologists I mentioned in an earlier post were in private practice and not part of my academic center. I rotated with them when I was a student/intern...on "out" rotations.

In the end, someone must bite the bullet, interpret the images and decide upon a diagnosis. Peoples' lives are on the line and we don't have the luxury of hedging. I realize we both have strong opinions on this subject. The difference is that I am dealing with the problem on a daily basis. You are mearly watching from afar. Why don't you contribute when you actually have something to say.:rolleyes:

Alexander,

I seriously doubt that neurorads would ever become a neuro fellowship. The only real reason for pursuing such a fellowship would be to charge for readings...something few people are interested in doing. Why spend 1-2 years in a largely redundant fellowship just so you can charge for reading your own films. Hardly a cost effective endeavor. On the rare occasion that interpretation is difficult, most would prefer to simply consult a neuroradiologist.

Neurogirl it is time for you to retire and keep your opinions to yourself. You chose a loosing field. Do not try to belittle radiologists.

When you are in private practice in podunk, you will be seeing stroke after stroke after stroke. Prescribing aspirin after aspirin after aspirin. Seeing the same unfortunate hopeless patients. You will kick yourself every day for not choosing rads.

Neurogirl,

Obviously people are going to disagree about this issue. There is no doubt in my mind that fellowship trained neurorads are better than general rads with neuroradiologic imaging. There is also little doubt in my mind that academic radiology often has the edge on private practice groups (although this is contentious). Remember also that the hospital affiliated group that you trust also has the benefit of more and better history/clinical info than the peripheral rads -- this makes a huge difference.

However I think your comments about general radiologists being jack of all trades but master of none is inaccurate. They are much like non-FS'd specialists in other areas, such as neurology. I'd rather have an otoneurologist (or preferably a neurotologist) evaluate my dizziness, but I might end up getting a general neurologist the first go. In addition, there are some exams firmly in the domain of general rads, i.e. body CT. General rads do get extensive training in neurorads, but the onus is on them to keep up or get a FS'd subspecialist in.

However, I do not agree with oldandtired. I tip my hat to you for choosing a specialty that you enjoy, and I am glad that you have had positive interactions with radiologists that you trust. I think that type of interaction is beneficial for both the referring doctor and the radiologist.

To Oldandtired,

What's wrong...are you sick or something? Surely you can come up with a better comeback than that! Pretty weak!

BTW, I seriously doubt I'll ever wish I'd chosen rads. The thought of spending my life in a darkened room without patient contact, is nothing short of depressing!

1) Saying that needing to understand the very basic physics behind MRI before being allowed to read MRI films effectively is akin to saying that people need to understand purine savage cycle (or other basic biochemistry pathway) in order to treat gout (or some other common diseases) effectively. That is simply BS.

2) Isn't there a discussion of different radiologists coming up with different reads at relatively high frequency?

Originally posted by Thewonderer
1) Saying that needing to understand the very basic physics behind MRI before being allowed to read MRI films effectively is akin to saying that people need to understand purine savage cycle (or other basic biochemistry pathway) in order to treat gout (or some other common diseases) effectively. That is simply BS.


I agree... you need to understand some very basics about how T1 and T2 weighting work, and which types of scans are good for getting contrast in different kinds of tissues.

but you definitely dont need to know how to derive the Bloch equations or know the different methods of encoding K space in order to know how to interpret an MRI.

99.8% of the knowledge base that rads people use on an everyday basis has NOTHING to do with physics and more to do with getting experience seeing different kinds of tissues in normal and pathological states.

Unless you are trying to develop a new MRI pulse sequence, which only very few rads people have the physics background to be able to do effectively, you dont need to understand very much of the physics. I could teach you the basic physics you need to understand MRI in one day. You wouldnt be very good at interpreting images however, that only comes with practice/experience. But my point stands that the primary work of a radiologist has nothing to do with physics or mathematics behind MRI and everything to do with getting used to seeing different tissues under different types of scans.

Most rads dont even understand the basics of how the more advanced scans work anyways (STIR, diffusion tensor imaging, etc). They understand the end result, but they definitely dont understand the spin equations or the fourier transforms that drives the image sequence itself). Thats what the physicists are for who generally work in MR labs.

Well, I think it is usefull to have a basic understanding of imaging fundamentals as it is often necessary to tailor an imaging protocol (i.e. to better image a certain region, rule out an uncommon pathology, improve a diagnostic test etc). These decisions are driven by radiologists, because they have the knowledge to integrate a basic understanding of the imaging technique with the pathology/medical aspects of the case.

I agree that research faculty know more about the physics of imaging. However, it is important to realize the the (admittedly very applied) teaching radiology residents receive on imaging technique/physics is significantly more than residents in other specialties get (they have a whole bunch of other stuff to focus on). Radiologists have a different expertise to bring to bear on a case than other MDs, just as they have different skill set w.r.t. the medical physicists and techs.

Cheers

I agree for the most part. I have already vastly surpassed the physics that most radiologists know, but I dont know jack relative to them about how to interpret various pathologies on an MRI.

I can explain to them how a certain pulse sequence works and derive the spin equations that show how an image is generated, but as far as looking at a tumor on film they run circles around me.

The rads people that I've worked with generally have a superficial understanding of the math/physics involved, but in all honesty they dont really need to understand the details unless they are trying to design a new pulse sequence.

I think one thing that rads people could do a better job with is the understanding of how/why artifacts are created. I've seen plenty of subtle ghosting and motion artifacts which can corrupt the image in subtle ways that the radiologists sometimes miss.

That is the great thing about going into path. No one wants to look at their own slides, make the diagnosis, and sign the paper. Everyone thinks they can read the x-rays, MRIs and CTs, but no one wants to make a real diagnosis like only a pathologist can.

Originally posted by pathstudent
That is the great thing about going into path. No one wants to look at their own slides, make the diagnosis, and sign the paper. Everyone thinks they can read the x-rays, MRIs and CTs, but no one wants to make a real diagnosis like only a pathologist can.

So there's no turf battles whatsoever over pathology? What about allied health people fighting for rights to look at slides? What about PhDs in cell biology or other fields?

If its really as you say it is, then thats gotta be the only field in all of medicine with zero turf fighting.

Are you serious? PhDs and Allied Health people wanting to look at slides and making the diagnosis? Without even having had a med school class in pathology?

Path truly has no turf battles. Pathologists are the only one in the whole hospital that can do what they do. Lots of people think they can do what the others do (i.e. surgeons think they can administer the gas, read the MRIs, and do the angiograms) but no one questions the call of the pathologist.

I have read this post with great interest as I am currently struggling to decide between Radiology and Neurology. I am wondering if things have changed since 2003 when this thread was started?

I am not trying to reopen the original debate...I am just wondering if there are alot of neurologists in private practice who are reading their own films (without getting sued.) I know that there are Neuroimaging fellowships for Neurologists, which I believe are different than fellowships for neurointerventional. For someone like me, whose only interest in Radiology is neuro, and who also wants patient interaction, this seems like a dream come true.

Any thoughts from those in the know? Thanks!

The problem is you are not properly trained in the physics of MRI to interpret images. If all you know are t1 and t2 and don't understand MRI physics and it's principles then you will not understand what images from other sequences mean. Thus, you cannot interpret Brain MRI images as good as even the general radiologist. And the radiologist will be required to keep up with changes in the MRI technology even when he finishes residency. He sees tons of brain MRIs every day and not just the cases that you personally refer, but ones from the entire community of neurologists in his geographic area. Many private practice neurologists do not even look at the images once in clinical practice, but read the reports. Also, radiologists are not blinded by our clinical diagnosis so that we look at the the whole image not just one particular area.

Lastly, I doubt many neurologists have the time or the energy or desire to keep up with the nuances of the different MRI sequences because these neurologists are busy running a practice. You may be the exception, but I think this is generally true. Radiologists however must and do keep up with the technology. I'll put up my neurorad skills (once I finish residency) against any general neurologist out there. Bring it.


OK I have to step in here. General radiologists DONT KNOW JACK **** ABOUT MRI PHYSICS. I spent 1 year doing MR research and I guarantee you I know more about MR physics than every single one of the general rads guys in my hospital, which is one of the best academic medical centers in the country.

Now maybe a fellowship trained neurorads guy is different, but implying that general rads people know the math/physics behind MR is a total joke and you know it. Half of them dont even know what a Fourier transform is, much less how to program pulse sequences to stimulate different MR spectra.

The entire issue is all political anyway. It will be very difficult to ever put together a decent study proving that one group or another is better at neuroimaging. Sure a neuroradiologist may be better than a general neurologist, but what about a neuroradiologist versus a stroke neurologist in evaluating a head CT in a patient with suspected stroke? When you specialize in a specific disease, you tend to be better able in correlating the clinical data with the imaging data and the literature. Cardiologists have proven this obviously with their mastery of ultrasound. On the other hand, someone who only reads head CT's and brain MRI's all day is going to be as good as one needs, and probably the best around for most applications--so why not just use them all the time?

The arguement works for both sides pretty well. What is really going to decide the issue will be how a neurologist doing neuroimaging will affect the bottom line for insurance companies and the CMS. Thus the HUGE turf war between radiologists and every clinician/surgeon out there at present.

My take? Cardiology is the most successful field of medicine next in terms of their advancement and ability to take care of patients. I believe that a lot has to do with how the field is run--allowing a fertile environment for innovation in academic institutions and rapid deployment of new technologies, techniques, and ideas in the private world. (As an aside: I also believe that CT surgery has been losing in large part due to keeping themselves out of the cardiology camp. If they had been more ready to join cardiology groups and share earnings, I wonder if bypass surgery could have been a lot better than it currently is?)

I think neurologists should do their own neuroimaging when it pertains to their area of expertise. I.e., MS doctors should read their patient's MRI's and get compensated for it, cognitive neurologists should read their patients' MRI's to diagnose alzheimers or whatever they can hopefully in the future, and stroke docs should themselves be allowed to read all of their own CT's, CTA's, MR's, etc. It is clearly better for the patient in the long run, and will eventually be better for progress and the bottom line.

B

In answer to your question, the landscape has not changed very much in the past couple years. There are some neurology groups reading their own outpatient imaging, unchanged from before, but the majority of neuroimaging is done by radiologists.

THe orthopods appear to have made the greatest inroads into purchasing in-office MRI, but what has been interesting for radiologists has been that the vast majority of those groups have ended up sending the films/images for interpretation by a bone radiologist. Some people see this as reassuring for radioloigsts but I actually do not like the trend because I feel that the interpreting radiologist should have control over the technique and protocols as well as QC, and not be a passive reader.

But I digress...

I would like to respond to a few points however:

what about a neuroradiologist versus a stroke neurologist in evaluating a head CT in a patient with suspected stroke? When you specialize in a specific disease, you tend to be better able in correlating the clinical data with the imaging data and the literature. Cardiologists have proven this obviously with their mastery of ultrasound.
I have not found this to be true. I do not think that an expert in Parkinson's disease is the best person to interpret an MR in a patient with undifferentiated dementia/delirium/decreased LOC/"rule out pathology".

The cardiologists who do echo do it like radiologists; there is not as much clinical correlation as u think. And the range of pathology is much smaller than in the brain and H/N. Neuroradiology encompasses brain, spine facial, orbital bone and neck imaging as well as imaging of portions of the peripheral nervous system like the brachial plexus. Other specialists are not familiar with all these areas, and cannot be expected to appreciate findings outside of their expertise (and even within their expertise, half the time), but these findings routinely appear on neuroimaging studies.
What is really going to decide the issue will be how a neurologist doing neuroimaging will affect the bottom line for insurance companies and the CMS.
This is probably true, but the answer is already known from many years of experience. When clinicians do their own imaging (even in-office with radiologist interp) the volume increases precipitously.

I think neurologists should do their own neuroimaging when it pertains to their area of expertise. I.e., MS doctors should read their patient's MRI's and get compensated for it, cognitive neurologists should read their patients' MRI's to diagnose alzheimers or whatever they can hopefully in the future, and stroke docs should themselves be allowed to read all of their own CT's, CTA's, MR's, etc. It is clearly better for the patient in the long run, and will eventually be better for progress and the bottom line.

I think this is a recipe for poor quality imaging and poor quality medicine. When all you have are hammers, everything looks like a nail.
Also, self-referring physicians have no incentive to make sure their equipment and protocols are state-of-the-art, in fact imaging is just an ancillary service to them. In-office imaging is often of substandard quality.

I am sorry you have such a negative view of radiology. Many of us are working very hard to provide you and our patients with the finest quality imaging and most accurate and timely interpretation possible.

I am not at all making any kind of informed comment on this. What I mean is, I don't know anything about the politics or legal issues behind it.

What I have observed however....the neurologist I have worked with (3) read the films themselves but also have the radiology report. I am assuming that they aren't billing for it but they look at the films out of curiousity and as backup since sometimes they say they see things rads doesn't.

One neurologist I worked with is being sued because in a hospital setting a lumbar spine MRI was done (I don't remember what the problem was, some kind of compression or mass that should have had immediate surgery) and the radiologist missed it. This neurologist missed it as well or had looked at it later when it was too late (can't remember now) and so in addition to suing the radiologist he was suing the neurologist because at some point he had looked at the MRI as well. This made this particular neurologist nervous about officially being the reader in the future. Awesome doc too, patients adored him, trained med school/residenct at Emory.

I am not at all making any kind of informed comment on this. What I mean is, I don't know anything about the politics or legal issues behind it.

What I have observed however....the neurologist I have worked with (3) read the films themselves but also have the radiology report. I am assuming that they aren't billing for it but they look at the films out of curiousity and as backup since sometimes they say they see things rads doesn't.

One neurologist I worked with is being sued because in a hospital setting a lumbar spine MRI was done (I don't remember what the problem was, some kind of compression or mass that should have had immediate surgery) and the radiologist missed it. This neurologist missed it as well or had looked at it later when it was too late (can't remember now) and so in addition to suing the radiologist he was suing the neurologist because at some point he had looked at the MRI as well. This made this particular neurologist nervous about officially being the reader in the future. Awesome doc too, patients adored him, trained med school/residenct at Emory.

This is just another example of how a bit of clinical information can aid in the interpretation of the neuroimaging study. If the neurologist in question would have went down to read the MRI with the radiologist and told him that this particular patient for example had a history of prostate cancer and presented with an acute onset of bowel/bladder changes and lower extremity weakness, the spinal cord compression wouldn't have been missed. However, the neurologist is probably being sued as well because he was the clinican of record, not because he happened to have glanced at the film.

I have not found this to be true. I do not think that an expert in Parkinson's disease is the best person to interpret an MR in a patient with undifferentiated dementia/delirium/decreased LOC/"rule out pathology".

I agree. Experts in dementia (not PD) however might be if they spend a year in studying neuroradiology. I don't mean that neurologists straight out of training can become experts in reading relevant imaging, but that one who is an expert in dementia should be allowed the credentials to do so if they spend time training for it. Right now, only radiologists are officially allowed by the ACGME to train in neuroradiology.

The cardiologists who do echo do it like radiologists; there is not as much clinical correlation as u think. And the range of pathology is much smaller than in the brain and H/N. Neuroradiology encompasses brain, spine facial, orbital bone and neck imaging as well as imaging of portions of the peripheral nervous system like the brachial plexus. Other specialists are not familiar with all these areas, and cannot be expected to appreciate findings outside of their expertise (and even within their expertise, half the time), but these findings routinely appear on neuroimaging studies.

Most cardiologists I know doing echo do at least some clinical work also--even if they also spend a lot time in research! And I know quite a few in private and academics also. Again, I am not asking that neurologists also learn to read spine, facial, neck and brachial scans also. Simply that a stroke neurologist should be able to bill for a head CT when evaluating acute stroke. Or an MS doctor for reading an MR. If neurologists can be sued for missing signs on images relevant to their expertise in a particular disease, they should be allowed to bill for it.

This is probably true, but the answer is already known from many years of experience. When clinicians do their own imaging (even in-office with radiologist interp) the volume increases precipitously.

There are many good counter-arguments to this. If you want to read some of them, google "Coalition for patient-centered imaging". One example is in orthopedics where number of office visits, outcomes, and yearly expenditure per patient by medicare has gone down possibly becuase of in-office imaging. Thus, the answer is not known. It is still HIGHLY controversial. I would urge readers to look at all of this for themselves before coming to any conclusions.

I think this is a recipe for poor quality imaging and poor quality medicine. When all you have are hammers, everything looks like a nail. Also, self-referring physicians have no incentive to make sure their equipment and protocols are state-of-the-art, in fact imaging is just an ancillary service to them. In-office imaging is often of substandard quality.

I don't think this has held true for echos by cardiologists. In fact, it has been quite the contrary with echo technology advancing extremely rapidly--much faster than it would have, I suspect, if only radiologists could read echocardiograms. Self-referring physicians do have incentive of course, competition. The same that radiologists do.

I am sorry you have such a negative view of radiology. Many of us are working very hard to provide you and our patients with the finest quality imaging and most accurate and timely interpretation possible.

I don't have a very negative view of radiology. Indeed, radiologists who spend years specializing in a particular area of imaging provide great added value. Unfortunately, many do not do this due to no added income by doing so. I simply believe three things:

1) Clinicians should have access to specialty radiology training in their area of expertise, GI docs should be allowed to spend a year in training on abdominal CT's and MR's, cardiologists on chest CT's and MR's, neurologists on brain CT's and MR's. One doesn't need radiology training to train in neuroradiology--it is a matter of monopolizing the market and even the chairman of UPenn's radiology dept has publicly acknowledged this fact.

2) Experts in particular areas are probably better at the relevant imaging. Stroke docs are probably better at reading head CT's and MRI's for evaluating stroke than even some general neuroradiologists. Putting the imaging back in the experts' hands will likely drive technological development forward, as it has in cardiology. It will also allow patients "one-stop" clinical care, SAVING money and OPTIMIZING care, not the opposite.

3) Radiologists have been greedy. Don't even try to deny this, chairmen from top radiology depts are coming out saying this themselves. Eventually, the government will do what is cheapest and according to the largest lobby. Cardiology, grouped with many other clinician groups, are clearly larger than the radiology lobby, and I sense that in the end they will win. Radiologists will need to discover their true value in an upcoming new climate where clinicians do their own readings. Will a radiologist simply be the lawsuit preventor by making sure a clinician doesn't miss the sinusitis in a head CT evaluated for ICH in an acute stroke patient? Will they be the engineers ensuring QC and that a machine is working properly? Or will they be the docs who one can go to in case a clinician needs a second opinion on some scan? I would like to see radiology to turn in to ER medicine where they don't specialize but basically deal with images that the family doc wants, or the whole body CT scans that patient's will be getting in the future. I for one don't need any radiologist looking at any head CT's for me in the future, but won't mind one if I need some imaging of the brachial plexus.

B

There are so many inaccuracies here I don't even know where to begin...

One example is in orthopedics where number of office visits, outcomes, and yearly expenditure per patient by medicare has gone down possibly becuase of in-office imaging.The number of office visits does NOT go down. In no orthopedics practice will you find patients going into the office, see the surgeon, have an H&P done, then head over to the MRI suite, wait the 30-60 minutes needed to get everything prepped, the scan performed, wait additional time for the surgeon to review the study, and then have the surgery scheduled. That surgeon has spent significant additional time during the day while following up with the patient and is unable to bill for it, whereas if the patient returned on a separate day, they could bill for a second office visit. It also commits a patient to probably a 2-3 hour office visit, which doesn't fit in with clinic flow when you are booking off time for lunches, and trying to get out of the office by 5:00 pm.

What is FAR more likely to happen, is that the patient is registered via referral as having a knee complaint, the patient is asked to come to the office 2 hours ahead of the scheduled appointment, and a default MRI of the knee is performed automatically, in advance of the patient ever having been seen.

This is the whole problem with in-office imaging. Not only does the fact that the surgeon have a financial stake in the operation (it's the same reason you can't run a pharmacy out of your physician's office), but it also encourages excessive ordering of studies. The financial benefit of owning your own MRI machine is in the technical fee, where every study is reimbursed several hundred dollars. The professional fee, or what is reimbursed for the official act of reading the study, is paltry in comparison.

Since the upkeep of running an MRI is several tens of thousands of dollars per month, you have to generate a huge number of patient exams to make back your money. Seeing as MRI isn't an invasive procedure, orthopods feel free to order huge numbers of studies. The same is true for cardiology and OB/GYN. Since when was the last time you saw a cardiology consult without an echo, even if the guy freakin' had one last week, and by history and physical has a CHF exacerbation, just like the other 15 times he's done it that year. Ditto with prenatal ultrasound, where every insured patient gets one, whether it's truly indicated or not.

In office imaging has been shown to dramatically increase the rate of studies (anywhere from 2-8 times!) sent to that scanner by the physician group that owns the machine. And why wouldn't it? For every patient you send to the scanner, you pay for its overhead and keep a significant chunk as pure profit. Think like a businessman. I don't think this has held true for echos by cardiologists. In fact, it has been quite the contrary with echo technology advancing extremely rapidly--much faster than it would have, I suspect, if only radiologists could read echocardiograms. In Canada, many radiologists still read echos. An echo really isn't anything impressive. And "echo technology" hasn't really improved. At the end of the day, it's just another ultrasound, and it advances at the same technological rate as ultrasound machines do. Look at the valves, look at the wall thickness and its motion, throw on the Doppler and see where the blood flow is going, and check for a pericardial effusion. An echo isn't a complicated study to read.

At the place where I did my internship, there were a select few cardiologists who did nothing but read all the echos generated by their group. I spent a lot of time with them, picking up information and learning the echo anatomy. There was little to no clinical correlation there, since they were reading studies on patients they'd never examined, and, as it turns out, cardiologists give just as crappy histories on their echo requisitions as any other clinician would for their radiology requisitions... :)1) Clinicians should have access to specialty radiology training in their area of expertise, GI docs should be allowed to spend a year in training on abdominal CT's and MR's, cardiologists on chest CT's and MR's, neurologists on brain CT's and MR's. One doesn't need radiology training to train in neuroradiology--it is a matter of monopolizing the market and even the chairman of UPenn's radiology dept has publicly acknowledged this fact. I think once you spend time in a radiology department, and actually see how residency functions, that you'll realize that this is a really limited view. The whole point of a radiology residency is to discover that a disease is often visualized on several different modalities in several different organ systems. The same diseases show up whether you are doing an MSK, GI, GU, Chest, or Neuro rotation. As an example, a lesion that you see in an tibia or fibula might very well appear in a vertebra or in the facial bones.

The fact that you've coned in on one organ area already negates that cross-training experience, and makes it MUCH more likely that you will focus on the one diagnosis that you actually recognize. We see the pitfalls of this all the time. It's already happened twice in the last 2 weeks that I've reviewed CT scans with surgeons, only to point out the pulmonary emboli that happened to be incidentally found. It happened last week as I was reviewing an abdomen and pelvis CT scan with a gasteroenterologist done for pancreatitis that I happened to notice the lytic bone lesion in the pelvis.

You can't see what you aren't looking for, or worse yet, what you wouldn't recognize anyway even if you saw it.

It's the same reason why you need a core 3 years of Internal Medicine to qualify for a Cardiology fellowship, or why you need to have done the vast majority, if not completed a General Surgery residency to qualify for its fellowships. Your cardiology patient is going to come in with COPD, which you need to know how to manage. Your vascular surgery patient is going to have wound-healing issues just like other General Surgery patients, even if you did an aortic aneurysm repair, and not a hemi-colectomy. There's a certain baseline competance that needs to be achieved in order for you to handle the potential breadth of the patients you encounter.

Clinicians have great depth at handling the 10-20 common diagnoses that they've subspecialized into, with absolutely no breadth for most diagnoses outside of this comfortable range.

Anyone can handle the simple cases, but it's the one with multiple findings, or where the findings suggest a different diagnosis than is implied from the history and physical, that you need that additional training.

2) Experts in particular areas are probably better at the relevant imaging. Stroke docs are probably better at reading head CT's and MRI's for evaluating stroke than even some general neuroradiologists. Putting the imaging back in the experts' hands will likely drive technological development forward, as it has in cardiology. It will also allow patients "one-stop" clinical care, SAVING money and OPTIMIZING care, not the opposite. That's the whole point of the above. The "experts" are the ones who are familiar with imaging, as well as its limitations, across modalities and organ systems. Those are radiologists. A stroke doc is going to catch the stroke, particularly if he/she has already examined the patient. In the process of doing so, the middle ear disease, or the subtle meningioma, or other non-stroke lesion is going to be missed. We see it every week in the radiology reading room when an astute clinician notices the major finding, but unfortunately misses the subtle one.

One-stop care increases imaging utilization dramatically. It's the only reason that clinicians have moved into it, because it increases their revenues at a time when the fees for seeing patients and doing procedures has steadily dropped year by year. If by playing radiologist, they could make money equivalent to what radiologists do, why wouldn't they do it?

What we will probably end up seeing at some point in the near future is a global lowering of technical and professional fees for imaging, to the point where it's no longer financially profitable to image patients in office. When the time comes that the revenue isn't there to support the huge overhead needed to run an MRI or CT scanner, you'll see the clinicians bailing out of it like rats out a sinking ship.

(Part 2 since the original reply was too long)


The last important fact is that in general, in-office imaging increases redundancy. Stuff done in the hospital on hospital equipment gets loaded into the PACS system, and is accessible from within the OR, the hospital floors, and in many/most clinician's offices through an on-line web portal type system.

In office imaging is often poor quality. The equipment is often older, the film quality is lower, and less well maintained. It is often painfully obvious when you are interpreting outside studies that they were done on an open MRI or a lower-end machine. The imaging findings are much vaguer, and in several cases, borderline non-diagnostic.

As well, the studies never seem to be available for review. When's the last time you were able to view a cardiac echo the same way you can pull up a chest x-ray on PACS? Who is quality-controlling these studies? When a chest x-ray goes online on PACS next to the radiologists report, you have quality control. Anyone can, and will compare their findings with the official report. When the echo gets done, it's usually impossible to find later for review, and a chart copy often shows up a couple days later, long after the decision to diurese the CHF patient.

It's even worse in the outpatient setting, where both the MRI, and its report are available only to the original orthopedic surgeon, and unavailable for peer review by any other physicians unless it's released by that office.

Oftentimes, a repeat study is performed in the hospital simply because the prior imaging wasn't available for review. This also happens on a daily basis. Talk about a waste of resources.

3) Radiologists have been greedy. Don't even try to deny this, chairmen from top radiology depts are coming out saying this themselves. Eventually, the government will do what is cheapest and according to the largest lobby. Cardiology, grouped with many other clinician groups, are clearly larger than the radiology lobby, and I sense that in the end they will win. Radiologists will need to discover their true value in an upcoming new climate where clinicians do their own readings. I would like to see radiology to turn in to ER medicine where they don't specialize but basically deal with images that the family doc wants, or the whole body CT scans that patient's will be getting in the future. I for one don't need any radiologist looking at any head CT's for me in the future, but won't mind one if I need some imaging of the brachial plexus.Radiologists are greedy like every other physician is greedy. No one turns down the opportunity to perform procedures or generate revenue. If you think differently, look at the cardiologists, who basically milk the cash out of each patient. Treadmill stress, followed by echo, followed by nucs study, followed by a diagnostic cath on day 3 followed by a therapeutic cath on day 4 so they can bill for both caths separately.

You are right that the government will do what is cheapest, and what is cheapest is to curb the incentive for excessive imaging by making it non-profitable. In office imaging drives up imaging costs, no matter what you think. If it wasn't a business-profitable enterprise, one that was commensurate with the huge financial risk of buying a multi-million dollar piece of equipment and its service contract, no one would be doing it!

Radiology has become more and more subspecialized with each year, with the majority of each graduating class going to to pursue additional subspecialty training. Why on earth would we as a specialty want to downgrade and become generalist backups for when clinicians miss the subtle findings? Has ANYTHING in medicine become less specialized in the last few decades???

What is far more likely to occur is an ever increased reliance on subspecialized radiologists, with clinicians cherry-picking certain profitable imaging modalties. At least until the reimbursement cuts hit.

Your points are well taken, and frankly, I don't have the data to counter all of them. But some counterpoints, nevertheless:

1) The idea that in-office imaging raises costs is because of the way Medicare is set up right now. If physicians could separately bill for reading images within the same visit, than the entire scenario you describe doesn't hold water any more. See the following argument from the ACC (admittedly biased--but an argument made to the MedPAC last year):

"Third, in-office imaging can limit Medicare spending by reducing the number of office visits and other physician encounters that are billed to the system. By providing “one stop shopping” the orthopaedic surgeon has reduced the number of office visits required to complete the diagnosis and treatment decisions for the patient. The alternative requires one visit to the physician to determine that an image is needed. This is followed by the encounter with the radiology practice. Finally, the patient must return at least once to the physician’s office for review of the image and treatment decision. All of these encounters engender a separate billing to Medicare. In-office imaging reduces the number of billed encounters, thereby reducing spending for evaluation and management services." MedPAC noted in their March 2005 report that there isn't sufficient evidence proving that in-office imaging would cost Medicare any more money.

So I don't think that calling the debate on in-office imaging "controversial" was by any means inaccurate.

2) The idea that radiology teaches one to be able to correlate lesions across imaging modalities can be easily extended further. Clinical training teaches one to correlate findings across everything: exam, history, pathology, imaging, surgical findings, electrophysiology, etc. For every subtle sinusitis missed on head CT by a neurology, there is a hypoattenuation in the left cerebellum missed by the radiologist. Strength of clinical suspicion is key in interpretating imaging data and the radiologist cannot simply blame the clinician for not sending this information. If they want to be more effective, they should ask for the clinical data themselves, or go see the patient while they get their scan (it only *seems* like an absurd concept because of how radiology practices are currently set up) (admittedly, some of the top radiologists at my institution do this, but very few).

3) There are advantages to radiology training, yes. But my entire argument is not that radiologists are useless. It is that they block clinicians from being able to bill for reading images themselves when there are obvious advantages to this also. The best clinicians I know regularly spend time reading images to help care for their patients. So why shouldn't clinicians be reimbursed for this? Especially in the scenario where you still require the clinician to get additional training (i.e. 6 months to 1 year) in imaging a particular area of the body. Please address this specifically, because this is the argument on the table. (I still fail to see how learning to read MRI's of the knee will help a neurologist in reading head CT's in the future.)

4) About "physicians being greedy". I wouldn't call a pediatric intensivist, who spent years in training to make one of the smallest incomes in medicine greedy. There is a gradient of greediness among the fields and to just say that all physicians are greedy is like saying that all humans commit sins. Do you really believe that you are compensated fairly when compared to other physicians?

5) Cardiac echocardiographers have far, far, more clinical knowledge and skills than radiologists. To say that echo's are "easy" and not very advanced is fairly trite when one compares the usefulness of a cardiac echocardiogram to an echo of, say, just about any other organ in the body. Well, except maybe prenatal ultrasound which, btw, happens to be in the hands of clinicians also.


B

Isn't it funny.
The only unstickied threads in the neuro forum that make it past the 30 post limit seem to be the ones where people beat the dead horse of self-referred imaging. Is neuro really so boring otherwise ?

Isn't it funny.
The only unstickied threads in the neuro forum that make it past the 30 post limit seem to be the ones where people beat the dead horse of self-referred imaging. Is neuro really so boring otherwise ?


Or maybe it is the fact that over the past year, radiology has been engaged in a huge turf war against the so-called "Coalition for Patient-Centered Imaging" involving MedPAC's reports to CMS. If it were such a 'dead horse' why don't you go run MedPAC or the CMS yourself? These are serious issues that are going to change clinical practice in our careers.

B

1) The idea that in-office imaging raises costs is because of the way Medicare is set up right now. If physicians could separately bill for reading images within the same visit, than the entire scenario you describe doesn't hold water any more.You are blending two issues into one. Let me separate them.

The first is: "Should we be encouraging in-office imaging?" I would argue that the answer to this question is an emphatic "No", because numerous studies have shown that in-office imaging leads to significant (2-8x) increase in imaging volume. The reason is very simple, and it's purely financial. The imaging equipment becomes a revenue-generating device (and is a liability if it doesn't cover its own overhead), and therefore is treated like any other billable procedure. ie. let's maximize it and get as much money as we can by ordering scans as often as possible.

As I've previously mentioned, the bulk of the profit from in-office imaging comes not from reading the scan, but rather simply performing it. The fee earned by performing the scan is many times greater than the one for interpreting it, and it also doesn't require the physician's input; the exam is performed by your tech, coded by your office assistant, and you pick up the check from the insurance company. It's like passive income. In-office imaging is a highly abusable resource, with questionable benefit to the patient (it's extraordinarily rare that the patient actually gets the scan done and the images reviewed on the same day).

The second issue is: should clinicians be interpreting their own studies? Many clinicians already are. Their efficacy with doing so is something not well studied, for the same reasons that comparing efficacy and accuracy rates across radiologists are also not well studied. It's simply VERY difficult to evaluate this in any sort of objective and fair manner. Anecdotally however, we see clinicians come down to the reading room all the time, and these individuals are very often biased either by their H&P (and therefore don't look for other possibilities within the radiologic differential diagnosis), or simply aren't even looking for, or wouldn't recognize that other pathology because it is significantly outside the scope of their practice.

If I or a family member had a condition requiring a CT scan, I can assuredly tell you that I'd want a radiologist interpreting the study, while being supplied good clinical history by the ordering physician, either on the order requisition, or else in person in the reading room. I think this is the interpretation scenario most likely to lead to a complete and accurate diagnosis for the patient.

Like I said above, just recently I've caught two missed PE's, and what looks like metastatic ca in front of clinicians who were diligent enough to actually come down and review findings with me. They had already looked through the images before talking to me. Any radiology resident or attending will relate that these sorts of stories occur on a weekly or daily basis.

2) The idea that radiology teaches one to be able to correlate lesions across imaging modalities can be easily extended further. Clinical training teaches one to correlate findings across everything: exam, history, pathology, imaging, surgical findings, electrophysiology, etc. For every subtle sinusitis missed on head CT by a neurology, there is a hypoattenuation in the left cerebellum missed by the radiologist. Strength of clinical suspicion is key in interpretating imaging data and the radiologist cannot simply blame the clinician for not sending this information. Yes, they can, and should. Your job as a clinician is to evaluate the clinical differential diagnosis for the patient. My job as a radiology resident is to evaluate the radiologic differential diagnosis given both the imaging and supplied history. You are supposedly the expert in auscultating the crackles over your patients right lower lobe. You do that 40 times per day.

Since I'm reading 40 chest x-rays per day, I'll be the one correlating whether your patient being febrile or this being an acute illness means that this is more likely to be a consolidation from pneumonia, versus a bronchogenic carcinoma. If you don't supply me that history, or come down to discuss the film with me, then I will give you both within my report. I am a consultant trying to answer your clinical question. It's within your responsibility to supply that information to your consultants (otherwise, why did you even bother obtaining it?).

The crappy histories that we get as radiology residents limits the usefulness of the report we can generate. If you truly are trying to get to the bottom of the study, it would be extremely helpful to supply your consultant with the information required in order for him/her to answer your clinical question.

You'd never ask a surgeon to go see a patient, with an order that states: "Pain" as the indication. You'd never ask the pathologist to interpret a microscopic slide without telling him/her what organ you chopped that tissue out of. And by the same token, giving your radiologist colleague a crummy history virtually guarantees that the report will be much vaguer and less accurate than one that actually supplies a clinical history and asks for confirmation/exclusion of a given set of disease entities.

I'm frankly surprised with all the medicolegal CYA garbage entangling our system that clinicians have been able to get away with ordering potentially invasive tests with such weak indications as: "Pain", or "Dizziness", or "Fall". Have you ever seen a patient get an anaphylactic reaction to contrast? I have. Not to mention the number of patients within the PACS system who have 20-40 CT scans to their credit. I read a patient yesterday who had 80 prior CT scans. That's a hell of a lot of radiation.

3) There are advantages to radiology training, yes. But my entire argument is not that radiologists are useless. It is that they block clinicians from being able to bill for reading images themselves when there are obvious advantages to this also. In the office setting, clinicians can bill for their own image interpretation all they want. A significant percentage of medicare billing claims are generated by non-radiologists. This includes orthopods doing MRI, ENT's doing sinus CT's, cardiologists with their echo's and Nucs studies, and OB/GYN with prenatal ultrasounds. In the hospital setting, radiologists often have an exclusive contract with the hospital. This is no different than a set of surgeons defending their OR time, or vascular surgery trying to block cardiology from gaining privileges to do carotid stents, or a closed ICU where intensivists run the show.

If you don't like the exclusionary contract, go work at a hospital that doesn't support them. Then don't come bitching when the PM&R's are doing all your EMG's, the cardiologists and vascular surgeons are doing the carotid dopplers, the neurosurgeons decide that they'll take over the "interventional neurology" service (whatever that is), the intensivists are running your Neuro-ICU, and a competitor neurology group or radiology group underbids you and gains priveleges to read the head CT's and MRI's on your personal patients.

Exclusionary contracts are all over the place in medicine, whether it's the group that holds the contract to supply the cafeteria food, or the scrubs you wear on call, or the local nurses union, or the pathologists who are interpreting your slides, or the anesthesiologists pushing the propofol in the OR. They certainly aren't unique to radiologists. Every specialty and every profession protects its own turf.

The best clinicians I know regularly spend time reading images to help care for their patients. So why shouldn't clinicians be reimbursed for this?As I've mentioned above, this already happens. If you are willing to accept the medicolegal liability for it, also can get your malpractice insurer to cover it, and finally can convince your local insurance company to pay for it, go right ahead. Nowhere within that system is the radiologist present to block it.

Especially in the scenario where you still require the clinician to get additional training (i.e. 6 months to 1 year) in imaging a particular area of the body. Please address this specifically, because this is the argument on the table. (I still fail to see how learning to read MRI's of the knee will help a neurologist in reading head CT's in the future.)The next time you see a calvarial lesion on a head MR, or a head CT for that matter, and blow it off as a venous lake or an odd cranial suture, it will become very clear why a strong knowledge of bone lesions is important. In all probability, you've already missed a calvarial lesion, at whatever your current training level is. Just hope that it's a benign one.

As I've mentioned earlier, lesions and diseases often don't limit themselves to a single organ system, and clinicians who have never been exposed to the imaging outside of their clinical interest (in other words, those 10-20 diseases they've subspecialised into), are going to miss findings.

An orthopedic surgeon will catch the fibrous dysplasia in the facial bones because he/she has seen many cases of it in the femur. The average ENT surgeon will as well, because he/she has seen many cases of it in the maxilla. A neurologist is likely to blow by it, but might catch the basilar tip aneurysm. A radiologist is far more likely to catch both, by virtue of that cross-training.

That's why we do it. If it wasn't an integral part of being an imaging specialist (which is what we are), we wouldn't be doing it, and would instead be cranking out radiologists through a 3 year residency so we could make more bucks.

(Part 2 since the original message was too long)

4) About "physicians being greedy". I wouldn't call a pediatric intensivist, who spent years in training to make one of the smallest incomes in medicine greedy. There is a gradient of greediness among the fields and to just say that all physicians are greedy is like saying that all humans commit sins. Do you really believe that you are compensated fairly when compared to other physicians?Physicians ARE greedy. Feel free to disagree with this, but you'd be wrong.

Obviously there is a spectrum of greediness, just like there's a range for any other human characteristic out there. But to state that radiologists are greedy because they make more than the median physician, is to also declare that ENT's, orthopods, cardiologists, GI docs, radiation oncologists, dermatologists, urologists, anesthesiologists, and ophthalmologists are also greedy because their income:hours worked:lifestyle ratio is much more favourable than your average family physician or general internist.

It's a specious argument.

I didn't create the system where radiologists happened to become incredibly productive thanks to PACS, and clinicians practicing CYA medicine. I WILL be practising within the radiology system for my career, even through the salary cuts that I predict are coming. Does that make ME greedy?

5) Cardiac echocardiographers have far, far, more clinical knowledge and skills than radiologists. To say that echo's are "easy" and not very advanced is fairly trite when one compares the usefulness of a cardiac echocardiogram to an echo of, say, just about any other organ in the body. Well, except maybe prenatal ultrasound which, btw, happens to be in the hands of clinicians also.The clinical knowledge is relatively unimportant until cardiologists start supplying their echo-reading colleagues with great clinical histories. The skills part is also somewhat dubious, in that I rarely, if ever saw a cardiologist (particularly the one interpreting the study), actually lay hands on the ultrasound probe itself. Within radiology, we learn to scan ourselves because often you need to do it on call, or prior to an ultrasound-guided biopsy or other ultrasound procedure like a line placement or thoracentesis/paracentesis. If you are talking about imaging skills, rest assured that cardiologists are much more reliant on their echo techs than radiologists need to be on their ultrasound techs in the acquisition and interpretation of their images.

Finally, the importance of a study has nothing to do with how easy or hard it is to read. I'm just telling you that echos really aren't that hard to read, not moreso than other ultrasound studies once you master the principles of ultrasound and echo anatomy. As I've mentioned, radiologists in Canada sometimes still read echos, and radiologists in general used to read echos before it was co-opted by cardiology. After all, who do you think owned the first ultrasound machines in the hospital? It sure wasn't the cardiologists...

I'm done with this thread. Thanks for the debate. I just happen to disagree with the vast majority of what you've stated.

I am replying partly to clarify something and also to get the last word. But I want to sincerely thank Flankstripe for a very thoughtful (and polite) debate and argument. The truth is that I am strongly considering radiology as a career direction myself, but still have strong feelings about clinicians reading their own imaging.

Clarifications:

1) I am not arguing that clinicians should be paid for running their own scanners. They in fact already do this, and this is an issue that is separate from allowing clinicians to bill for interpreting their own imaging. If you own a scanner and you can send your patients to it, you will drive up costs and the number of unnecessary imaging. This happens as often with "in-office imaging" as does in institutions with "in-house" radiology departments by the way. If Medicare reduces their technical fees, this situation can be rapidly changed.

2) Radiologists do block physicians from billing for reading their own images. Protection from insurance companies, and gaining contracts at hospitals is in large part based on accreditation. That is the whole point of accreditation. When radiologists block accreditation, they inherently block billing contracts. Simple economics.

3) You keep arguing about the value of a radiologist in finding things that say a neurologist wouldn't have found on a head CT. That this will happen is true. But I am arguing that the converse is also true: neurologists will find things that radiologists won't. The reason is due to their extended clinical training. There is ample anecdoctal evidence for this as much as you would like to provide in favor of radiologists. So who is better? It is premature (and possible immature) to simply try and choose one. The mature response is to realize that in some situations, the neurologist will be better (e.g. acute stroke) and others the radiologist (delirium or trauma). Neurologists should be able to bill like the radiologists in these circumstances.

4) Finally, it is dangerous to keep using anecdoctal evidence to try and prove your points. First, there is anecdoctal evidence supporting my side of the argument. Second, we all know that anecdoctal evidence is often wrong in the end.

I am not asking you to give up your career, simply to allow neurologists to be accredited in reading head CT's in the setting of acute stroke (or of NICU patients in evaluating bleeds and midline shifts--or of MS patients in evaluating their lesions). In the last case, anecdoctally by the way, I have a friend who got an MRI because of neck and spine tingling and pain. The orthopedic surgeon read it as a syrinx and to be sure had it confirmed by a neuroradiologist. They both felt it *was* a syrinx, so she got surgery. Three years later she had an episode of hemiparesis. By this time, the neurologist will have figured what is going on. What clinched it was reviewing the MRI and getting a history showing that patient also had an episode of transient blindness many years ago. The failure here wasn't in imaging. But in correlating clinical data with imaging data. This correlation is important and powerful, and continues to be the reason why top physicians spend so much time reading films of their patients despite getting no compensation for this activity.

So if a neuroradiologist can miss MS, surely a neurologist can miss a Calvarial lesion? (I personally always look at the bone window carefully.)

B

Without rehashing what has been said by others, I feel that it is not reasonable for a neurologist specializing in stroke to read "stroke CT" or one in MS to read "MS MRI" because there will be all kinds of other pathology on those scans other than that which is expected. I think a 1 year fellowship for other specialties is ridiculously short -- you will barely master the imaging relevant to diagnoses you treat, but no mastery of all the other thing that are routinely on the films (i.e. for a neurologist, I mean neurosurgical, bone, ENT, ophthalmic, and metabolic lesions) that will show up on "stroke CT" and "MS MRI"

Perhaps an abbreviated residency in the 3-4 year range can be considered -- I suspect if the proposal is to get similar levels of training to a board certified radiologist, with commensurate time investment, the interest level would drop.

The desire to carve up radiology services is all about money, and has nothing to do with quality or patient care.

One other thing: how would you feel about carving up neurology? I doubt you would appreciate it if throacic surgeons could do sleep fellowships (I know Resp and Psych have alrady started taking it, whatever). In principle anyone can learn anything, but the reason we have the specialty lines that we have is to ensure that the independent practitioner of a specialty is well-equipped to deal with issues that will come up in independent, unsupervised practice. The idea is that it makes more sense for a neurologist to deal with stroke patients than a cardiologist, as the former has more training in neurological disease, even thought the latter could learn it in principle. The only thing preventing this is that there is no "benefit" in terms of reimbursement for doing this.

It is all about money.

sorry rpt post.

So if a neuroradiologist can miss MS, surely a neurologist can miss a Calvarial lesion? (I personally always look at the bone window carefully.)

B
And what do you do if you see a lesion? I presume you take it to a radiologist.

If that is the answer, then consider this: By taking cases away from radiology, you will reduce the volume seen by radiologists. This in turn will make it impossible for radiologists to maintain competency. You as a neurologist will not have the expertise, and by practicing "radiology" without full training, you reduce the demand for people who have the requisite expertise.

You could say you would show the films to an orthopod or a neurosurgeon. But the truth is that the orthopedic oncologists bring films to us all the time -- and they are the non-radiologists most familiar with bone oncology. And is that a good use of resources?

And finally, what about things that you straight out miss because you have no experience in it? The eye see what the mind knows, and when it comes to imaging the radiologists eye is far more extensively trained.

Thank you for your comments EB. I think you are hammering in on the point that I am trying to make, except that you might have some unrealistic ideas of how much additional training one would need to master a specific modality of imaging. I agree that a neurologist wishing to be reimbursed for read head CT and brain MRI's needs additional training--the question is how much. Historically, neurologists were doing the imaging themselves (carotid injections, LP injections of dye). When CT came into the picture, there was discussion about who would be accredited to read head CT's, and neurologists allowed the radiologists to master this field--now with brain MRI, to be truly any good at reading head CT's and brain MRI's, you need a 2 year fellowship in neuroradiology.

That is what I would want a neurologist to have to endure to be qualified to read both head CT's and brain MRI's. 1 year if only one modality (head CT's for example along with carotid dopplers and TCD's, which neurologists already get a lot of training in at some programs). It is already happening, by the way, and neurologists have created their own accreditation scheme with some neurologists getting imaging posts at places like MGH. It is not a farfetched scenario. There is no reason for a neurologist to have to spend time reading MSK images of the knees and ankles, ultrasound of the abdomen, learning to put Hohn catheters in under fluoro--you get my picture.

Two additonal comments. One, 4 years is stupid because that is how long radiologists spend in training post internship already. Neurologists have already done their internship. 3 years makes more sense, and some radiology programs have already allowed this to happen (as does the RRC). This is to be a full radiologist in addition to neurology, mind you, and not just a specialist in head CT's or brain MRI's. 2 years to specialize in all brain imaging makes sense--doesn't it? It is also a compromise between what the radiologists want (minimum 3 years) and what neurologists are trying to do (1 year "Neuroimaging" fellowships).

Two, sleep as you realized is already open to psychiatrists and pulmonologists. The latter are really taking over the field, and neurologists are allowing this to happen. The neurology-sleep director at one prominent institution was in the meeting that decided to make sleep an IM pathway and was happy about this result. Here is true devotion to the field and patients rather than money.

One INR doctor told me once that the reason radiology is allowing (and technically being forced to allow per the ACGME) neurologists in their INR fellowships is because radiologists are making up for the fact that they had been blocking neurologists from training/accreditation in neuroradiology. Now with the turf war between radiologists and clinicians (see above), and between vasc/cardiologists and INR doctors for carotid stents, it is in radiology and neurology's best interest to work together to allow neuro-trained folks to take on INR. There are very legitimate concerns about allowing cards/vasc folks to do carotid stents without any experience in intracranial endovascular interventions since stenting has a 1-2% risk of causing stroke *after* sufficient training. Ideally, in the future, the doc doing the stent should be able to go in a resolve this stroke when it happens, but one needs intracranial skills to do that. Also, many databases charting stroke rates shows that non-neuro folks doing the stents cause strokes at a far higher rate (mainly because they can't see what's happening).

But I digress.

B

Also, many databases charting stroke rates shows that non-neuro folks doing the stents cause strokes at a far higher rate (mainly because they can't see what's happening).

For my own education, please provide a quote to substantiate this claim.

It is already happening, by the way, and neurologists have created their own accreditation scheme with some neurologists getting imaging posts at places like MGH.

Those two did full two year neuroradiology fellowships at MGH before before becoming staff.

Admittedly, the idea that non-neurointerventionalists have worse outcomes in general than neurointerventionalists is highly controversial. And there is no good study showing this to be true. But I know of three databases being privately held at three different institutions where this type of thing is being noticed (these databases are typically run by stroke physicians who want to send their patients to interventionalists with the best overall outcomes). The only public one I have seen is at the Cleveland Clinic where the vascular/interventional neurologists compare their own outcomes to that of the nation, and find a substantially better rate. The interventional cardiologist there who also does them and was an author of the SAPPHIRE trial is also a neurologist and does intracranial interventions all the time--so in my mind doesn't completely count as a "non-neurointerventionalist". I don't have numbers from the first 2 databases, just 2nd-hand info from the stroke doctors that run them.

For a great editorial on what it takes to do carotid stents appropriately, see Sacks and Connors in Radiology 2005, 234:49-52. They basically note that the 100 cerebral angiogram requirement is important. There is one paper looking at 175 consecutive cases of CAS done by vascular surgeons at Northwestern. Their complications rate is slightly worse than those reported by neurointerventionalists, but these studies are very difficult to compare.

In the end, a true study comparing training background and complication rate will never be done due to politics. Instead, one has use the extensive literature showing that training in cerebral angiography and CAS directly affects outcomes (even at 100 procedures or so), so the corollary is simply that someone who does cerebral angiography and CAS as their only job would likely be better than one who doesn't.

Hope that helps.

B

the idea that non-neurointerventionalists have worse outcomes in general than neurointerventionalists is highly controversial. And there is no good study showing this to be true.

Enough said.

Those two did full two year neuroradiology fellowships at MGH before before becoming staff.


http://myprofile.cos.com/bakshi86

B

I made the mistake of scrolling further up in this thread:


2) Radiologists do block physicians from billing for reading their own images. Protection from insurance companies, and gaining contracts at hospitals is in large part based on accreditation. That is the whole point of accreditation. When radiologists block accreditation, they inherently block billing contracts. Simple economics.

Facility accreditation by the ACR is open to any healtcare organization. When they drew up the accreditation guidelines, they where very careful to comply with anti-trust issues. Nowhere does it restrict accreditation to facilities supervised by a radiologist (it does however require that you proove adequate instruction in radiation protection before you start irradiating the populace at large).

If you talk about accreditation for physicians: Neurology has its own 'neuroimaging' certification. It is up to hospital credentialing committees to accept it or not. Do you expect the neuroradiology CAQ to be opened to neurologists ? (last thing I know, the american board of surgery won't certify you in vascular surgery if you did a dermatology residency)

Hospital contracts exist because hospitals want to make sure that every study obtained ends up being read. The radiology group gets the 'right' to interpret all cross-sectional stuff in exchange for the obligation to cover loss-leaders such as mammography, ED coverage and low-end IR work.

Those two did full two year neuroradiology fellowships at MGH before before becoming staff.


http://myprofile.cos.com/bakshi86

B

Rohit is not at the MGH, he works at the Brigham. They are different hospitals. His work is almost all MS work now. There is one scanner for the MS patients (clinical and reasearch) and he works there now doing some clinical and also research in collaboration with people in the radiology department.

duplicate

The only public one I have seen is at the Cleveland Clinic where the vascular/interventional neurologists compare their own outcomes to that of the nation, and find a substantially better rate. The interventional cardiologist there who also does them and was an author of the SAPPHIRE trial is also a neurologist and does intracranial interventions all the time--so in my mind doesn't completely count as a "non-neurointerventionalist".

B

Jay Yadav pretty much does only carotid stents and stroke work. He doesn't do aneurysms/AVMS/fistulas/trauma. He does a lot of "cherry picking" if you know what I mean, so the statistics will be good. Even Tony Furlan is not very happy with him. Sorry, I just have some insider info.

to be truly any good at reading head CT's and brain MRI's, you need a 2 year fellowship in neuroradiology.


B
Come on, since this is all about money and not competency, there the issue of doing a 2 or 3 year fellowship is moot. None of the clinical specialists are talking about doing partial residencies -- we are talking about buying a scanner and doing a vendor-sponsored weekend CME in "ENT imaging for the neurologist-imager"

You mention neurologists coming up with your own (non-accepted) credentialling. Lets look at that, a shining example being the "credentialling" offered by the "American society of neuroimaging" You will note the following rigorous qualifications to sit their exam:


http://www.asnweb.org/index.php?submenu=Examinations&src=gendocs&link=ApplicationsandEligibilityTo be eligible for the examination, a candidate must meet and provide documentation of the following criteria:
1. Hold a valid medical license (or equivalent)
2. Be Board certified or eligible for Board in an ABMS recognized specialty (or equivalent for non-US trainees)
3. Completed a residency or fellowship which has met guidelines of adequate training (as follows) in neurologic MRI/CT interpretation as verified by a letter from program director:
a) During the course of clinical training or clinical practice the candidate reviewed MRI/CT studies of patients with brain/spine disorders.
b) The candidate’s own findings on these studies were compared with the opinion an attending physician taking care of the patient or the official reader of the study.
c) The analysis of the studies included teaching from an attending about the technical aspects of the study, anatomical localization and morphology of the lesion, differential diagnosis, and electing appropriate further neuroimaging studies.
d) The candidate participated in regular integrated neuroscience/neuropathological conferences that included clinical and MRI/CT correlation.


What a joke.

They want to say that hanging around the viewbox = a radiology residency. However, this is a much moe common position from non-radiologist imaging coaliitions. None are coming close to ABR standards even for their and KEY RELATED" subspecialties. (Example, where is ENT imaging in the above? )

Here is the whopping recommended number of hours of training, less than what a junior radiologiy resident would get in his first year, counting call and excluding PET/SPECT (which are usually covered in 2nd yr.)

Modality Minimum Hours
Neurosonology 40
CT 80
MRI 160
SPECT 100
PET 160

The requirements for CT/MR are crazy low, and I guarantee most residency trained neurologist has not 1/10th that experience in nuclear imaging.

The only credential worth the paper it is written on for imaging including neuroimaging is ABR board certification (fine, excluding echo).

And let me leave you with another important thought: If you want to come forward with a proposal to let neurologists sit the neuro CAQ, please explain how they intend to cover radiology call when the hospital radiology group leaves.

I don't accept the ASN certificate of neuroimaging--and I doubt most hospitals would either. I think there should be a neuroradiology CAQ within neurology, much as there is in radiology (i.e. certified by the American Board of Psychiatry and Neurology) that should take 2 years. This is precisely the accreditation that is being blocked. The analogous situation in cardiology would be a cardiologist reading cardiac CT's and MR's which is going to be commonplace. If we can do this, why not the former?

The fact that Bhakshi (sorry that I mixed up BW and MGH, but that doesn't change the point) does mostly MS work gets to my second point about neuroimaging in neurology. An MS expert should be allowed to be a neuroimager for MRI's that are monitoring the progress of an MS patient. I suspect that this entire issue is going to blow-up into a large turf war very soon as MRI becomes the defacto standard in evaluating acute stroke. Who will evaluate the PWI-DWI images, the HARM images, etc to figure out when a patient needs a particular treatment versus another? And who will bill for this evaluation? What if someone invents an MR based "brain stress test"? Or how about using fMRI to monitor rehabilitation? As far as I can tell, most of the major academicians studying the clinical use of fMRI are neurologists.

It is this latter scenario that I am really interested in hearing thoughts on from radiology residents. I sense a very defensive tone from the newer posts above, making me think that this is more of a political, money driven turf issue that has gotten many of the radiology residents worried about the future. I don't intend to move neuroradiology into neurology, but trust that in certain scenarios, we might be better off having the neurologists read MR's and CT's. If you still think that all neuroimages should only be officially evaluated by radiologists in all situations, then please plead your case.

B

I think there should be a neuroradiology CAQ within neurology, much as there is in radiology (i.e. certified by the American Board of Psychiatry and Neurology) that should take 2 years. This is precisely the accreditation that is being blocked.

On what level ? Has the ABPN proposed such a CAQ to ACGME ?


Who will evaluate the PWI-DWI images, the HARM images,

A radiologist (in the ideal case a neuroradiologist).


to figure out when a patient needs a particular treatment versus another?

The neurologist who has examined the patient, has discussed the treatment options with the family/patient and is willing to bear responsibility for the treatment decision.


This whole discussion about neuroimaging by neurologists is not about who reads the stroke-MR at 5am. There is no money in off-hours stroke imaging. This discussion is about self-referred imaging of marginally symptomatic patients during office hours (the cardiology way). Stroke imaging is the camels nose, self-referred imaging at a facility the neuro group owns a share is the camel.

The folks at your professional society are a bit more honest about this. They want to get the additional income from imaging into neurologists pockets so they can attract the cream of graduating medschool classes into the specialty.

If you still think that all neuroimages should only be officially evaluated by radiologists in all situations, then please plead your case.

B
(First of all, we are not pleading -- in reality any licensed physician in the US can do any procedure they feel like. These are reasons I feel non-radiologists should consider.)

We have given you many reasons why we feel that neuroradiology should be a part of radiology. Radiologists receive the most training and experience in the performance (including physics, artifact etc), and interpretation of these tests. We have expereince with all pathologies encountered by region of the body and across all organ systems (which is what gets imaged) rather than by specialty (surgical, neurological, endocrine etc. etc.) which is how clinicians are trained.

Furthermore, I feel that cherry picking cases will erode the ability of radiologists to maintain competence, which I feel is a valid issue.

I also feel that if a radiologist is available, then hospital should utilize their expertise to interpret imaging tests. Just like if a hospital has a vascular surgeon, they usually will avoid having their general surgeons perform vasc. surgery.

As for the idea of a full length 2-3 y fellowship in neuroimaging for neurologists, this is feasible but will not I suspect be popular due to the length. Most specialty groups are talking about doing imaging without additional training, claiming that they are already well trained in imaging, which is not true. I also am concerned that by training non-radiologist neuroimagers, the supply of radiologists available to provide on-call services will be reduced (these imagers can only provide neuroimaging). I am much more in favor of training neurologists in 3 years to get full BC in radiology, but that will be even less popular.

We may disagree on the 2-year neuroradiology question leading to a CAQ accepted by the ACGME for neurologists (and despite neurologists being allowed to do neuroimaging, a board sanctified CAQ is very important for several reasons as I have mentioned above), but I appreciate your comments. I agree that most neurologists will find an additional 2 years to be unpopular--but as neuroimaging becomes even more important in the management of many common neurological illnesses, I suspect that there may be several neurology residents who would be interested in this plan.

The 3 year BC in radiology post internship and further clinical training is a great idea for those who want to be full neuroimagers but maintain clinical interest as well. However, spending 7 years (and most likely another 1-2 more to develop specific expertise in neuroradiology and a subspecialty of neurology) would be prohibitive to many. Nevertheless, I know of 2 neurology residents that have done this (one spent 10 years to become a double-board certified interventional neurologist!), and have heard of few others as well. I personally think this a great path for academic neuroimagers, and may consider it myself, but is obviously too much to ask for someone interested in private neurology.

You have all made me question my beliefs about neurologists doing their own neuroimaging, but I still wonder if there couldn't be some easier way of certifying stroke neurologists to read (and bill for) their own MRI's and CT's in the setting of acute stroke. Am I wrong, or are stroke neurologists still not able to bill for their own interpretations of head CT's during acute stroke at most institutions and hospitals? I doubt that this would hurt the supply of radiologists out there, and think that the analogous situation is the cardiologist reading a patient's EKG to evaluate their treatment of AMI.

B

I doubt that this would hurt the supply of radiologists out there, and think that the analogous situation is the cardiologist reading a patient's EKG to evaluate their treatment of AMI.

B
I don't know if that is a typo or what, but the analogous situation would be an ED of FP doc reading a patient's EKG and billing for it. In most hospitals, the EKGs are saved and read by a cardiologist days or weeks later (in my experience, it is much worse than xrays now), and the ED and FP do not get paid for their interpretation. However, hospitals credential the cardiologists to provide the final reads.

I do not wish to comment on how useful this is in the ECG realm.

In the x-ray world, we now usually read the ER films within 3-12 h, and there is a healthy mix of missed pathology picked up by us, and the odd fracture that the ED picks up that honestly I would have missed (of course sans history) (I am willing to admit it, but I am also confident that that is the exception rather than the rule, even without clinical info, and I am still in residency).

Back to head CTs -- you are correct that most hospitals do not let the stroke neurologist bill for it. I believe this is appropriate, because as I have said before, many pathologies can present clinically as a stroke, not all are familiar to the stroke neurologist. And I feel it is patently unreasonable to expect the radiologists to stand around as a "back-up" in case something pops up that the ordering physician is uncomfortable with interpreting, but otherwise forego the billing in "straightforward" cases.

And very importantly, even if a stroke neurologist were to undergo the training to read head CTs (all pathologies, "medical-neurological" and otherwise), in the day-to-day imaging of his own patients, I do not think he would see enough cases to maintain good competence. And let's remember that in terms of professional development, he is going to focus on stroke, and stroke imaging, not neuroimaging. To be a good film-reader, he would have to devote a significant part of his practice to reading films, many more films than patients he could possibly see -- which is what radiologists do! And is the busy clinician who reads a few scans per week going to ensure that the radiology department is properly equipped, that the images are of top quality, and that the latest techniques are being used?

I think we should tread carefully. Imaging could easily be carved up, but I believe quality would suffer.

As someone who is willing to train for 10 years, I appreciate your arguments in favor of radiology--I might have to use them to explain why I put myself through that much residency time. But allowing a stroke neurologist to bill for stroke imaging has important advantages that you should still consider:

First, I don't think the analogous situation is an IM or FP (or ED) doc reading an EKG. The critical and detailed treatment decisions will be made by a cardiologist for AMI's, not the other doctors. Similarily in stroke, the critical decisions will be made by the neurologist, not any other doctor. Regardless of whether they bill for it or not, the neurologist will be trained and will proceed to read the CT or MRI immediately in the setting of acute stroke to plan their treatment--I doubt they will wait for the radiologist in most settings. This is due to the practical need to treat as soon as possible in order to secure better outcomes ("time is brain"). This situation will be especially important in places that don't have neuroradiologists on call (and even more in places that don't have radiologists on call!). So a stroke physician will likely need to be well trained to read the imaging to manage their patients acutely.

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke. Suddenly, stroke physicians would be willing to spend 2 years in fellowship post residency securing far more training in CT and MRI than they would have gotten from their typical 1 year fellowship (I argue that one needs only 1 additional year to learn stroke imaging rather than the 2 for complete neuroradiology training). This would likewise translate to far better care of stroke patients given above. The billing structure might simply be a extra fee in the compensation to a stroke neurologist when reading a head CT or MRI in the setting of acute stroke--not a difficult thing to add. Without this, I fear that neurologists will not get this training, keep stroke imaging dependent on radiologists and lead to increased time to thrombolysis or other treatments. Even an extra 30 minutes makes a difference in outcomes, and this is likely to be even more true as the time window for treatment of stroke extends to 12 hours in the coming years with many more options than simple IV tPA.

The analogous situation again is the cardiologist determining the treatment for an AMI patient and being able to read all, bill for, and interpret all the necessary data available him or herself. Such a situation is not necessary at large academic institutions with their own comprehensive stroke centers, but will be in community hospitals.

B

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke.

You seem to have an unrealistic expectation about the professional fee for the interpretation of a head-CT.

If you want the stroke neurologist to bill the imaging, he should also be obliged to interpret all the other CNS imaging studies obtained by the ED (all the head CTs for 'AMS' and other results of CYA medicine).

Last I checked, professional fees for head CT's and brain MRI's range from around $50 per scan to $200 per scan depending on whether one uses contrast, does 3-d reconstructions, looks at angiography, checks perfusion images, etc. While right now all we typically do is a non-con head CT (fee ~$50), I think there is a good chance that we will be doing MRI's with PWI/DWI images and probably angiography in the future with fees of around $200 each instead. Add another fee for follow up imaging which may also become standard of care in the future. This would all be in addition to fees for consultation, thrombolysis if used, ultrasound/dopplers if used, and post-care management.

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

B

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

Enjoy !
(and look forward to be called 10-20 times per night to read another 'usually delusional, now paranoid delusional, r/o stroke' CT)

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

B

Firstly I doubt many fellowship trained stroke neurologists are that interested in doing another lengthy fellowship.

Secondly, if your hospital hires a general surgeon and then tells them "our FPs and EPs do all the appys and choles" (ct heads), we just need you to do the colostomies and bowel resections (necks, temporal bones) and help out the FPs and EPs if they have a question" they will tell you to take a hike. As a condition of signing on, they will take over the procedures that traditionally fall in their expertise. You want to provide your hospital/ED with imaging? You had better be prepared to do it all I mean barium enemas all) because your radiologists will leave.

Last I checked, professional fees for head CT's and brain MRI's range from around $50 per scan to $200 per scan depending on whether one uses contrast, does 3-d reconstructions, looks at angiography, checks perfusion images, etc. While right now all we typically do is a non-con head CT (fee ~$50), I think there is a good chance that we will be doing MRI's with PWI/DWI images and probably angiography in the future with fees of around $200 each instead. Add another fee for follow up imaging which may also become standard of care in the future. This would all be in addition to fees for consultation, thrombolysis if used, ultrasound/dopplers if used, and post-care management.

B

You must not know much about reimbursement. These fees are what is on paper. The amount that you will actually be able to collect in the end usually varies between 35% to 70% of the published fees. Plus you mentioned the repeat studies, the majority of which will be done for free since the third party payors and their DRGs have a limit on what they will pay. So for the 10 CT/MRIs that a patient gets in the hospital, you'll be probably be paid for 2-3 of them. The rest is pretty much done for free. Income often comes from well-insured outpatients.

BTW, perfusion MRI and perfusion CT are NOT reimbursable. You only get paid as much as a regular contrast MRI or CT. Depending on your carrier, you may be able to get a very small reimbursement for postprocessing. Spectroscopy is NOT reimbursable either in any form.

I am not trying to reopen the original debate...I am just wondering if there are alot of neurologists in private practice who are reading their own films (without getting sued.) I know that there are Neuroimaging fellowships for Neurologists, which I believe are different than fellowships for neurointerventional. For someone like me, whose only interest in Radiology is neuro, and who also wants patient interaction, this seems like a dream come true.

Any thoughts from those in the know? Thanks!

You can check out the ASN website - asnweb.org for additional info. There is plenty to go around, and you should have no difficulty doing neuroimaging after a neuro residency - your opportunities are more plentiful in private practice though. Except for the Buffalo group and Dr Bakshi at Harvard, I don't know of anybody else in neurology that does the CT/MRI stuff in academic setting. There is a better market for neurologists to do angio/endo work in the academic setting

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke. Suddenly, stroke physicians would be willing to spend 2 years in fellowship post residency securing far more training in CT and MRI than they would have gotten from their typical 1 year fellowship (I argue that one needs only 1 additional year to learn stroke imaging rather than the 2 for complete neuroradiology training).
B

Why the extra-training? Some neurology residencies are structured that they get plenty of neuro-imaging even at the resident level. You need to do extra-time if you want to learn the endovascular procedures - one to two years at most.

Why the extra-training? Some neurology residencies are structured that they get plenty of neuro-imaging even at the resident level. You need to do extra-time if you want to learn the endovascular procedures - one to two years at most.

This is exactly what I mean. The discussion of advanced training is almost moot because while there is no standardization of imaging training at the residency or board level in these specialites, people will claim they have all this expertise just from doing a non-radiology residency. There is no standardization, and it is a guarantee that these people have little or no experience with pathologies outside the realm of neurology. Reviewing the results of your patients' scans does not constitute a radiology residency. This is whay hospital credentialling committees, and now some insurance payors won't buy it.

The thing about my hope for a 1 (for particular applications) vs 2 (for all neuroradiology) year neuroradiology fellowship for neurologists is that it was a way for them to have to endure the standardized, rigorous training that radiologists get. It is part of vision for American medical training that allows multiple specialties to get training in the fellowship programs fighting the constant turf wars out there. The leaders of INR had this vision and the results have been fairly impressive to me so far. Diagnostic neuroradiology could take a similar route. Note that this is not just a problem in neuro. Currently EM docs are not allowed to get boarded in critical care, though they get quite a bit of relevant training and would likely get the remainder via their critical care fellowship.

Saying that a neurologist could simply do neuroimaging from their residency training is like saying that a neurosurgeon could do endovascular procedures without ever doing an interventional fellowship. The problem is simply that errors are dependent on an operator/imager's experience and training. To best minimize errors, one has to train an operator/imager with a sufficient number of cases in a standardized format.

B

Most neurologists do zero training in head and neck/ENT radiology. These things are on every head MR, and bad stuff often lives in the spaces of the neck. Also, while I agree that neurologists see alot of images in their training, the average rads resident probably sees more images on their first neurorad month than the average Neuro resident sees in their residency. (by time you do your 1 hour history and physical, and look a the images, I'm through a wide range of studies...and so on for ever hour)

Most neurologists do zero training in head and neck/ENT radiology. These things are on every head MR, and bad stuff often lives in the spaces of the neck. . .


which is why gastroenterologists shouldn't be doing virtual colonoscopies . . . but ultimately it falls on the the lack of public exposure by radiologists so that the general public demands a trained professional interprets imaging