Time to put the axe to your profession

FutrrENT · Dec 13, 2011

I'm not going so far as to say that radiology shouldn't exist, but the specialty strikes me as one that exists out of, perhaps, fear of getting sued rather than a real medical need.

I'm an ENT resident. I was on trauma call last night and sure enough we had an MVA involving some facial injuries. I read the CT myself. Went over it with my chief resident. Discussed it with our attending. And we took the patient to the OR without ever seeing the "official read" from the radiologist on call. In fact, the official read wasn't available until a few hours after the patient was wheeled into the PACU. This is the routine. Not just for my service, but for most services. The official read on images is often an after-thought.

In reading the official read, the radiologist noticed a calcified cervical lymph node. Great.

My problem with radiology is this:

First, what other service in any hospital, with infectious disease being perhaps the only other, is automatically consulted for every test, diagnosis, or treatment that falls within its scope? For example, could you imagine if hematology was automatically consulted to evaluate every CBC/diff that was ordered? Or nephrology consulted for every urinalysis? Or plastic surgery for every wound? So why is it acceptable for every last image ever taken in a hospital from a brain MRI to an ankle x-ray to be required to be evaluated by a radiologist (who will then make money for reading the film....often a couple hours after the fact even in the middle of the day).

I had asked this of the radiology residents at my hospital and he said this: "Because we may catch something that other people missed".

This statement really angers me because 1. It applies to consulting every specialty out there, and 2. because it justifies radiologists' automatic involvement in every study by incidental, serendipitous, irrelevant findings (e.g. the calcified node I mentioned above).

Yes, radiologists make plenty of findings on images that the doctor ordering the study was not even looking for. Even if some of these findings are serious and worthy of further investigation, it needs to be noted that radiologists aren't doing this for free as a favor for patients. They are getting paid ungodly amounts of money to make these incidental findings. And the key word here is incidental. If a patient gets an abdominal CT for a uterine mass and the radiologist identifies the the uterine mass (after the OBGYN identified it), but also identifies an inguinal hernia or a kidney stone or whatever, this does not justify paying a radiologist.

Having a radiologist read the image to make extraneous findings unrelated to the "targeted" pathology is a luxury. But in our system, it is a luxury that takes place by default, and radiologists have been raking in piles of money for this.

Combine that with the fact that any cardiologist can read an echo every bit as well as a radiologist (and identify its clinical significance far better), any neurosurgeon can read a head/spine CT or MRI as well as a radiologist, any pulmonologist a CXR or chest CT, and so on, one becomes very hard-pressed to see why it is that radiologists make so much money. And the reality on the ground supports this question, as I mentioned above. Clinical decisions are made routinely without even bothering to look at the radiologist's read. And there seems to be a lot of out-sourcing of images for evaluation.

Anyone care to discuss this?

princess peach · Dec 14, 2011

FutrrENT said:
I'm not going so far as to say that radiology shouldn't exist, but the specialty strikes me as one that exists out of, perhaps, fear of getting sued rather than a real medical need.

I'm an ENT resident. I was on trauma call last night and sure enough we had an MVA involving some facial injuries. I read the CT myself. Went over it with my chief resident. Discussed it with our attending. And we took the patient to the OR without ever seeing the "official read" from the radiologist on call. In fact, the official read wasn't available until a few hours after the patient was wheeled into the PACU. This is the routine. Not just for my service, but for most services. The official read on images is often an after-thought.

In reading the official read, the radiologist noticed a calcified cervical lymph node. Great.

My problem with radiology is this:

First, what other service in any hospital, with infectious disease being perhaps the only other, is automatically consulted for every test, diagnosis, or treatment that falls within its scope? For example, could you imagine if hematology was automatically consulted to evaluate every CBC/diff that was ordered? Or nephrology consulted for every urinalysis? Or plastic surgery for every wound? So why is it acceptable for every last image ever taken in a hospital from a brain MRI to an ankle x-ray to be required to be evaluated by a radiologist (who will then make money for reading the film....often a couple hours after the fact even in the middle of the day).

I had asked this of the radiology residents at my hospital and he said this: "Because we may catch something that other people missed".

This statement really angers me because 1. It applies to consulting every specialty out there, and 2. because it justifies radiologists' automatic involvement in every study by incidental, serendipitous, irrelevant findings (e.g. the calcified node I mentioned above).

Yes, radiologists make plenty of findings on images that the doctor ordering the study was not even looking for. Even if some of these findings are serious and worthy of further investigation, it needs to be noted that radiologists aren't doing this for free as a favor for patients. They are getting paid ungodly amounts of money to make these incidental findings. And the key word here is incidental. If a patient gets an abdominal CT for a uterine mass and the radiologist identifies the the uterine mass (after the OBGYN identified it), but also identifies an inguinal hernia or a kidney stone or whatever, this does not justify paying a radiologist.

Having a radiologist read the image to make extraneous findings unrelated to the "targeted" pathology is a luxury. But in our system, it is a luxury that takes place by default, and radiologists have been raking in piles of money for this.

Combine that with the fact that any cardiologist can read an echo every bit as well as a radiologist (and identify its clinical significance far better), any neurosurgeon can read a head/spine CT or MRI as well as a radiologist, any pulmonologist a CXR or chest CT, and so on, one becomes very hard-pressed to see why it is that radiologists make so much money. And the reality on the ground supports this question, as I mentioned above. Clinical decisions are made routinely without even bothering to look at the radiologist's read. And there seems to be a lot of out-sourcing of images for evaluation.

Anyone care to discuss this?

lol. awesome post, thank you. ENT residents should protocol and interpret their own temporal bone CT/MRs then. so easy.

troll much? feeding but so hard to resist.

punkindrublic · Dec 14, 2011

look, you're obviously a troll or pissed that you're on q4 call. either way, this post exhibits a real ignorance about your patient and the wonderful god complex so many surgeons have. so good for you, you interpreted a trauma series in your specialty and made your decisions accordingly. competent surgeons can handle that. if you are unsure about something, rads is always there to call and get an answer, otherwise, go nuts and start cutting.

the god complex comes from the fact that you think the patient's treatment will begin and end with you. and there you're frightfully wrong. they'll be rounded on by multiple teams in the hospital and when discharged, may actually have a pcp in the community who will want to know exactly what happened with the patient and may not have your expertise. the final report is a record of what is seen in that study, which is the difference between a quantitative (CBC) and qualitative (CT etc.) test. it's similar to path. the best surgeons i've met can identify the wet preps of common tumors when consulting pathology, but sometimes the results are confusing. much like path, the radiologist is instrumental in creating continuity of care by providing a record that can be understood by clinicians in any field, and to clear things up when the results are murky. radiology doesn't exist to serve just surgeons, contrary to popular belief.

and by the way, you're right about cardiac echos. that's exactly what cardiology does, and shows how little you know about the field of radiology. but i'm sure once you lose your first lawsuit, you'll become well acquainted with us.

davidjones · Dec 14, 2011

While you're previous posts quite aptly demonstrate your ignorance I feel compelled to answer if only to spare your future patient some unfortunate mismanagement . With regard to your n=1 of an MVA I'm guessing it was such an obvious fracture or injury a premed student can see it. I agree that rads should not be consulted for every X-ray and CT and lord knows it's super obnoxious when im doing a consult in the icu where epistaxis after ENT couldn't stop the bleeding and some resident calls me because there's a Kindney stone CT that hasn't been looked at.

Extraneous findings such as a calcified lymph node are not important but things like AVMs and GBMs are. And when you have a cancer patient are you guys gonna read the PET too? Or the whole body CT or the liver MRI? Or if the patient has intractable bleeding from a tongue mass you guys going to embolize it?

For the record I'm curious why ENT is really a specialty? I mean thoracic and pulmonary can do all the airway stuff, endocrine surgeons can do thyroids OMFS and plastics can do the face stuff and neurosurgery can do the head stuff. I mean other the PE tubes what do you guys do ?

Grow up.

2012mdc · Dec 14, 2011

You are seriously comparing interpreting a CBC to interpreting a brain MR?

You are either really ignorant of other fields besides ENT or just a horrible troll.

Civil8 · Dec 14, 2011

Hey big guy, I just hope you had the guts to go tell the radiology residents this yourself.

CWUDoc · Dec 14, 2011

This guy has a history of ignorant and inflammatory posts about other specialties. Just ignore.

Radiculous · Dec 14, 2011

princess peach said:
lol. awesome post, thank you. ENT residents should protocol and interpret their own temporal bone CT/MRs then. so easy.

troll much? feeding but so hard to resist.

can't resist either. FutrrrrrrrrENT, this is without a doubt the dumbest thing I have ever read on SDN. you need to stop hating yourself for choosing ENT instead of rads. It's going to be okay. Breathe. Learn to love the mucus.

FutrrENT · Dec 14, 2011

princess peach said:
lol. awesome post, thank you. ENT residents should protocol and interpret their own temporal bone CT/MRs then. so easy.

troll much? feeding but so hard to resist.

We certainly interpret our own CTs and MRIs. I have yet to encounter a situation where a radiologist elucidated anything for us on any midface/skullbase/neck image. Obviously, the brain is not my area of expertise.

As for protocols, that is something a technician can handle from reading off a list of protocols for various imaging situations and equipment. Doesn't take a physician getting paid $500,000 a year to do that.

FutrrENT · Dec 14, 2011

CWUDoc said:
This guy has a history of ignorant and inflammatory posts about other specialties. Just ignore.

I've got a better idea:

Why don't you act like an adult and address the arguments I made questioning the necessity of radiologist involvement in every last radiographic image taken in our hospitals.

FutrrENT · Dec 14, 2011

Radiculous said:
can't resist either. FutrrrrrrrrENT, this is without a doubt the dumbest thing I have ever read on SDN. you need to stop hating yourself for choosing ENT instead of rads. It's going to be okay. Breathe. Learn to love the mucus.

Mucus, huh? That's what you've determined to comprise the bread-and-butter of our profession?

Funny though: in today's cochlear implant case, I don't think I saw a drop of the stuff.

FutrrENT · Dec 14, 2011

davidjones said:
With regard to your n=1 of an MVA I'm guessing it was such an obvious fracture or injury a premed student can see it.

Well, you guessed wrong. Look, I have two functioning eyeballs just like the radiology resident who read the CT and the radiology attending who confirmed it, and was able to identify the break in continuity of the bone (where one wasn't expected). My diagnosis was identical to theirs.

Extraneous findings such as a calcified lymph node are not important but things like AVMs and GBMs are.

I'm not denying this. But you are getting paid huge amounts of money to serendipitously find other pathology that was not the target of the exam. Do you not see my point here?

And when you have a cancer patient are you guys gonna read the PET too?

Some day, I would like to learn how to do this. My attendings sure as hell do.

Or the whole body CT or the liver MRI?

No. Because I'm an ENT. We'd let the general surgeons or gastroenterologists read the liver CTs.

As for the whole body CTs, then fine. Bring in a radiologist for that simply because they have experience in all the areas of the body consolidated into one physician. But for isolated regions, e.g. brain/spine, head/neck, thorax, abdomen, pelvis, the physicians ordering the imagine are usually able to interpret them just fine, be they CTs or MRIs.

Or if the patient has intractable bleeding from a tongue mass you guys going to embolize it?

No. Are you? Not unless you do a fellowship in interventional radiology.

Besides, interventional cardiologists seem to do just fine cathing hearts themselves. Neurosurgeons and neurologists seem to do just fine cathing brain vasculature. I'm sure it wouldn't be too hard to train an ENT to cath vascular malformations in the head/neck region that aren't amenable to surgery.

For the record I'm curious why ENT is really a specialty? I mean thoracic and pulmonary can do all the airway stuff

This statement is factually incorrect. Thoracic does the heart/lungs. They don't - at least not in my hospital - operate on the airway above the mediastinum.

endocrine surgeons can do thyroids OMFS and plastics can do the face stuff and neurosurgery can do the head stuff. I mean other the PE tubes what do you guys do ?

Head/neck oncology. Otology. Upper airway surgery. Laryngeal surgery. Those are some areas we have a stranglehold on for starters. A few OMFS here and there try to dabble in head-neck oncology and very few of them establish themselves as doctors to whom such cases should be referred.

FutrrENT · Dec 14, 2011

punkindrublic said:
look, you're obviously a troll or pissed that you're on q4 call. either way, this post exhibits a real ignorance about your patient and the wonderful god complex so many surgeons have. so good for you, you interpreted a trauma series in your specialty and made your decisions accordingly. competent surgeons can handle that. if you are unsure about something, rads is always there to call and get an answer, otherwise, go nuts and start cutting.

the god complex comes from the fact that you think the patient's treatment will begin and end with you. and there you're frightfully wrong. they'll be rounded on by multiple teams in the hospital and when discharged, may actually have a pcp in the community who will want to know exactly what happened with the patient and may not have your expertise. the final report is a record of what is seen in that study, which is the difference between a quantitative (CBC) and qualitative (CT etc.) test. it's similar to path. the best surgeons i've met can identify the wet preps of common tumors when consulting pathology, but sometimes the results are confusing. much like path, the radiologist is instrumental in creating continuity of care by providing a record that can be understood by clinicians in any field, and to clear things up when the results are murky. radiology doesn't exist to serve just surgeons, contrary to popular belief.

and by the way, you're right about cardiac echos. that's exactly what cardiology does, and shows how little you know about the field of radiology. but i'm sure once you lose your first lawsuit, you'll become well acquainted with us.

Don't even try it, bub.

DO NOT compare radiology with pathology!

A pathologist looking at tissues has before him a "specimen" offering far more information than a radiologist looking at an MRI does. A light micrograph shows him the organization of the cells, the variety of cells, sizes of cells, shape of cells, connections between cells, number of cells, cellular contents (each of which can vary greatly in pathologic states), uptake of staining, and on and on and on. He is looking at what is actually there and making a diagnosis based on what needs to be an exhaustive knowledge of anatomical pathology. There is huge amounts of information to be ascertained from a slide. And that's just LM. They also use EM.

Not so from a chest x-ray, or a CT, or even an MRI. Compared to the tissue samples a pathologist examines under a microscope, CTs, MRIs, and PET scans are incredibly blunt tools. They don't offer anywhere near as much raw, interpretable information as a tissue sample does.

Think about it: every doctor out has some skill reading plain-films, CTs, and MRIs. Very few doctors, however, would have a clue how to even identify cancer on a light-microscope slide (much less differentiate lichen planus from pemphigoid on a slide).

Bad comparison on your part.

rem6775 · Dec 14, 2011

This post does not even make sense if you have even a semblance of common sense. Of course, the purpose of the post is only to be inflammatory and not actually make sense.

So before you even discuss the actual bulk of what you are saying, you can throw out your idea based on simple logistics. So first of all, you have a (clearly false) altruistic reason that radiologist are doing a disservice by charging patients to read their films. This is irrelevant because if you were reading their films, you would charge the same price. So drop the bogus altruism.

Secondly, your suggestion basically amounts to this: As the ENT, you're going to read the neck soft tissues/vasculature. Supposedly, thoracic is going to read the lungs/heart included on your image and neurosurgery is going to read the brain on your image. So, who is going to get paid for reading it? You? The neurosurgeon? The thoracic surgeon? You planning on splitting the already small professional fee? When exactly are you going to write the report for your section? When are you going to combine it with the reports that you're now asking neurosurgery and thoracic surgery to do since you can't read those parts? When during the day are you going to read and dictate all those studies? Between patients?

These issues are so blatantly obvious (and there are more) that I do not believe anyone who was intelligent enough to go into ENT actually believes them. That makes the rest of your points irrelevant as far as I'm concerned, because it means you're either without common sense or simply trying to be inflammatory. Why anyone would get worked up or care what you think is a whole different story.

badasshairday · Dec 14, 2011

Congrats, from now on, never look at the dictated report.
I wonder why so many doctors keep coming into the reading room, including pulm, neurosurg, ent, gen surg, since they already know everything about the films. I guess they just want to shoot the **** and slow the the radiologists work efficiency. I mean obviously, radiologists are useless.

oops, i think i fed the troll. argh.

MedPR · Dec 14, 2011

FutrrENT said:
I'm not going so far as to say that radiology shouldn't exist, but the specialty strikes me as one that exists out of, perhaps, fear of getting sued rather than a real medical need.

I'm an ENT resident. I was on trauma call last night and sure enough we had an MVA involving some facial injuries. I read the CT myself. Went over it with my chief resident. Discussed it with our attending. And we took the patient to the OR without ever seeing the "official read" from the radiologist on call. In fact, the official read wasn't available until a few hours after the patient was wheeled into the PACU. This is the routine. Not just for my service, but for most services. The official read on images is often an after-thought.

In reading the official read, the radiologist noticed a calcified cervical lymph node. Great.

My problem with radiology is this:

First, what other service in any hospital, with infectious disease being perhaps the only other, is automatically consulted for every test, diagnosis, or treatment that falls within its scope? For example, could you imagine if hematology was automatically consulted to evaluate every CBC/diff that was ordered? Or nephrology consulted for every urinalysis? Or plastic surgery for every wound? So why is it acceptable for every last image ever taken in a hospital from a brain MRI to an ankle x-ray to be required to be evaluated by a radiologist (who will then make money for reading the film....often a couple hours after the fact even in the middle of the day).

I had asked this of the radiology residents at my hospital and he said this: "Because we may catch something that other people missed".

This statement really angers me because 1. It applies to consulting every specialty out there, and 2. because it justifies radiologists' automatic involvement in every study by incidental, serendipitous, irrelevant findings (e.g. the calcified node I mentioned above).

Yes, radiologists make plenty of findings on images that the doctor ordering the study was not even looking for. Even if some of these findings are serious and worthy of further investigation, it needs to be noted that radiologists aren't doing this for free as a favor for patients. They are getting paid ungodly amounts of money to make these incidental findings. And the key word here is incidental. If a patient gets an abdominal CT for a uterine mass and the radiologist identifies the the uterine mass (after the OBGYN identified it), but also identifies an inguinal hernia or a kidney stone or whatever, this does not justify paying a radiologist.

Having a radiologist read the image to make extraneous findings unrelated to the "targeted" pathology is a luxury. But in our system, it is a luxury that takes place by default, and radiologists have been raking in piles of money for this.

Combine that with the fact that any cardiologist can read an echo every bit as well as a radiologist (and identify its clinical significance far better), any neurosurgeon can read a head/spine CT or MRI as well as a radiologist, any pulmonologist a CXR or chest CT, and so on, one becomes very hard-pressed to see why it is that radiologists make so much money. And the reality on the ground supports this question, as I mentioned above. Clinical decisions are made routinely without even bothering to look at the radiologist's read. And there seems to be a lot of out-sourcing of images for evaluation.

Anyone care to discuss this?

So you think it's ok to treat the patient only for what their immediate or assumed condition is? If the radiologist catches something you weren't looking for, serious or not, then it was worth it for him/her to read the CT/MRI/whatever. In your example you asked your chief res, and your attending, not just because you're a resident, but because it's good to have multiple opinions. Why isn't the radiologist's opinion (e.g the most trained opinion) worth it?

Everyone involved in patient care is important in some way. You learned to draw blood in med school, so why are you leaving it up to your nurse/phlebotomist to do it for you? We should axe their professions too.

People like you are the mistakes ADCOMs wish they hadn't made.

MrBurns10 · Dec 14, 2011

FutrrENT said:
I'm not denying this. But you are getting paid huge amounts of money to serendipitously find other pathology that was not the target of the exam. Do you not see my point here?

Define "serendipitously." While many of the findings are irrelevantanomas like a calcified granuloma, many others are absolutely relevant and aren't noticed by the primary team. This happens daily, if not hourly. Like the surgery team today who didn't notice the subtle new lucencies in the pleural space on the chest x-ray that we informed them about, got the CT (which we read), which turned out to be an empyema. Or the surgery team who didn't see the fistula between the gastric pull-through and the pericardium on CT. Or the pulmonologist who ordered the ILD protocol CT scan who didn't (wouldn't ever) see the dilated hepatic ducts and soft tissue within the CBD. Or the medicine team who almost inserted a chest tube in a skin fold mimicking a pneumothorax. Or even the surgeon who called down concerned about a line on the lateral view (...the scapula). I could go on and on. Just because you happen to be able to read a facial CT scan on bone windows doesn't mean you're qualified to read anything else. Nor should you be...there's a reason we train for 5 years.

I don't disagree with you that neurosurgery can read their head CT scans or that ortho can read their plain films just as well as us if not better, considering they have the benefit of physical exam. That's a valid point. But there's a reason we have to know how to read every type of modality for every body part, and know differentials for them all (yes, because sometimes it matters what we say something is). If I'm a patient, I know I'd want a radiologist reading my study, in communication with the primary/consult team to correlate with the clinical findings.

MossPoh · Dec 14, 2011

People are best at what they do the most. These statements simply tell me that you don't know enough to say you don't know. It takes guts to say you are better than any other specialty at something they dedicate their lives to. People tend to magnify the amount of things they do right. Sure, you probably can do the majority of cases right but I guarantee that if there were 100 studies in front of you, it would take you much longer to read those studies with a much greater error rate.

FutrrENT · Dec 14, 2011

rem6775 said:
This post does not even make sense if you have even a semblance of common sense. Of course, the purpose of the post is only to be inflammatory and not actually make sense.

Well, as the person who wrote it, I am telling you that it wasn't meant to be inflammatory. Perhaps you become inflamed far too easily.

So before you even discuss the actual bulk of what you are saying, you can throw out your idea based on simple logistics. So first of all, you have a (clearly false) altruistic reason that radiologist are doing a disservice by charging patients to read their films.

When you charge patients for evaluations they didn't pay for (in this case, the evaluation from a highly-paid radiologist), then yes, you are ethically doing them a disservice (even if that disservice leads to an important, unrelated diagnosis). When I order a head CT on a patient who I believe has mid-face injuries, I'm not ordering the image so that a radiologist can serendipitously locate a brain tumor.

This is irrelevant because if you were reading their films, you would charge the same price. So drop the bogus altruism.

I had some knee x-rays performed recently and my orthopedist charged for the x-rays. I don't remember seeing any "x-ray reading fee" anywhere on my bill. Maybe it's included in the fee for the x-ray, maybe not. Regardless, the fee was cheap. Had that image been taken at my hospital where a radiologist would be sure to read it, the fee (for someone) would be more.

No doctor who reads x-rays, be it a neurosurgeon, orthopedic surgeon, OBGYN, or even your stinking dentist rakes in as much money per image as a radiologist. Yet, they do almost as good a job when reading images related to their field of work.

Secondly, your suggestion basically amounts to this: As the ENT, you're going to read the neck soft tissues/vasculature.

Correct. That's part of being a doctor. Reading images of areas of the body that fall within the scope of your practice.

Supposedly, thoracic is going to read the lungs/heart included on your image and neurosurgery is going to read the brain on your image. So, who is going to get paid for reading it? You? The neurosurgeon? The thoracic surgeon? You planning on splitting the already small professional fee? When exactly are you going to write the report for your section? When are you going to combine it with the reports that you're now asking neurosurgery and thoracic surgery to do since you can't read those parts? When during the day are you going to read and dictate all those studies? Between patients?

Oh, now I see. So what you're saying is that these radiologists who are making money hand over fist are there simply to consolidate the reading responsibilities into one entity....you know, for simplicity's sake. I was under the impression that a specialty should exist because its doctors possess unique knowledge and skill that can't be accessed elsewhere.

As for who would get the fee, each could charge a small fee for evaluation of their "part" of the film. I have no doubt that in the long run, this would end up costing our health system less than paying radiologists half a million dollars a year.

FutrrENT · Dec 14, 2011

MossPoh said:
People are best at what they do the most. These statements simply tell me that you don't know enough to say you don't know. It takes guts to say you are better than any other specialty at something they dedicate their lives to. People tend to magnify the amount of things they do right. Sure, you probably can do the majority of cases right but I guarantee that if there were 100 studies in front of you, it would take you much longer to read those studies with a much greater error rate.

Surely you've heard of the law of diminishing return, haven't you?

ENTs read enough head/neck CTs and MRIs to be proficient at reading them.

Moreover, your assumption that radiologists have more practice reading head/neck images is simply false. You are forgetting that any doctor (ENTs included) will read every image he orders. So, ENTs read nothing but imaging related to otolaryngology, and we read a lot of them.

A radiologist is reading images from everywhere. Head, neck, abdomen, pelvis, GI, spine, shoulders, knees, etc. etc.

Who do you think has more practice reading head/neck images?

Who do you think has more practice reading brain images? The neurosurgeon or the radiologist?

Who do you think is more experienced reading shoulder or knee images? The orthopedist or the radiologist?

Are we as fast as radiologists? Maybe not. And I will never waste my time by timing m speed at reading head/neck images. If we're a little slower, who cares? We are not being paid outlandish sums of money for reading images.

officedepot · Dec 14, 2011

FutrrENT · Dec 14, 2011

MrBurns10 said:
Define "serendipitously." While many of the findings are irrelevantanomas like a calcified granuloma, many others are absolutely relevant and aren't noticed by the primary team. This happens daily, if not hourly. Like the surgery team today who didn't notice the subtle new lucencies in the pleural space on the chest x-ray that we informed them about, got the CT (which we read), which turned out to be an empyema. Or the surgery team who didn't see the fistula between the gastric pull-through and the pericardium on CT. Or the pulmonologist who ordered the ILD protocol CT scan who didn't (wouldn't ever) see the dilated hepatic ducts and soft tissue within the CBD. Or the medicine team who almost inserted a chest tube in a skin fold mimicking a pneumothorax. Or even the surgeon who called down concerned about a line on the lateral view (...the scapula). I could go on and on. Just because you happen to be able to read a facial CT scan on bone windows doesn't mean you're qualified to read anything else. Nor should you be...there's a reason we train for 5 years.

I don't disagree with you that neurosurgery can read their head CT scans or that ortho can read their plain films just as well as us if not better, considering they have the benefit of physical exam. That's a valid point. But there's a reason we have to know how to read every type of modality for every body part, and know differentials for them all (yes, because sometimes it matters what we say something is). If I'm a patient, I know I'd want a radiologist reading my study, in communication with the primary/consult team to correlate with the clinical findings.

I'm not saying that radiology doesn't need to exist. Of course not. For some fields, who knows, there may be things you catch that the specialists in that field won't. Personally, this is a scenario I've encountered exceedingly rarely, and certainly not while on-service. If your role is to be a sort-of insurance policy for the items you mentioned above, then you're an awfully expensive one, wouldn't you say? Because the vast majority of images are adequately read by the people who order them.

For every last image in a hospital to pass by your eyes is simply unacceptable. And it is from this you are making huge amounts of money.

officedepot · Dec 14, 2011

FutrrENT · Dec 14, 2011

officedepot said:
not really sure where to begin but there are some flaws in your argument...

1. Residency is different than the real world. When you have a private office with hundreds and hundreds of patients good luck trying to read every single scan you order on them... you just won't have the time likely.

Wrong.

2. Other specialties "reading" their own films is a flawed concept because you are not "reading" the film, you're looking for specific findings associated with the clinical concern and that's not too difficult to do when a patient comes in the trauma bay with facial trauma.

You have to remember that the image was ordered for a specific purpose in the vast majority of cases. Possibly, to identify or rule/out a specific diagnosis. Or to narrow down a list of differentials.

But when it passes the radiologist's eyes, two purposes are being pursued: 1. To look for whatever it was the ordering physician was, and 2. To perform a survey of the entire image and find anything and everything that might be on the film.

It's that second purpose I have a problem with, because it's extraneous and unwarranted. Yes, it might produce something. But it's a superfluous exam that is often not germane to the original purpose of the film. And you guys are raking in money for this.

Put another way, the way in which you have your hands on every image taken in a hospital gives you a virtually unlimited supply of patients and diagnoses from which you can make money.

This was debated already by a pulm cc fellow and rads guy earlier and it basically amounted to the fact that non-radiologist rely on their clinical picture to get any sort of "read". And to think obgyn "reading" their own films... that made me laugh. Cardiology has a special fellowship for learning to read their own studies and echos.

Funny, both in medical school and when doing a medicine rotation during residency, cardiologists always seemed to read their own echos and caths. Without exception.

3. Saying clinical decisions are made "routinely" without rads input is also false because, again, your "reads" are 90% based on the patient's clinical presentation.

I will remind you again that it is usually clinical presentation that causes the image to be ordered in the first place. So, of course our reads of these images are going to be performed with clinical presentation in mind.....which is exactly how it should be.

Hell, even the frigging radiologists often say, "findings should be correlated with clinical exam"!

I'd bet if you looked at that facial trauma scan you'd miss anything not related to a facial fracture - in this case, yes, a calcified node but I highly doubt you'd see a small brain mass...

I see. And for that reason, there should be a hoards of doctors getting paid piles of money....just to make these adventitious findings? I don't think so.

Pulm will look at their own cxr because you know what? most of those daily cxr are not necessary and decisions could be made without them. Ortho "reads" their own bone films but again it is all based on their clinical picture. I doubt they would catch anything subtle.

You doubt [ortho] would catch anything subtle? That's a convincing argument!

General medicine does not read any of their own films. Attendings were in contact with rads often at my institution.

Some do. Some don't. All are perfectly capable of doing so, however.

FutrrENT · Dec 14, 2011

officedepot said:
this guy is a troll... interventional cards is a separate fellowship. Your regular joe cards cannot do that. Besides this branched off IR. And the interventional neuro is still very much in the realm of rads. It's a separate 1-3 year fellowship that rads, neurosurgeons, and appropriately trained neurologists have the ability to apply to. Did you even know that?

I knew it was a fellowship for neurology. Not neurosurgery, however.

officedepot · Dec 14, 2011

officedepot · Dec 14, 2011

shark2000 · Dec 14, 2011

You are obviously not a resident.
Your example was the worst one.
Answer my Questions: (Your case was a trauma case)

How did you know this patient did not have epidural, subdural or subarachnoid hemorrhage?
What about odontoid fracture?
What about orbital injury ?
What about pneumothorax?
What about carotid injury/dissection?
What about CC fistula (you may not even know what the heck is that)?
What bout aortic dissection?
What about esophageal rupture?
What about cribriform plate fracture with CSF leak?
What about brain contusion?
All can happen in MVA and all are more important than facial trauma (but not to you).
And a lot of other incidental findings that I do not have time to list here and also you do not know most of them.

And BTW, nobody takes a facial fracture to the OR in the middle of the night, unless there is a life threatening bleeding. In that case you need a CTA of head and neck to make sure there is not carotid dissection. So go and protocol it and read it yourself. Good Luck!

Oh I forgot to mention that many life threatening bleeding are managed by IR these days.

shark2000 · Dec 14, 2011

A trauma service can not survive more than half an hour without a radiologist.
If you want to troll, do it better next time. You are really horrible at it, boy.

davidjones · Dec 15, 2011

Quick question:

You take a patient for an intraoperative laryngoscopy to evaluate for an ulceration, you incidentally note that the adenoids are hypertrophied and patient has a history of lymphoma. You take the adenoids out biopsy comes back benign and patients gets bill for this serendipitous surgery for which they weren't consented. Should you be paid for it?

Or a patient with history of smoking comes to you with hoarseness, your part of the work up is negative yet the patient serendipitously coughs up blood in your office. Do you if ignore it? Or would you at that to your note and bill for a level 4 instead of a level 2 visit?

The vast majority of imaging is done now for random historical or physical findings with absolutely no specific indication.

You think it's ok for a facial trauma patient to not have a head CT? Whose going to read that you? For that matter who's going to read every other facial bone CT coming out of the ER or someone other than ENT, you?

Even IR who are much better trained at imaging than other clinicians don't trust their imaging skills over those of a diagnostic radiologist. I have attendings who do hundreds of liver cancer cases a year, ablations, lysis, embolization and no more about live cancer than any one yet discuss cases routinely with body imagers. Why? Because its what's good for the patient .

Have you ever been to a tumor board, or multidisciplinary breast clinic or liver center? The diagnostic rads isn't only a part of the team, everyone else clams up when they have something to say. And this is at places where people specialize in whatever disease or organ is being treated.

Also for the record rads don't make 500,000 , it's closer to 250-300, IR can make that much but usually they are working 80 hrs a week and do elective things like varicose veins.

The professional fee for an MRI of the abdomen is a few hundred dollars, it's the technical fee thats thousands of dollars and the rads that own machines can make a lot of money because of that.

That's not as egregious as cards or ortho who own machines and scan people for financial gain. Even in those cases the MRI is read by rads somewhere else. In fact those people are largely responsible for the high cost of imaging, not the rads. And they are more likely about 50% more likely to have a study be negative. Even if a rad owns his own machine he can't shunt patients into it .

This is where the whole debate about who should read comes from. It's about money.

I hope you do not demonstrate this level of immaturity or ignorance in your residency.

Apollyon · Dec 15, 2011

davidjones said:
Also for the record rads don't make 500,000 , it's closer to 250-300, IR can make that much but usually they are working 80 hrs a week and do elective things like varicose veins.

I don't know - I have a friend that makes more than that for her direct pay, and doubles it as partner.

davidjones said:
That's not as egregious as cards or ortho who own machines and scan people for financial gain. Even in those cases the MRI is read by rads somewhere else.

Granted, it's anecdote, but, at Duke, at least when I was there, cards had their own MRI, and had their own radiologist to read them. When, one day, all 3 of the regular MRIs were down (the 4 research MRIs weren't used clinically), rads asked cards if they could use the cards MRI. Cards' response? "No." Not even, "No, sorry."

davidjones · Dec 15, 2011

It's not impossible to make >500k in rads, the numbers are listed are the median salary, if I remember you're anesthesia? I'm sure there is a big salary differential as well.

The MRI reads by other rads was referring to ortho, but you can see where cards or ortho owning imaging could lead to extreme overuse, as very many studies have demonstrated. Docs who own their own equipment are about 50% more likely to image a patient and collect the technical fee.

fun8stuff · Dec 15, 2011

why do you guys feed the trolls- he's obviously FOS??? i'd be miserable too in ENT... but somebody needs to do it.

USAFGMODOC · Dec 17, 2011

I'd have no problem with ENT or Neuro or Ortho reading their own MRI's or CT's. Especially in the middle of the night... Go for it!

It would only take 1 case when you or an ER doc or other non-trained Rads person "missed" something causing severe morbidity and mortality to soothe your quest for demeaning all Radiologists. I think we provide a great service to our patients and their physicians. I can't count the number of times a surgeon missed free air, missed a tumor, missed 5 mm aneurysms, missed additional fractures (some of them significant), or missed subtle plain film findings... I would have expected that by the time you became an ENT Resident, you'd realize that every medical specialty has a niche for a reason.

I'm also very sure your malpractice insurance would rise dramatically if you were reading CT's/MRI's and remember, it only takes 1 case of a missed cancer to result in a multi-million dollar settlement. Miss a tumor on an infant/child/pregnant mother and you'll be having a heck of a time explaining to a Jury why you felt it necessary to "interpret" your own studies - then sign over your paycheck to the malpractice attorneys/clients! Try getting a job with that on your record!

That being said, I encourage you to continue to read CT/MRIs to confirm the suspected clinical diagnosis and as a "backup" to your patients in case a Rads read doesn't include a significant finding. I would hope as a potential patient of yours one day, you'd embrace the "team" approach and concentrate on excelling at your surgical skills and keeping up with the everchanging advances in the ENT world with new chemo/drugs/surgical techniques and such.

I recommend developing a positive attitude and possibly consider channeling your anger/frustration to something other than bagging on other docs... If you are "one" of those docs, the kind of doc whom is so high and mighty that you can do everything better than anyone; I can guarantee you will fall hard when you have you're first bad outcome/death or missed head/neck cancer or happen to hit an aberrant artery near the skull base when you are operating... You will have wished you'd have had Radiology read that MRI/CT angio/MRA....

Good Luck in ENT! ENT is a great field! We (future patients/colleagues) need you to learn your profession well and I want you to become a great ENT surgeon.

Finish residency and become/maintain board certification! Right now, those should be you're primary professional goals...

cowme · Dec 17, 2011

FutrrENT said:
Are we as fast as radiologists? Maybe not. And I will never waste my time by timing m speed at reading head/neck images. If we're a little slower, who cares? We are not being paid outlandish sums of money for reading images.

Word. You caught us, we're just trolling all you surgeon folks and taking yer picture moneys. U mad, bro?

PokerDoc · Dec 18, 2011

FutrrENT said:
I knew it was a fellowship for neurology. Not neurosurgery, however.

It's actually very rare for neurologists to go this route.. Neurosurgeons are the most common start point, followed by radiologists.

Illusive Man · Dec 18, 2011

I think I read somewhere that nearly 60% of people in the field are Radiology trained and the majority of academic fellowship PDs are radiology trained. However due to lifestyle issues, NIR spots are often unfilled leading to a rising proportion of neurosurgeon trainees. Interestingly, the SNIS is composed of both neuroradiologists and neurosurgeons indicating the leadership of the field is developing jointly perhaps because it is still such a small community (versus the SIR which represents IR docs and Society for Vascular Surgery which are two separate organizations).

Gute · Dec 18, 2011

FutrrENT said:
Don't even try it, bub.

DO NOT compare radiology with pathology!

A pathologist looking at tissues has before him a "specimen" offering far more information than a radiologist looking at an MRI does. A light micrograph shows him the organization of the cells, the variety of cells, sizes of cells, shape of cells, connections between cells, number of cells, cellular contents (each of which can vary greatly in pathologic states), uptake of staining, and on and on and on. He is looking at what is actually there and making a diagnosis based on what needs to be an exhaustive knowledge of anatomical pathology. There is huge amounts of information to be ascertained from a slide. And that's just LM. They also use EM.

Not so from a chest x-ray, or a CT, or even an MRI. Compared to the tissue samples a pathologist examines under a microscope, CTs, MRIs, and PET scans are incredibly blunt tools. They don't offer anywhere near as much raw, interpretable information as a tissue sample does.

Think about it: every doctor out has some skill reading plain-films, CTs, and MRIs. Very few doctors, however, would have a clue how to even identify cancer on a light-microscope slide (much less differentiate lichen planus from pemphigoid on a slide).

Bad comparison on your part.

Really? MRI and PET are just blunt tools without an incredible amount "raw, interpretable information"? Path slides and medical images both have huge amounts of information and require expertise to interpret.

I bet if your access to path slides was as easy as it is to images, then you would probably think you were just as good as a pathologist.

officedepot · Dec 18, 2011

PokerDoc · Dec 18, 2011

officedepot said:
I think it is funny how FutrrENT disappeared. Clearly he was outmatched in this "debate". Lots of good points made though. Good for arguments with other med students who think like futrrent.

I'm still scratching my head as to why someone with a medical education made such a pointed statement using anecdotal arguments only.

NAGNAM · Dec 19, 2011

I'm just curious why a troll who's so uninformed that he thinks radiologists read echos got so much attention.

MossPoh · Dec 19, 2011

Sometimes it is fun to take the bait.

deleted103644 · Dec 20, 2011

FutrrENT said:
First, what other service in any hospital, with infectious disease being perhaps the only other, is automatically consulted for every test, diagnosis, or treatment that falls within its scope?

Cardiology. At our hospitals every EKG gets an official read from cardiology - doesn't mean internists ignore ST elevations until the final report. Likewise, most people could understand a basic echo (if the images were easily accessible), but that also requires an official cardiology report. As for lab results, every positive troponin requires a note within a day.

Does the current medical system make sense? Of course not. I think you're greatly over-estimating the reimbursements per study for radiologists at your hospital though. The way private practice radiologists make large amounts of money is by reading many studies. Most of the big fees you see are equipment fees for things like MRI or CT, which just go to whoever owns the machine.

I think the comparisons you made for specialists vs radiologists was a bit disingenuous too. They may be able to outperform a general radiologist in their particular specialty, but not a fellowship-trained radiology subspecialist.

Also, as far as radiologists on call go - admittedly the reports are often a bit slower in coming than they should be, and this is actually something that is changing in most hospitals. That said, critical findings should be communicated to you directly immediately even if the official reports are a bit delayed.

Dr. USMLE · Dec 30, 2011

johnnydrama said:
I think the comparisons you made for specialists vs radiologists was a bit disingenuous too. They may be able to outperform a general radiologist in their particular specialty, but not a fellowship-trained radiology subspecialist.

It is a shame FutrrENT got banned, isn't it? While all of the defense mechanisms (both mature and immature) displayed here were entertaining, clearly he had a number of valid points and admittedly revived an otherwise moribund forum. The big hole in his argument is at the level of legal liability, but even that can be circumvented. All they would need is to create a formal certification process that is defensible in a court of law. After all, how is this much different than any other field encroaching on radio, like vascular on IR?

I would imagine the appropriate counterargument to the above would be that it is challenging (if not impossible) for even a fellowship-trained subspecialist to perform as well as a specialist in the region since said specialist has the benefit of the full H&P. This does not even address the advantage of continuity of care...being able to mentally correlate the imaging with both clinical and surgical findings, in both previous and current patient encounters.

Where the ENT may falter initially is with the incidental findings due to lack of formal, more comprehensive imaging training. Since these are not the target of the exam, as he points out, it can be argued that it is OK to miss these. Of course, here is where legal liability intersects the issue and where the argument starts breaking down since it only takes 1 missed case. The potential counterargument there is that if ENTs went through a certification process and were being paid to interpret the studies, they would be incentivized to spot incidentals enough to be in keeping with what would be expected reasonably from a BC DR.

FearlessHyena · Dec 30, 2011

Dumb said:
It is a shame FutrrENT got banned, isn't it? While all of the defense mechanisms (both mature and immature) displayed here were entertaining, clearly he had a number of valid points and admittedly revived an otherwise moribund forum. The big hole in his argument is at the level of legal liability, but even that can be circumvented. All they would need is to create a formal certification process that is defensible in a court of law. After all, how is this much different than any other field encroaching on radio, like vascular on IR?

I would imagine the appropriate counterargument to the above would be that it is challenging (if not impossible) for even a fellowship-trained subspecialist to perform as well as a specialist in the region since said specialist has the benefit of the full H&P. This does not even address the advantage of continuity of care...being able to mentally correlate the imaging with both clinical and surgical findings, in both previous and current patient encounters.

Where the ENT may falter initially is with the incidental findings due to lack of formal, more comprehensive imaging training. Since these are not the target of the exam, as he points out, it can be argued that it is OK to miss these. Of course, here is where legal liability intersects the issue and where the argument starts breaking down since it only takes 1 missed case. The potential counterargument there is that if ENTs went through a certification process and were being paid to interpret the studies, they would be incentivized to spot incidentals enough to be in keeping with what would be expected reasonably from a BC DR.

The bolded part is key. Stealing procedures is one thing. Anyone can learn a procedure. Imaging is another issue as it is more cerebral in nature. Why would you subject a patient to radiation and only have a specialist, in this case ent, read the image, when you can have a DR read the image and be able to find any other significant findings? There are two issues. One is whether a specialist is as good as a radiologist. Let's play devil's advocate and say this is the case with respect to their specialty. Do they have the clinical understanding to look for other differentials? This is what makes Radiology difficult. The DR is responsible for not only what the referring clinician expects but is expected to look for possible alternatives that could play a part in the case as well. I would argue it is for the latter part that DR are needed. In general, when a specialist reads an image, they already expect or know the situation and so reading is easy, who needs the dumb DR is what some think.

You raised some key points. The legal issue plays a big role. However, in the new health-care reform, some may find this to not be worthwhile? no? I think at the end of the day, it is about optimizing health-care for the patient. Having a DR read will most likely have the most qualified person to read and catch other findings. However, optimal health care is not what American medicine is about, otherwise Cardiologists wouldn't be stenting the iliacs or in the brain would they?

These are the musings of a non-traditional MS0 who has lots of experience with health-care delivery and radiology in general.

shark2000 · Dec 31, 2011

Dumb said:
It is a shame FutrrENT got banned, isn't it? While all of the defense mechanisms (both mature and immature) displayed here were entertaining, clearly he had a number of valid points and admittedly revived an otherwise moribund forum. The big hole in his argument is at the level of legal liability, but even that can be circumvented. All they would need is to create a formal certification process that is defensible in a court of law. After all, how is this much different than any other field encroaching on radio, like vascular on IR?

I would imagine the appropriate counterargument to the above would be that it is challenging (if not impossible) for even a fellowship-trained subspecialist to perform as well as a specialist in the region since said specialist has the benefit of the full H&P. This does not even address the advantage of continuity of care...being able to mentally correlate the imaging with both clinical and surgical findings, in both previous and current patient encounters.

Where the ENT may falter initially is with the incidental findings due to lack of formal, more comprehensive imaging training. Since these are not the target of the exam, as he points out, it can be argued that it is OK to miss these. Of course, here is where legal liability intersects the issue and where the argument starts breaking down since it only takes 1 missed case. The potential counterargument there is that if ENTs went through a certification process and were being paid to interpret the studies, they would be incentivized to spot incidentals enough to be in keeping with what would be expected reasonably from a BC DR.

I agree that it was not right to ban him. He was an obvious troll.
It is not about liability. It is about good practice of medicine. Many who talk about legal aspect, want to justify their sloppy or underqualified practice.

Most things that are done (esp at sub-specialist level) in medicine have a marginal effect (if at all). I can assure you that out of 10 consults a day, at most one is useful. The same is going for preop comsults, ... . The benefit of having a headache specialist compared to a family doctor seeing headaches is marginal. The same is for imaging. And many other things.

His case scenario is an obvious troll. In his case a trauma comes to the hospital. In trauma the least important thing is facial fracture. You have to rule out a whole lists of pathology before anything else, including ICH, Neck fracture, orbital injury, Neck vascular injury, .... In his case the trauma was so hard that needed OR in the middle of the call. And these pathologies happen once in a while, but can kill people.
Similar scenario happened to me this year on call. Patient had trauma a week ago (didn't come to ED), came with sever back pain. They ordered a CT thorax which showed a wedge deformity. The CT was non-con, but to me there was a hematoma around the intima of the aorta (displaced intimal calcification). I called the ortho resident and told him this may an Aortic dissection.
Guess what; It was a dissection proved later on Angio.
Orthopods are very good at picking up the fracture, characterizing it and planning the management. But, never ever they could pick up such subtle but life threatening abnormality. In fact patients symptoms were mostly secondary to dissection, not wedge fracture.
To me this does not have anything to do with legal issues. It is not overdo to have a radiologist read the images. It is the only proper way of practicing. It is a rare scenario, but happens.
But again, I agree that banning him is to much. We have to be more tolerant to people, whatever their intention is.

deleted103644 · Dec 31, 2011

re: specialists having the H&P

I know it's not general practice right now, but the radiologists really should have access to the full H&P as well since everything should be on the computer. The one-liner sent with the image really shouldn't be the only information available, although I suppose it does keep your mind open to alternative diagnoses.

Taurus · Dec 31, 2011

Kinda late to this discussion. I haven't read the entire thread but here's my two cents.

In large academic centers, the subspecialists may look at their own images. But they don't want to dictate the reports because of the time it takes and the liability.

In private practice, most subspecialists do not even look at the images. They are depend on the radiologist report.

So this guy's perspective is obviously skewed because he's still in training.

Any radiologist can list tons of examples of serious incidental findings. If the subspecialist wants to read the images, then they have to be responsible for everything like we are. Otherwise, they are just crying a river.

davidjones · Jan 1, 2012

I will share another anecdote, that seredipitously is related to this disussion:

My brother is an ENT, and I was going through some cases, and almost seredipitously was going over a head and neck case, he walks by and says "oh that's chronic sinustis" (not something you really need a medical degree to diagnose off a CT, but I digress) "see we don't need you guys" and I, being the kindly brother decided to use this as teaching moment. The CT was for facial swelling, he literally looked at it for 10 minutes and couldn't come up with anything.

Then I asked him if he looked at the lungs, (most H&N CTs catch the apices, if done right); he was quite shocked that the lungs were even on the study, but there was a huge right apical mass, not very subtle. He was pretty quiet after that...

The sub-specialists who say they don't need DR, have complete tunnel vision, and only focus on whatever the patient's complaint is with regard to the imaging, as they should. But even then they just don't have the experience to know the differential for every finding, sure the clinical findings often help narrow the ddx, but relying on only clinical findings to make a radiologic diagnosis is often a good way to make the wrong diagnosis.

Radiologists often serve as expert witnesses in malpractice suits against other docs who do imaging, for instance the orthopod who does his own plain films and misses a lung ca on a shoulder x-ray, or the cards guy who does his own nucs, who misses the uptake of technetium on the raw data in the breast, which is breast cancer. Now these people all had great careers up until they had that one case which forever ruined them. The lesson is, it's easy until it isn't.

Taurus · Jan 1, 2012

Dumb said:
Also important is that other fields are not compensated to read images (and therefore to find incidentals). If that were to change, as FutrrENT is proposing, it would be no great challenge to establish a training/certification process that addresses incidentals in the H&N region, too. Indeed, they could hire a DR to do it!

This is false. Pretty much any physician or other health care provider can read and bill for their own studies, as long as the insurance company or Medicare agrees to pay. Cards read and bill for echoes and cardiac nucs. Some neurology groups are reading their own head CT's and MR's. ED physicians will try to bill for x-rays and ultrasound. Etc.

Vast majority of ordering clinicians do not try to read the studies because of the liability, especially when you have studies that show more than the area of interest. Cardiac CT shows the heart but it shows the lungs and bones. Cardiologists are trying but not making much progress in taking over cardiac CT or MR.

If subspecialists do try to read their own studies, then they typically will want a radiologists to overread it to catch the serious incidentals.

Lawsuits are a bitch but they are there for a reason. So people should stop whining about it. I can make the same argument about any field. The ENT who tries to do cosmetics. The NP who thinks that they are as good as a physician. Etc. If you know your limits, then you're probably fine. Go outside of it and risk a multimillion dollar lawsuit.

Time to put the axe to your profession

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