Cardiologists win over radiologists

[drjaymehta]

The "war" as I may call it between the cardiologists and radiologists has increased for grabbing the MRI and cardiac CT as well as other coronary procedures..

However, there are news that MRI coronary angiography which is primarily a domain of the radiologists will take over lot of lucrative work from the cardiologists..

Well, reports also suggest that cardiologists are interfering a bit too much in the domain of interventional radiology..

Cast your views everyone..

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[OptimusPrime]

cardiologist taking over the domain of interventional radiology? never heard that one. Are you talking about stents or valvular procedures? if so, I don't think those were ever considered to be interventional radiology domains.

 

[dadr]

cardiologist taking over the domain of interventional radiology? never heard that one. Are you talking about stents or valvular procedures? if so, I don't think those were ever considered to be interventional radiology domains.

Peripheral intervention training is being offered by more interventional cardiology programs these days.

 

[drjaymehta]

Apart from valvular and stenting, I was talking about the MR angiography which is a new speciality in the field of radiology..I know a few rad guys who are doing fellowships in that..

Literature says some day MR angiography of the coronaries will replace percutaneous coronary angiography..

 

[dragonfly99]

I don't think PCI is going away any time soon. Not ANY time soon.
These other modalities are interesting, but still somewhat experimental. People were trying to say that cardiac CT would replace diagnostic caths as well, and that hasn't really happened.

 

[dr niceguy]

Apart from valvular and stenting, I was talking about the MR angiography which is a new speciality in the field of radiology..I know a few rad guys who are doing fellowships in that..

Literature says some day MR angiography of the coronaries will replace percutaneous coronary angiography..

I would be interested in these references regarding MR angiography "taking over" PCI. From the incredibly little I know of the imaging literature, MR angiography is still a developing field which requires larger clinical trials to determine its sensitivity/specificity against conventional angiography, determination of which patients would be appropriate, and probably most importantly cost effectiveness models. You're talking about an expensive and limited resource used for diagnosis of one of the most prevalent diseases in the country- many of which may need a therapeutic intervention. Given recent trials of PCI in stable coronary disease, elective angiography/PCI has gone down nationally and non invasive imaging is certainly the future but this is for an appropriately selected population.

OP, as a med student, one thing I would think critically about are blanket statements which over-generalize a specific, technical topic.

 

[tibor75]

Literature says some day MR angiography of the coronaries will replace percutaneous coronary angiography..

Uh, no. Last time I checked, you can't place a stent while a patient is in an MRI or CT scanner. MR or CT angio can replace diagnostic angio for those paitients at very low-risk, but for everybody else, you're doing a cardiac cath because you can diagnose AND treat at the same setting.

 

[drjaymehta]

ok..

Since, cardiac CT and MRI are the new developments in the field of radiology, would it be unfortunate to lose out such lucrative developments to the cardiologists..

Also, when everyone knows that the cardiologists do not understand the actual mechanics behind the actual radiological aspects..

shouldnt they just simply hand these areas to the radiologists..rather than being so greedy..

 

[cdql]

yeah, that's not so bright coming to a cardiology board and asking questions like that........

 

[dragonfly99]

In my experience the cardiologists are definitely better at reading the MRI's.
For nuclear scans, it seems the radiologists call a lot of things "positive" that are just apical breast attenuation, etc. I'm sure they do understand the technical/physics aspects of the various scans better than most cardiologists, but they understand less about cardiac physiology and do not integrate the clinical information as well, which can affect the final assessment/final reading on the scan.

I think the skill of the individual reading the scan is more important than the specialty of the doc reading the scan, and wish the specialties would quit feuding over who "should" read these, because it adversely affects the training of both cards fellows and radiology residents.

 

[lemonade02]

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[drjaymehta]

I agree to that statement..that the best person should opine..

But out here, most of the work does go to the radiologists, and the cardiologists are called in only in cases of difficulty..

Also, most of the referrals are given straight to the radiologists..

Some work of diagnostic cardiac catheterizations is also being done by the VIR guys, though that is only at some major centers..

as already the cardiologists, have a lot of work of their own as regards to handling the MI patients, and the other ECHO work, they have let it go to the radiologists..

Also, there are talks to end the turf war, as the radiologists are taking more stricter action and getting the stuff of reading Cardiac MRI and CT-Scan sanctioned from the universities, which gives them certification for the same...

Any fresh opinions on this...

 

[dragonfly99]

At my teaching hospital where I did residency, all cardiac MRI's were read by cardiologists, not radiologists. The cardiology division also owned the MRI scanner that was used for this (dedicated MRI for cardiac studies only).
I think who reads what is very institution-dependent (same with cardiac nuclear studies).

 

[Trifling Jester]

It's been my experience that studies read by radiologists are read as positive far more often than studies read by cardiologists.

-The Trifling Jester

 

[dragonfly99]

Agreed.

 

[drjaymehta]

hmmm...yeah..but then whats this turf war about...

Atleast here, the radiologists do everything..

 

[tibor75]

I agree that radiologists don't know how to real nuclear stress tests well. Oftentimes their readings don't make anatomic sense.

 

[dragonfly99]

Yes that is true.
But the radiologists would say that most cardiologists don't understand jack about the principles of physics/radiology that the nuclear scans are based on. Both criticisms are likely true.

 

[drjaymehta]

yeah...both sides the arguements are true..

But its ok..as long as they guarantee better patient care..

also, there is a lot of talk about the radio guys coming in and actually acting as clinicians...they also "try" to manage the patients post Interventional procedure..thats a dangerous thing to happen..

 

[drjaymehta]

hey also, to everyone coming to this discussion, just to share a piece of Information..

I just heard of a Virtual coronary angioscopy using Multi slice CT for detection of coronary artery stenosis..

its an experimental trial that has begun out here..

carried out by a team of radiologists..sounds very interesting..

anyone already aware of this technique..

 

[wrx04silver]

DrJayMehta,

Your enthusiasm speaks volumes to your future success in medicine. Having said that, you seem to lack a basic understanding regarding the fields of Cardiology and IR. In other words, you are talking out of your ...
This is to be expected, given your status as a medical student. However, I applaud you foresight. Radiologists will, in my opinion, become less involved in cardiovascular imaging, because lets face it, they don't know jack about clinical medicine, and most cardiology diagnostic imaging procedures require more than simple anatomic characterization to be useful to the extent that they were ordered. CT/MRI fellowships, often pursued by cardiologists after a general cardiology fellowship, are plenty sufficient to train the clinician in the technical aspects of the scans (more important for MRI). However, no amount of radiology training can prepare the radiologist for the clinical decision (required to appropriately interpret the CT/MRI/Nuclear scans) when compared to the 3 years of internal medicine and 3 to 4 years of cardiology training. As such, in the future, Cardiology will own the heart (as they should). Pardon my grammar.

 

[drjaymehta]

thanks wrx04silver..

But the point I am trying to make is, how many cardiologists would prefer to read just the MRI or the CT Scan especially when there is a trained radiologist for it..

Also, this is all from what I have heard, that reimbursements are going down and hence cardio guys are not prefering to own their machines..

Also, ACR is trying to make laws wherein only a radiologist would be interpreting the scans..

I still agree with you and also say that no matter how much the rads do IV cardiac will always stay with the cards..

 

[drjaymehta]

also, dont you think that a collaborative effort of both the specialities is needed..

What if a cardio guy misses a mediastinal pathology..??

Is he adequately trained to see even that..

 

[Taurus]

Also, this is all from what I have heard, that reimbursements are going down and hence cardio guys are not prefering to own their machines..

Also, ACR is trying to make laws wherein only a radiologist would be interpreting the scans..

Isn't that somewhat the point? Change is the only guarantee for the future. People follow the money and lifestyle. It's no different in medicine. If imaging becomes much less lucrative unless you do it full-time like a radiologist, cards will leave imaging. Rads recognize that they have to become more clinical and they are.

Bottom line, do whatever will make you happy, not based on the current incentives.

 

[drjaymehta]

exactly..with the laws coming up that deny self referrals it will become even more difficult..and so it should be..

As a student I fully agree that all interventional work related to the coronaries shoud be with the cards..But then when it comes to MRI and CT, then there are some things behind them that make them different..It takes a student 4-5 years to master radio in his residency...

Since these are the new noninvasive modaltities in cardiac imaging..I suppose radio guys have already included cardio imaging in their curriculum and with that, cards shoud either tie up with them, or give up like most places and wait for better things to come...

I hope most of the people will agree..

 

[drjaymehta]

why have the posts dried up.....

First of all let me congratulate all the lucky guys who have made it to cardio..

Also, havnt the CT surgeons or vascular surgeons tried doing the cardiac catheterizations..

 

[jeffreyfrog]

Of course it's a real job. A radiologist is a physican who specializes in the interpretation of medical images such as MRI scans, CT scans, x-rays, nuclear medicine scans, mammograms and sonograms. They are specially trained to identify injury and disease in each of the body's systems, whether bone, tissue, organs or blood vessels. Radiologists may specialize in fields such as neuroradiology, angiography, cardiovascular-interventional radiology, pediatric radiology or nuclear medicine. Pleasanton Radiation Oncologist.

 

[ThinkTooMuch]

so how does the new 5 year IR only *will not be able to board in DR* residency that is coming soon affect this debate?

 

[drdavemd]

The ability to image the coronaries with CT-angiography has been around for several years. It is gaining a lot more steam now as bugs are worked out. At this stage, it compares to invasive angiography in performance somewhere in the same sens/spec as CT colonoscopy does to the real thing. There is a TON of data out there already on CT-angio. (check for the CORE-64 study recently published in NEJM for an example)

I know less about MR-angio, but all the radiologists I have spoken to (who specialize in cardiac imaging) believe that MR tech is at its limits of resolution and that MR-angio of the coronaries is not adequate to replace invasive angio now and may never be due to limitations of MRI as we currently understand it.

With regard to turf wars, I am lucky to be training at an institution where the Cards and Radiology attendings actually SHARE and read together and CT, Nuclear, and MRI readout is a great learning experience for everyone. Again, as mentioned, Cardiologists know less about the physics, but Radiologists know less about clinical/anatomical application.

Why would any cardiologist want to sit around reading studies when there are radiologists to do it? Because non-invasive imaging is steadily growing in use and application and someone needs to read the studies. Imaging fellowships are beginning to pop up and people (myself included) are taking focused time aside from traditional clinical training to learn about noninvasive imaging. (see UVa's 4 yr T32 sponsored training program which gets you a Master's degree and 2 years of imaging training).

 

[drjaymehta]

Yeah..true..Its growing and so should it grow..

Do you think that its still and will mostly be a radiologist who will continue to be a final statement when it comes to imaging..be it any organ..
Most of the places do have come up with collaborations the way you have mentioned..

As far as interventional radiology goes, especially vascular interventions, isnt there an increasing stand of the cardiologists to take up the simpler procedures whereas only the more complex ones being left for a radiologist..
Also, dont the CT surgeons try out such interventional stuff..

 

[dragonfly99]

Yeah..true..Its growing and so should it grow..

Do you think that its still and will mostly be a radiologist who will continue to be a final statement when it comes to imaging..be it any organ..
Most of the places do have come up with collaborations the way you have mentioned..

No. I think it will continue to be institution-dependent, as far as who read the cardiac MRI's. Like I said, @my hospital the radiologists don't read ANY cardiac MRI's at all. It's all done by cardiology. If anything, I think cardiology is more likely to win if there is a turf war, b/c they control the referrals.

 

[NYCRES]

It's not Vascular and Interventional Radiology as much as it now just Interventional Radiology. I like IR but after talking to a very respected IR doc it is shifting its direction to other fields like oncology. Even that may be picked up by someone else someday in the future.

IR does not touch the heart. IT does do peripheral work though but that is now being done by InterventionalCardiology and Vascular Surgery. It is hard for IR to get referrals because each group tries to refer inside each owns speciality.

I believe Cardio will own Cardiac imaging.(Radiologist will also do these imagining modalities but not at big centers.) I say this because they already own CT angios at many sites. Cardiologist can take a CT angio course (3 levels and like 9 days all together) to become certified. Cardiology is a powerful body of medicine that runs many hospitals due to there high cash volume being brought in. Also to get into Cardiology is very competitive and I believe these doctors don't just stop being competitive because they are done with med school, residency and fellowship. They continue in their practicing lives and they will always be so.

 

[drdavemd]

FYI, These rapid learn courses are being phased out. There is a limited time for people to grandfather in.

Interventions are as much of a turf war as imaging is and it is highly institution dependent, for example, who gets to stent carotids, kidneys, subclavians, femorals, etc. Referral bias clearly plays a huge role in this. If a given PCP refers a patient to a radiologist and another to a cardiologist who are both "qualified" to perform the same procedure, you can bet that the MD-patient relationship, the quality of the feedback/report, and other such factors will play a huge role in who gets to do more procedures and therefore "own" that procedure in a given institution or geographic area.

 

[link138]

FYI, These rapid learn courses are being phased out. There is a limited time for people to grandfather in.

Interventions are as much of a turf war as imaging is and it is highly institution dependent, for example, who gets to stent carotids, kidneys, subclavians, femorals, etc. Referral bias clearly plays a huge role in this. If a given PCP refers a patient to a radiologist and another to a cardiologist who are both "qualified" to perform the same procedure, you can bet that the MD-patient relationship, the quality of the feedback/report, and other such factors will play a huge role in who gets to do more procedures and therefore "own" that procedure in a given institution or geographic area.

Very True

 

[ynhh1226]

I don't think PCI is going away any time soon. Not ANY time soon.
These other modalities are interesting, but still somewhat experimental. People were trying to say that cardiac CT would replace diagnostic caths as well, and that hasn't really happened.

Right. Not until the MRI machine can start putting in stents.