Internist predicts doom for radiology

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Written by Bob Wachter, chair of medicine at UCSF.

Nothing appears to be particularly new. Well, rough article summary: due to the advent of PACS and increased workloads, other physicians don't meet with radiologists to discuss images as they would have in the past. In addition, radiologists really don't want to be bothered by specialists and ED docs intruding on their workday, mainly as a function of large lists of studies that need to be read.

Radiologists also run the real risk of having their jobs shipped to Mumbai for 1/10th the cost of US-trained radiologists.

The author also predicts that pattern recognition computer software and algorithms will upend medicine and radiology.

https://ww2.kqed.org/futureofyou/2016/10/25/technology-radiology/

 

[Pathman1000]

This guy is not a radiologist. Maybe he should be more worried about his own specialty's issues like being replaced by nurses or the imminent decline of the buttscope in favor of a blood test.

 

[colbgw02]

That's written as if the author penned it in 2005, lost it for a decade, and still somehow managed to get it published.

 

[Cognovi]

It's okay that the author is a hospitalist and not a radiologist. His perspective is valuable.

Here is a radiologist commenting on the problems of hospital medicine: http://www.nejm.org/doi/full/10.1056/NEJMp1608289

It's also okay that this is not a new problem. It's still a relevant problem that hasn't received enough attention in the broader medical community and has seen few solutions.

The author is giving the opening speech at RSNA this year.

 

[meister]

Many of the issues he raises are fair. Particularly the poor state of in-person consultation. I have seen surgery or medicine teams treated less than warmly when they do happen to remember where we are and it always makes me wince. I tend to embrace those sorts of interactions but I'm afraid not all do the same. Much of that stems from fear or uncertainty, I suspect. If someone asks you about a study telling them to read the report is such a b*tchas* passive aggressive reply.

Radiology has issues at the moment and pretending otherwise is not going to help. What's the answer? To a large extent I think of the three As: available, affable and to a lesser extent able. That and pray that the machines currently deeply learning our field realize through their studies that other fields or professions can be had for less effort!

The author's quoting that hot take from the USC EM beret-wearing guy is funny. USC now has 24/7 attending radiology coverage. And you're more likely now to find a 30 something brand new EM attending with a big bonus driving a BMW anymore than the still-a-resident-for-three-more-years radiology resident. Hah!

 

[GadRads]

Radiology has issues at the moment

What issues are these?

 

[yoyoniner]

I'm bothered by this article not because I see it as a threat to myself as a radiologist but because much of it is written in ignorance. He makes many fair points, but the last half of the article sounds like something that is 10 years old and written by someone who has no idea what I do all day.

All the in person consultations have been replaced with constant phone calls. And despite any fears of displacement, radiology has become more and more vital and needed than ever before. Now instead of waiting hours for the report, I get a phone call if it is 5 minutes late. And the explosion of NP/PA's ordering studies over the past few years cannot be understated.

Despite what parts of the article says, radiology is probably the safest specialty to be in. Everyone seems to need you. No NP/PA's are knocking on the door looking to replace us. I spend half my day doing procedures which require me to be in-house.

And what he says about clinicians/surgeons not reading the report anymore is a total lie. What rogue clinician is out there ordering studies and not reading the radiology report--that clinician may not even last a week in practice. I get that most surgeons look at the images before they operate, and they should. But I know of no surgeon that also does look at the report.

This guy has never been a radiologist for even a day and it's totally clear by that. Some of what he writes assumes radiologists are all about detection, but detecting an abnormality is just a small part of my day. The requirement to think, process, solve the puzzle, dig through the chart and read the op note, do the procedure, etc.--let's just say if a radiologist gets replaced by a computer, ever, then the rest of the jobs out there are not safe at all. Heck my 10th generation mammography CAD system can't even detect a soft tissue neoplasm in a sea of fat on a static x-ray image, let alone process and think about it. How the heck is it going to solve a CT CAP or MRI of the hip, and communicate a clear and accurate report. Again, it's not about detecting.

 

[RadsFTW123]

I agree, this article truly lacks insight. Yes, he points out some very obvious threats to radiology (all of which have existed for at least a decade) but there are many huge threats to all fields that I could easily name. Probably the biggest threat he brings out is that most people (like him) really don't understand what we do, but I think that everyone underestimates the difficulty of what other jobs do.

The biggest real threat to radiology is bundled payments, because even if the providers realize how important our role is, they will be too greedy to financially acknowledge it. If you follow the bundled care movement closely though, it's very limited in scope and unlikely to grow too much in the immediate future. Radiologists still do well (compared to other specialties) in captitated systems like Kaise, VA, etc. so I don't think that (if) ACOs become prevalent, it will be any worse for radiology than anyone else.

The real question is why do people like this guy and Zeke Emanuel get off spending their time writing about the "downfall" of Radiology? Ego? Trying to help medical students avoid the field? I can't imagine the chair of UCSF medicine doesn't have better things to do.

 

[maxxor]

I'm bothered by this article not because I see it as a threat to myself as a radiologist but because much of it is written in ignorance. He makes many fair points, but the last half of the article sounds like something that is 10 years old and written by someone who has no idea what I do all day.

All the in person consultations have been replaced with constant phone calls. And despite any fears of displacement, radiology has become more and more vital and needed than ever before. Now instead of waiting hours for the report, I get a phone call if it is 5 minutes late. And the explosion of NP/PA's ordering studies over the past few years cannot be understated.

Despite what parts of the article says, radiology is probably the safest specialty to be in. Everyone seems to need you. No NP/PA's are knocking on the door looking to replace us. I spend half my day doing procedures which require me to be in-house.

And what he says about clinicians/surgeons not reading the report anymore is a total lie. What rogue clinician is out there ordering studies and not reading the radiology report--that clinician may not even last a week in practice. I get that most surgeons look at the images before they operate, and they should. But I know of no surgeon that also does look at the report.

This guy has never been a radiologist for even a day and it's totally clear by that. Some of what he writes assumes radiologists are all about detection, but detecting an abnormality is just a small part of my day. The requirement to think, process, solve the puzzle, dig through the chart and read the op note, do the procedure, etc.--let's just say if a radiologist gets replaced by a computer, ever, then the rest of the jobs out there are not safe at all. Heck my 10th generation mammography CAD system can't even detect a soft tissue neoplasm in a sea of fat on a static x-ray image, let alone process and think about it. How the heck is it going to solve a CT CAP or MRI of the hip, and communicate a clear and accurate report. Again, it's not about detecting.

I think there's something to be said for "everyone is getting busier" and as a senior hospitalist with residents, he's possibly insulated from that reality.

The amount of work that physicians / residents are expected to do has significantly exploded while ancillary staff has not caught up. Dictating admit notes / hand writing progress notes / dictating discharge summaries / dictating clinic visits are all TONS faster than typing, but unfortunately transcriptionists are being phased out. Instead we get these Dragon systems which now make us data entry / transcriptionist / and editor while trying to maintain our clinical duties.

Radiology volume has increased a huge amount and no referring resident has the time to wander down and be collegial, because their censuses and associated administrative work has also ballooned.

Hell, we just had a safety report filed on us because the ICU residents felt it was unreasonable for them to physically come down to the reading room for a "stat wet read" while their patient was in the ED scanner. That's the dirty secret this guy is overlooking and blaming us for: EVERYONE IS SO GODDAMN busy as we all try to get the volume of tasks done in the finite hours of the day.

 

[blebb]

The guy makes some valid points. Radiology has changed, our volumes are much higher and we don't have nearly as much time to review studies with the clinical service. He's also very wrong about a few things, most importantly our value as US trained radiologists. Like most non-radiologists, he assumes that our work can be easily outsourced. Final reads will never be outsourced to people without a US license. You can't sue them. Try finding some random dude in India that missed a nodule on your CXR.

 

[meister]

What issues are these?

Bundled payments/payment reform is the big one.

All this Silicon Valley deep learning nonsense.

Transition from consultant standing in a room to virtual consultant with twice as many studies to review.

Never ending increase in number of residents trained.

Questionable job market which has shown promise recently but remains a question mark.

Perpetual poor PR and all the problems that engenders. (Being outsourced to the moon, computers already doing the job, "don't you take the X-ray? My mom is learning that at night school")

I could go on. Or were you being purposefully obtuse?

 

[vm26]

Bundled payments/payment reform is the big one.

All this Silicon Valley deep learning nonsense.

Transition from consultant standing in a room to virtual consultant with twice as many studies to review.

Never ending increase in number of residents trained.

Questionable job market which has shown promise recently but remains a question mark.

Perpetual poor PR and all the problems that engenders. (Being outsourced to the moon, computers already doing the job, "don't you take the X-ray? My mom is learning that at night school")

I could go on. Or were you being purposefully obtuse?

Bundled payments/payment reform is probably biggest threat but it is a big unknown at this point and will affect all in medicine...I am in a very small group which makes us pretty vulnerable in a way, but doing light IR and breast imaging/biopsies gives us some leverage at this point...also get in-person consults for complex cases

 

[meister]

Being available and doing procedures is a great way to protect yourself and your group, both from contract sniping and from Watson moving in.