Mid Level Creep in Radiology - California NPs can now interpret diagnostic images without a physician.

[piii]

CA AB 890 just approved by the California Senate. Thoughts?

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[qxrt]

From a practical standpoint, won't matter. NPs are not going to be putting out reads on CTs or MRs or even radiographs when any error in interpretation is going to be saved for perpetuity and obvious for all to see. Radiology is not like most clinical fields where routine patient admissions have a routine order set that any monkey can put in and errors in interpretation of clinical signs can be hidden away. There is no such thing as a "routine" CT scan. Sure, there may be a normal scan, but you do not know that until you've interpreted it as such. As for radiographs? If there's an obvious fracture, you do not need a radiologist to read it. And an NP is not going to be taking a patient with broken bone to surgery. And if they miss a pneumothorax or mass on chest radiograph, their error will be documented in a way they can not hide as in other clinical fields.

I mean, even other non-radiologist physicians are technically allowed to "read" imaging. Does not mean that they have any idea what they are talking about when they ask me about that "lung mass" (i.e. pulmonary artery) or the "free abdominal fluid" (i.e. seminal vesicles), both situations that have actually happened to me.

Also, I just read the bill, and interesting that no one mentions "(d) A nurse practitioner shall inform all new patients in a language understandable to the patient that a nurse practitioner is not a physician and surgeon. For purposes of Spanish language speakers, the nurse practitioner shall use the standardized phrase “enfermera especializada.” Seems like a good thing that NPs can no longer hide behind patient misconception of them not being a physician, and are now formally required to clarify their role as NOT a physician nor surgeon.

 

[redoitall]

I think, at least in my state most doctors (IM, ER, Surgeons etc) can interpret radiographic studies t least and charge for it. Yet, they always prefer a prelim read from a resident, particulalry when whatever finding can have implications (like discharge, feeding, using a line, taking to the OR etc...).
As for NP, and PAs, even on a CXR or a KUB, my conversation with them shows how little they know about imaging. Frankly, I wouldn't mind if these $7 dollar reads are done by someone else. I mean it is a significant risk we take as radiologists. May as well do so on studies that pay a bit more.

 

[Dave1980]

I would actually love to see an NP read a CT or MRI. They can probably do a fine job on the more useless exams like pre-op chest x-rays and abdominal x-rays to evaluate for constipation.

 

[Clean7795]

In the long term I am not worried about radiology because I know it's complex enough that it cannot be done without proper training, and it isn't something you can easily 'partition off'.

I worry though for patients. I know of a few bad stories of NPs making bad misses in the ER, ones that a physician would never make. I can already imagine a NP thinking they don't need a radiologist for a particular "simple" X-ray, making a miss, and permanently maiming or killing a patient.

 

[JRY6788]

Agree with many of the points made above. It's truly terrifying that politicians without any medical background/knowledge or exposure to the healthcare field are pushing through bills that may drastically impact the quality of healthcare for patients. Why go to medical school /residency if an NP with 6 months of "clinical" experience can replace a radiologist with a mere 4-6 years of dedicated radiology training? I guess radiologists need to hire some better lobbyists on capitol hill....

I was wondering if anyone knew the technical details re mid level providers requirements for insuring themselves. Will NPs/PAs have to pay similar malpractice insurance rates as radiologists? If they're under the "supervision" of an MD I understand they may fall under the umbrella of that doctor's insurance, but not sure how they could avoid major premiums if they're truly operating independently. And if that's the case, wouldn't NPs/PAs essentially have their salaries cut in half?

 

[NecrotizingFasciitis]

Agree with many of the points made above. It's truly terrifying that politicians without any medical background/knowledge or exposure to the healthcare field are pushing through bills that may drastically impact the quality of healthcare for patients. Why go to medical school /residency if an NP with 6 months of "clinical" experience can replace a radiologist with a mere 4-6 years of dedicated radiology training? I guess radiologists need to hire some better lobbyists on capitol hill....

I was wondering if anyone knew the technical details re mid level providers requirements for insuring themselves. Will NPs/PAs have to pay similar malpractice insurance rates as radiologists? If they're under the "supervision" of an MD I understand they may fall under the umbrella of that doctor's insurance, but not sure how they could avoid major premiums if they're truly operating independently. And if that's the case, wouldn't NPs/PAs essentially have their salaries cut in half?

Anecdotal but I’m sure there’s some consistent truth to this.

My first preceptor worked at a hospital that did the clinical education for one of the NP programs around where I am and he said they didn’t know anything about the drugs they prescribe and created a ton of extra work for him ‘cause notes were so poorly constructed and plans were no good.

Another preceptor I had this past year started refusing to take NP students because they’d get their hours signed for and never show up to clinic. And when they were there they never wrote notes or did any work, they just shadowed.

Thirdly, I know someone working through an NP program now and as of this point in time because of COVID they have had zero clinical hours.

Lastly, an NP I recently worked with was asking me what different tubes and medications did that she dealt with on a daily basis and openly admitted they never do any chart review before seeing patients. Because of this we went into a room and they had no idea this patient we saw was Vietnamese-speaking and assumed they were mute. I informed them after the “interview” if seen the patient before and we needed a translator as I hope this got the patient another proper interview later.

All of this to say, I have no idea where anybody in their right mind gets the idea this group of people deserves more clinical responsibility. Honestly hospitals would be better off/safer paying medical students 1/4 the NP salary and just having them (us) take their place, lol.

On the other hand, I’ve had a couple good experiences with NPs too. I personally saw an NP several years ago at my PCP’s clinic that was excellent and thorough, and the NP that worked on my surgery rotation this year was hard-working and smart as well. This doesn’t make me think they should be reading imaging though, or carrying any extra clinical responsibility.

 

[Matthew9Thirtyfive]

Anecdotal but I’m sure there’s some consistent truth to this.

My first preceptor worked at a hospital that did the clinical education for one of the NP programs around where I am and he said they didn’t know anything about the drugs they prescribe and created a ton of extra work for him ‘cause notes were so poorly constructed and plans were no good.

Another preceptor I had this past year started refusing to take NP students because they’d get their hours signed for and never show up to clinic. And when they were there they never wrote notes or did any work, they just shadowed.

Thirdly, I know someone working through an NP program now and as of this point in time because of COVID they have had zero clinical hours.

Lastly, an NP I recently worked with was asking me what different tubes and medications did that she dealt with on a daily basis and openly admitted they never do any chart review before seeing patients. Because of this we went into a room and they had no idea this patient we saw was Vietnamese-speaking and assumed they were mute. I informed them after the “interview” if seen the patient before and we needed a translator as I hope this got the patient another proper interview later.

All of this to say, I have no idea where anybody in their right mind gets the idea this group of people deserves more clinical responsibility. Honestly hospitals would be better off/safer paying medical students 1/4 the NP salary and just having them (us) take their place, lol.

On the other hand - so I’m not just trashing the specialty - I’ve had a couple good experiences with NPs too. I personally saw an NP several years ago at my PCP’s clinic that was excellent and thorough, and the NP that worked on my surgery rotation this year was hard-working and smart as well. This doesn’t make me think they should be reading imaging though.

I’ve seen an NP who was working independently extremely confidently interpret a plain wrist film completely incorrectly and then prescribe a treatment plan that was completely incorrect and potentially very harmful. Fortunately the patient was my wife, so as soon as the NP left I said, “Okay so this is what we’re really going to do...”

Edit: just to be clear we were doing what my attending had told us to do. We went to an urgent care because it was a lot closer than my school, but I had talked to my attending about her.

 

[Dave1980]

I’ve seen an NP who was working independently extremely confidently interpret a plain wrist film completely incorrectly and then prescribe a treatment plan that was completely incorrect and potentially very harmful. Fortunately the patient was my wife, so as soon as the NP left I said, “Okay so this is what we’re really going to do...”

If your avatar is correct you are still a med student? Not so sure you should be making a treatment plan for your wife in that case.

 

[Matthew9Thirtyfive]

If your avatar is correct you are still a med student? Not so sure you should be making a treatment plan for your wife in that case.

It wasn’t mine, it was what my attending said we should do lol. Sorry for the lack of clarity there. The point of the story wasn’t that I knew better than the NP, it was that she was so confident in her knowledge but was totally wrong (but yes, it was something so obvious that even a med student could recognize it). Edited my post to make it more obvious.

 

[scoopdaboop]

In the long term I am not worried about radiology because I know it's complex enough that it cannot be done without proper training, and it isn't something you can easily 'partition off'.

I worry though for patients. I know of a few bad stories of NPs making bad misses in the ER, ones that a physician would never make. I can already imagine a NP thinking they don't need a radiologist for a particular "simple" X-ray, making a miss, and permanently maiming or killing a patient.

Only a moroonic NP would do this. Any reasonable doctor I've worked with in the ER, even if they're 99 percent sure of what the treatment plan is, waits for radiologist's read before discharging a patient. I would imagine if NPs will be in big trouble if they chose to not wait for radiology reads before any drastic plans. I don't think this rule actually changes anything.

1-radiologists are still final read
2- I'm guessing NP's were already beginning to formulate treatment plans and starting them without having official read, this just sort of sets that premise in writing.
3- Midlevel radiology creep is absurd. It's not like primary care, where a NP works with physicians for several years then they get brave and say "i can do what they can" because they learned on the job. Also, this bill basically says that NP's have to be in practice for around 3 years i think before they can go practice by themselves.
4- The board that dictates this actually has some MD's in there, which is good.

 

[MedDoc305]

Only a moroonic NP would do this. Any reasonable doctor I've worked with in the ER, even if they're 99 percent sure of what the treatment plan is, waits for radiologist's read before discharging a patient. I would imagine if NPs will be in big trouble if they chose to not wait for radiology reads before any drastic plans. I don't think this rule actually changes anything.

1-radiologists are still final read
2- I'm guessing NP's were already beginning to formulate treatment plans and starting them without having official read, this just sort of sets that premise in writing.
3- Midlevel radiology creep is absurd. It's not like primary care, where a NP works with physicians for several years then they get brave and say "i can do what they can" because they learned on the job. Also, this bill basically says that NP's have to be in practice for around 3 years i think before they can go practice by themselves.
4- The board that dictates this actually has some MD's in there, which is good.

I'm just a starting m1, but I worked in the ED as a scribe for a few years. For x-rays and only x-rays, none of the doctors waited on radiology read before giving treatment and discharge. By department policy, the NP's and PA's had to show the doctors MOST, but not all, of the x-rays before making final decisions. That's just one hospital system though, I'm sure it varies greatly.

Edit: For every other type of imaging they would wait with the discharge papers in hand for the final read

 

[guytakingboards]

I'm just a starting m1, but I worked in the ED as a scribe for a few years. For x-rays and only x-rays, none of the doctors waited on radiology read before giving treatment and discharge. By department policy, the NP's and PA's had to show the doctors MOST, but not all, of the x-rays before making final decisions. That's just one hospital system though, I'm sure it varies greatly.

Edit: For every other type of imaging they would wait with the discharge papers in hand for the final read

My group has a seat where we read all the clinics xray's for a multi-specialty group. In a day we can expect 200ish xray's, overwhelmingly most of which are negative. What's interesting is that clinicians put in prelim reads on all studies that we can see.

I'd say every shift there's at least 10 if not 20-30 xray's where the clinician's read is wrong. Calling pneumonia's because they "heard egophony in the lung bases" when the xray's stone cold normal or missing the fracture that's obvious to any actual radiologist.

So to recap, on a set of 200 low-acuity xray's the clinician's (most of which are actually doctors) are about 10-15% less accurate than a radiologist despite being able to talk to and examine the patients.

I know its a moot point, cuz who cares if they're actually good at reading radiologic studies or not.

 

[MedDoc305]

My group has a seat where we read all the clinics xray's for a multi-specialty group. In a day we can expect 200ish xray's, overwhelmingly most of which are negative. What's interesting is that clinicians put in prelim reads on all studies that we can see.

I'd say every shift there's at least 10 if not 20-30 xray's where the clinician's read is wrong. Calling pneumonia's because they "heard egophony in the lung bases" when the xray's stone cold normal or missing the fracture that's obvious to any actual radiologist.

So to recap, on a set of 200 low-acuity xray's the clinician's (most of which are actually doctors) are about 10-15% less accurate than a radiologist despite being able to talk to and examine the patients.

I know its a moot point, cuz who cares if they're actually good at reading radiologic studies or not.

I completely agree. In my 3 years in the ED, every single EM physician, at least once, had to call a patient back after a preliminary read was incorrect for one reason or another.

Once a doctor sent a patient home and the radiology read a few hours later on a chest x-ray showed what they believed to be lung mets/tumor. It was not fun listening to the doctor make the call to the patient afterward

 

[medradthrowaway]

I completely agree. In my 3 years in the ED, every single EM physician, at least once, had to call a patient back after a preliminary read was incorrect for one reason or another.

Once a doctor sent a patient home and the radiology read a few hours later on a chest x-ray showed what they believed to be lung mets/tumor. It was not fun listening to the doctor make the call to the patient afterward

Although, I can name a few departments that don't really care for the final read: neurosurg, ent, ortho, radonc, neuroIR, a lot of the surgeons, and probably a few others. I'm sure the list is growing too.

 

[Taurus]

I don’t care who reads the study. Radiologist, non-radiologist, midlevel, or janitor. Images last forever and don’t change if stored electronically. What I’m more interested is, did you make a miss that caused irreparable harm to the patient and their family. If so, I may be hired by a law firm to be their expert witness and to explain how you screwed up. You will in the end be paying for my time and hourly fee, $500 per hour. So, go ahead, read the study.

 

[CallMeBigJeff]

Although, I can name a few departments that don't really care for the final read: neurosurg, ent, ortho, radonc, neuroIR, a lot of the surgeons, and probably a few others. I'm sure the list is growing too.

Sure they don't "need" the final read most of the time, but what happens with the ENT Maxillofacial CT shows evidence of bone mets? or the neurosurg head CT shows lymphadenopathy? or the ortho spine x-ray shows a AAA? That's why they still need Rads and why the good ones care about the read.

 

[guytakingboards]

Although, I can name a few departments that don't really care for the final read: neurosurg, ent, ortho, radonc, neuroIR, a lot of the surgeons, and probably a few others. I'm sure the list is growing too.

I know those types of doctors. They get sued a lot.

Lol if you think RadOnc doesn't rely on a radiology interpretation. All it takes is one distant lesion to make their entire treatment planning course moot.

 

[medradthrowaway]

I know those types of doctors. They get sued a lot.

Lol if you think RadOnc doesn't rely on a radiology interpretation. All it takes is one distant lesion to make their entire treatment planning course moot.

I don't know for sure if they do get sued a lot. Neurosurgeons almost always do their own read and could care less than to look at the final report. I don't think they get sued that more or less bc of it.

 

[medradthrowaway]

Sure they don't "need" the final read most of the time, but what happens with the ENT Maxillofacial CT shows evidence of bone mets? or the neurosurg head CT shows lymphadenopathy? or the ortho spine x-ray shows a AAA? That's why they still need Rads and why the good ones care about the read.

Sure, but I don't know if that's a great future to be proud of. Are you looking to be someone's insurance policy? I don't know if that will justify the costs in the long run. That can be legislated away in a jiffy. Radiology has to protect itself and offer more than that to secure a vital role in the future of medicine. Hence, we are seeing mid-level creep in what was otherwise an untouchable specialty, and I am sure this is just the beginning.

 

[Taurus]

I don't know for sure if they do get sued a lot. Neurosurgeons almost always do their own read and could care less than to look at the final report. I don't think they get sued that more or less bc of it.

I don’t think you understand how radiology fits into the bigger medical picture. The surgeon or whomever else looking at the images zeroes in on their area of concern or expertise. They don’t care about or have the expertise to look at rest of study, but they don’t have to because they know a radiologist will and will also create an official final report, including important incidental findings. If you only care about aortic aneurysm, you’re probably not looking at or comfortable looking at the lungs for pneumonia or mass or that spiculated mass in the right breast with abnormal nodes in the axilla. This is huge liability. Images last forever and do not change. If you want to take ownership and create the final report for a study, then you have to accept all of the liability. I’ve been an expert witness in enough cases to say only a fool would read a study they are not qualified to read.

 

[medradthrowaway]

I don’t think you understand how radiology fits into the bigger medical picture. The surgeon or whomever else looking at the images zeroes in on their area of concern or expertise. They don’t care about or have the expertise to look at rest of study, but they don’t have to because they know a radiologist will and will also create an official final report, including important incidental findings. If you only care about aortic aneurysm, you’re probably not looking at or comfortable looking at the lungs for pneumonia or mass or that spiculated mass in the right breast with abnormal nodes in the axilla. This is huge liability. Images last forever and do not change. If you want to take ownership and create the final report for a study, then you have to accept all of the liability. I’ve been an expert witness in enough cases to say only a fool would read a study they are not qualified to read.

Liability isn't as high of a barrier as you think. Often times, hospitals can settle these claims for cheap and it might even be worthwhile for them to hire mid-levels to churn out the revenues that will be more than enough to cover claims. Hire a few radiologists to sign off on the final reads and boom. It's something that the profession has to be mindful of. I'm surprised that you guys are just casually brushing this off as nothing. Maybe it's the fact that you're kind of helpless to stop this mid-level freight train and the only consolidation now is to explain it away. I think this bill will pave the way for so much more lobbying and mid-level penetration. It's a pretty big deal tbh.

 

[guytakingboards]

Liability isn't as high of a barrier as you think. Often times, hospitals can settle these claims for cheap and it might even be worthwhile for them to hire mid-levels to churn out the revenues that will be more than enough to cover claims. Hire a few radiologists to sign off on the final reads and boom. It's something that the profession has to be mindful of. I'm surprised that you guys are just casually brushing this off as nothing. Maybe it's the fact that you're kind of helpless to stop this mid-level freight train and the only consolidation now is to explain it away. I think this bill will pave the way for so much more lobbying and mid-level penetration. It's a pretty big deal tbh.

I gotta ask. Are you really a medical student? Much less a medical student mansplaining to a couple of attendings?

It'll take a super adventurous hospital system to credential mid-levels for diagnostic interpretation. I wouldn't be surprised if insurance companies choose not to reimburse mid-level interpretations. Then there's the inevitable backlash from the referring clinicians when the reads coming out of the hospital are dog-**** terrible because the mid-levels have vastly inferior training. Then the lawsuits against the hospital when they knowingly didn't meet standard of care.

I'm annoyed by this bill, but I'm not particularly concerned.

 

[medradthrowaway]

I gotta ask. Are you really a medical student? Much less a medical student mansplaining to a couple of attendings?

It'll take a super adventurous hospital system to credential mid-levels for diagnostic interpretation. I wouldn't be surprised if insurance companies choose not to reimburse mid-level interpretations. Then there's the inevitable backlash from the referring clinicians when the reads coming out of the hospital are dog-**** terrible because the mid-levels have vastly inferior training. Then the lawsuits against the hospital when they knowingly didn't meet standard of care.

I'm annoyed by this bill, but I'm not particularly concerned.

Hospitals supported this bill and will probably have radiologists training mid-levels to read and interpret soon enough. The academic top dawgs in their ivory towers are probably drawing up plans as we speak. As for insurance reimbursements, that's just a law or two away. They're already lobbying for parity in reimbursements with CMS and once that passes, the other insurances will follow suit.

I gotta ask. Are you really a medical student? Much less a medical student mansplaining to a couple of attendings?

I think, in fact, that those who are in it are most oblivious to the changes around them, or they're close to retirement and just don't care. Most importantly, these are external forces that are shaping radiology from the outside in. I don't know if the discussion should be restricted to those in the field. It's really an issue affecting all of medicine. Anesthesia is a prime example.

 

[Gadofosveset]

Sure, but I don't know if that's a great future to be proud of. Are you looking to be someone's insurance policy? I don't know if that will justify the costs in the long run. That can be legislated away in a jiffy. Radiology has to protect itself and offer more than that to secure a vital role in the future of medicine. Hence, we are seeing mid-level creep in what was otherwise an untouchable specialty, and I am sure this is just the beginning.

You have a perspective that’s very skewed by specialty surgery. Radiologists have a complementary and inverse role depending on who orders the study. For specialists they essentially treat the whole patient. For generalists they offer relatively specialist advice. If an internal medicine doc picks up a patient’s diabetes before a nephectomy, it doesn’t meant that they are the urologist’s “insurance.”

 

[Gadofosveset]

Also, medradthrowaway, I take it that you don’t participate in tumor boards, because the importance of the radiology read in patient workup and decision making becomes clear.

Relevant to his thread, a not insubstantial amount of time in tumor boards is clarifying confusing or erroneous radiology reads that could potentially push therapy in a different direction.

 

[medradthrowaway]

Also, medradthrowaway, I take it that you don’t participate in tumor boards, because the importance of the radiology read in patient workup and decision making becomes clear.

Relevant to his thread, a not insubstantial amount of time in tumor boards is clarifying confusing or erroneous radiology reads that could potentially push therapy in a different direction.

I have attended a lot of the tumor boards and while the radiologist does participate, it didn't seem to affect much of the decision making process. There are times where a radiologist could not make it, and a neurosurg or radonc attending would work through the images on their own, and it would be fine. I'd say even that when the radiologist hangs up, I'd often hear neurosurgery talk down on them (which is totally unprofessional by the way). I'm just saying that we often feel we contribute more than we actually do.

 

[Gadofosveset]

I have attended a lot of the tumor boards and while the radiologist does participate, it didn't seem to affect much of the decision making process. There are times where a radiologist could not make it, and a neurosurg or radonc attending would work through the images on their own, and it would be fine. I'd say even that when the radiologist hangs up, I'd often hear neurosurgery talk down on them (which is totally unprofessional by the way). I'm just saying that we often feel we contribute more than we actually do.

Well I can’t speak to your particular malignant tumor board but I run four of them and the surgeons and medical specialists ask good questions about the imaging and we have good answers to provide. It’s a healthy relationship. You do get a feel for what people do and do not know about imaging.

These are surgical and medical oncologists, though. I’ve heard that neurosurgery has a different culture... but you also have to remember that these specialists are only working in their small area of specialty. Start talking to a neurosurgeon about parathyroid imaging and she or he will be lost. Actually, radiologists often sell their own knowledge level short. Many surgeon I work with have a great “feel” for what’s going on and can spot abnormalities in their area, but sometime struggle with things that radiologists would consider basic and assume everyone knows. No one puts a surgeon on the hot seat like a radiology resident at conference... it’s only on the hot seat that the knowledge gaps begin to show.

We all have roles in patient care. One of the nice things about being an attending is that you’ve been around long enough to see enough mistakes made... so you know you provide value what value you provide... and you no longer need to worry about it.

 

[Taurus]

Liability isn't as high of a barrier as you think. Often times, hospitals can settle these claims for cheap and it might even be worthwhile for them to hire mid-levels to churn out the revenues that will be more than enough to cover claims. Hire a few radiologists to sign off on the final reads and boom. It's something that the profession has to be mindful of. I'm surprised that you guys are just casually brushing this off as nothing. Maybe it's the fact that you're kind of helpless to stop this mid-level freight train and the only consolidation now is to explain it away. I think this bill will pave the way for so much more lobbying and mid-level penetration. It's a pretty big deal tbh.

I learned a long time ago to not argue with idiots.

 

[MLNS]

Anecdotal but I’m sure there’s some consistent truth to this.

My first preceptor worked at a hospital that did the clinical education for one of the NP programs around where I am and he said they didn’t know anything about the drugs they prescribe and created a ton of extra work for him ‘cause notes were so poorly constructed and plans were no good.

Another preceptor I had this past year started refusing to take NP students because they’d get their hours signed for and never show up to clinic. And when they were there they never wrote notes or did any work, they just shadowed.

Thirdly, I know someone working through an NP program now and as of this point in time because of COVID they have had zero clinical hours.

Lastly, an NP I recently worked with was asking me what different tubes and medications did that she dealt with on a daily basis and openly admitted they never do any chart review before seeing patients. Because of this we went into a room and they had no idea this patient we saw was Vietnamese-speaking and assumed they were mute. I informed them after the “interview” if seen the patient before and we needed a translator as I hope this got the patient another proper interview later.

All of this to say, I have no idea where anybody in their right mind gets the idea this group of people deserves more clinical responsibility. Honestly hospitals would be better off/safer paying medical students 1/4 the NP salary and just having them (us) take their place, lol.

On the other hand - so I’m not just trashing the specialty - I’ve had a couple good experiences with NPs too. I personally saw an NP several years ago at my PCP’s clinic that was excellent and thorough, and the NP that worked on my surgery rotation this year was hard-working and smart as well. This doesn’t make me think they should be reading imaging though.

It’s not a specialty dude. Radiology is a speciality. Cardiology is a speciality, etc

in medicine speciality has the baseline understanding that its a field of medicine

don’t give charlatans and frauds credit/ title they did not earn and please don’t use words that in medicine are for physicians, for them

 

[NecrotizingFasciitis]

It’s not a specialty dude. Radiology is a speciality. Cardiology is a speciality, etc

in medicine speciality has the baseline understanding that its a field of medicine

don’t give charlatans and frauds credit/ title they did not earn and please don’t use words that in medicine are for physicians, for them

I wasn’t paying much attention to verbiage, that’s my bad. I’ll change it.

 

[guytakingboards]

I think, in fact, that those who are in it are most oblivious to the changes around them, or they're close to retirement and just don't care. Most importantly, these are external forces that are shaping radiology from the outside in. I don't know if the discussion should be restricted to those in the field. It's really an issue affecting all of medicine. Anesthesia is a prime example.

Quite the opposite. I'm a junior attending and I certainly care about the future of my specialty.

Not to be smug about it, but the average training a radiologist gets is closer to a neurosurgeon than a gas doc. Mid-levels carved out most basic part anesthesia, simple OR cases, but they're not doing much of any sub-specialty or complex cases. I would liken that to mid-levels carving out plain films. As I've explained above, non-radiologists are significantly worse at plain films than radiologists.

I can't foresee any circumstance in which a mid-level gets even half of the minimum time in specialty training (2 years) that a radiologist gets. I dunno if you know anything about the field, but a radiology resident after 1 year is about as useful as a hole in the ground. A post-2nd year resident is still woefully below standard of care for general radiology.

Could you train a mid-level to read degen spines or vascular imaging? Sure. With enough reps, you could train a 10th grader to read degen spine. You could also train me to do burr-hole craniotomies for subdural hematoma evacuations. Doesn't mean it's a good idea or that anyone would credential/reimburse me for it.

 

[GadRads]

I dunno if you know anything about the field, but a radiology resident after 1 year is about as useful as a hole in the ground. A post-2nd year resident is still woefully below standard of care for general radiology.

Not true at my institution, especially for post R2's after 2 full years of radiology.

 

[medradthrowaway]

Quite the opposite. I'm a junior attending and I certainly care about the future of my specialty.

Not to be smug about it, but the average training a radiologist gets is closer to a neurosurgeon than a gas doc. Mid-levels carved out most basic part anesthesia, simple OR cases, but they're not doing much of any sub-specialty or complex cases. I would liken that to mid-levels carving out plain films. As I've explained above, non-radiologists are significantly worse at plain films than radiologists.

I can't foresee any circumstance in which a mid-level gets even half of the minimum time in specialty training (2 years) that a radiologist gets. I dunno if you know anything about the field, but a radiology resident after 1 year is about as useful as a hole in the ground. A post-2nd year resident is still woefully below standard of care for general radiology.

Could you train a mid-level to read degen spines or vascular imaging? Sure. With enough reps, you could train a 10th grader to read degen spine. You could also train me to do burr-hole craniotomies for subdural hematoma evacuations. Doesn't mean it's a good idea or that anyone would credential/reimburse me for it.

I'm a medical student after all and love our profession. I appreciate the depth and intricacies, as I am going through the process. Just the thought of mid-levels lobbying and getting this stupid bill passed boils my blood. Fraudsters everywhere these days wanting to take shortcuts. I hope everyone in the profession would stick up for our profession (medicine in general) more and more and not take these bills so lightly cuz there will be plenty more where that came from. We should be up in arms tbh.

 

[clutch21]

Not true at my institution, especially for post R2's after 2 full years of radiology.

I agree, the average PGY-4 resident at a solid program should be close in ability to a general radiologist for the majority of imaging. This probably doesn’t hold true for the more advanced stuff (MR, head/neck imaging, mammo, etc), particularly when comparing to a sub-specialized radiologist.

It’s besides the point though. Compared to NPs, residents start their training at a different baseline in both anatomy and management/next step knowledge. I think even having a cursory knowledge of medicine and surgery (provided by medical school and internship), is more important than we give it credit for. One of the things I’d argue that separates a great radiologist, is the ability to blow off imaging findings that have no clinical relevance. That’s another discussion though.

Bottom line is, even with 2 years of training, an NPs diagnostic ability would not be remotely close to a PGY-4 rads resident. Yet alone a board certified radiologist. As a former nurse, I still believe radiology is relatively safe from midlevel encroachment. At least compared to just about any other specialty, aside from the surgical specialties. There may be some encroachment for radiographs and basic procedural stuff. Which is unfortunate as there is quite a bit of nuance to radiograph. NPs taking over cross sectional imaging though? I just don’t see it.

 

[guytakingboards]

I agree, the average PGY-4 resident at a solid program should be close in ability to a general radiologist for the majority of imaging. This probably doesn’t hold true for the more advanced stuff (MR, head/neck imaging, mammo, etc), particularly when comparing to a sub-specialized radiologist.

It’s besides the point though. Compared to NPs, residents start their training at a different baseline in both anatomy and management/next step knowledge. I think even having a cursory knowledge of medicine and surgery (provided by medical school and internship), is more important than we give it credit for. One of the things I’d argue that separates a great radiologist, is the ability to blow off imaging findings that have no clinical relevance. That’s another discussion though.

Bottom line is, even with 2 years of training, an NPs diagnostic ability would not be remotely close to a PGY-4 rads resident. Yet alone a board certified radiologist. As a former nurse, I still believe radiology is relatively safe from midlevel encroachment. At least compared to just about any other specialty, aside from the surgical specialties. There may be some encroachment for radiographs and basic procedural stuff. Which is unfortunate as there is quite a bit of nuance to radiograph. NPs taking over cross sectional imaging though? I just don’t see it.

On the side tangent: I agree a post-R2 resident is pretty darn good. I'd expect them to make the acute findings on anything CT/US/PF. That being said they have a ton more reps to go before I'd want them doing anything other than telerad prelims. I wouldn't want them reading MR, running a tumor board, doing mammo, nucs or most procedures. A post-R2 is still far more competent than i expect any NP training to go.

I 100% agree that 2 clinical years of medical school and 1 year of internship is a huge leg up on any mid-level in terms of understanding clinical relevance.

 

[DOFOSHO]

Symmetric bilateral lower lobe 2 cm nodules, stable per NP read. Strong work, NP. Strong work, indeed.

 

[Dave1980]

Not true at my institution, especially for post R2's after 2 full years of radiology.

To think that a resident with 2 years of radiology meets the standard for care for Radiology in the community is ridiculous. You my friend may be nearing the apex of the first peak on the Dunning-Kruger chart.

 

[Taurus]

Anyone who has taught residents will tell you that it takes longer to sign off on an imaging study than if they did it themselves. That’s the same with midlevels. If you have to co-sign, no radiologist will simply accept the intepretation of anybody (non-radiologist, resident, midlevel) without looking at the study too. If I have to look at the whole study myself, how does it save me time by having a midlevel? It doesn’t. A scribe would save me more time and be a lot cheaper than a midlevel. This is the fundamental difference between radiology and other medical specialties that heavily employ midlevels like anesthesiology, primary care, and ED. A midlevel only makes sense if they save the physician time or can generate increased revenue. That’s not true in radiology and why I’m not concerned about midlevel encroachment in radiology.

 

[medradthrowaway]

Anyone who has taught residents will tell you that it takes longer to sign off on an imaging study than if they did it themselves. That’s the same with midlevels. If you have to co-sign, no radiologist will simply accept the intepretation of anybody (non-radiologist, resident, midlevel) without looking at the study too. If I have to look at the whole study myself, how does it save me time by having a midlevel? It doesn’t. A scribe would save me more time and be a lot cheaper than a midlevel. This is the fundamental difference between radiology and other medical specialties that heavily employ midlevels like anesthesiology, primary care, and ED. A midlevel only makes sense if they save the physician time or can generate increased revenue. That’s not true in radiology and why I’m not concerned about midlevel encroachment in radiology.

People all say this about their respective specialties and yet, look where we're at now. PAs are doing a ton of IR procedures and even publishing studies to do colonoscopies in GI. In the end, if its a net reduction in cost for the hospitals (fewer hires for radiologist) then the admins will eventually push this model on their departments. If you listened in on the hearing, hospitals called in to support this bill. Not one single hospital called in to oppose it.

 

[GadRads]

To think that a resident with 2 years of radiology meets the standard for care for Radiology in the community is ridiculous. You my friend may be nearing the apex of the first peak on the Dunning-Kruger chart.

I think you are putting words in my mouth about standard of care after 2 years of radiology residency. Re-read the post, and the person I quoted said " A post-2nd year resident is still WOEFULLY below standard of care for general radiology." That is abjectly false at my institution. If you are a woeful resident after 2 years of training, then some questions need to be asked.

That said, the R3, R4 residents and fellows at my institution engage in independent call, and they are pretty good. Not as good as the subspecialty attendings, and not too far off general radiologists out there in community practice. This excludes neuro MRI, cardiac MRI, MSK MRI, breast, nucs and IR which we don't read/do as much on call. In fact judging from multiple bad reads we get from some general community rads reading complex studies in areas where they do not have subspecialty or dedicated training, they do not seem that much better than the senior residents and fellows in that particular subspecialty.

I don't know where you trained, but our attendings generally agree that having senior radiology residents and fellows on service speeds up the day.

 

[Clean7795]

People all say this about their respective specialties and yet, look where we're at now. PAs are doing a ton of IR procedures and even publishing studies to do colonoscopies in GI. In the end, if its a net reduction in cost for the hospitals (fewer hires for radiologist) then the admins will eventually push this model on their departments. If you listened in on the hearing, hospitals called in to support this bill. Not one single hospital called in to oppose it.

I've been through other specialties, radiology is very different.

1. It is very difficult to partition off work into smaller 'handable'/'easy' pieces for someone else to do (most non-IR procedures yes, but imaging and IR procedures no). IR PAs are there because IRs and general rads don't want to spend their time doing PICCs, thoras, and paras—they are like a reverse surgical midlevel (surgical midlevels handle all the floor work because surgeons don't want to spend their time doing ward work). They are very valuable members of the team because they fulfill the original design of a 'physician-extender', and you will be hard-pressed to find a surgeon or IR who doesn't like them.

2. Mistakes made in radiology are permanent and saved. It's hard to say someone 'missed' a critical H&P finding if they just use the same well-made documentation macros each time. It's very easy to see a miss on old scans, especially in retrospect. Perhaps this is the strongest deterrent given hospitals and midlevel organizations recognize money over anything else.

 

[Dave1980]

I think you are putting words in my mouth about standard of care after 2 years of radiology residency. Re-read the post, and the person I quoted said " A post-2nd year resident is still WOEFULLY below standard of care for general radiology." That is abjectly false at my institution. If you are a woeful resident after 2 years of training, then some questions need to be asked.

I can feel you hanging on the precipice of that 1st peak...it's quite a wild ride back to the top but I know you'll make it!

 

[AndM17]

There is a difference between license to practice, scope of practice, and reality on the ground. Licensing refers to what you are legally allowed to do. A license to practice "medicine and surgery" is generally understood to include image interpretation. It is legal for a family doc to read you knee MRI but not advisable. States vary in what a mid-level is licensed to do and these kind of bills seek to expand the legal definition of their practice.

Scope of practice is the somewhat nebulous term referring how different medical specialties and allied health professions practice. Issuing an official diagnostic imaging report is almost always within a radiologist's scope of practice, and for most forms of advanced imaging it is almost exclusively within a radiologist's scope of practice. It is also important to remember that most insurance companies in the USA either refuse to cover services outside the provider's scope of practice or pay much less for them. Additionally, mistakes made while acting outside your scope of practice may be considered negligent errors from an ethical and legal standpoint.

Lastly, reality on the ground refers to actual day-to-day practice and varies by location and can involve "supervision" that is totally inadequate. You could have, for example, a radiologist simply signing off reports ghost-written by mid-levels without looking at them because there is no way to provide adequate supervision while having a life outside your work. As far as I know, this is not happening yet and I imagine any practice that attempts it would quickly lose all its radiologists.

 

[Taurus]

I don't know where you trained, but our attendings generally agree that having senior radiology residents and fellows on service speeds up the day.

Lol. Because it’s widely known that volumes in academics is lower per radiologist and said radiologist tend to be much slower/lazier compared to private practice. For them, having residents dictate/scribe for their studies saves them from picking up the dictaphone themselves. Most private practices, which make up the bulk of radiology, are high volumes, requiring a lot of efficiency. A midlevel in private practice would be a drag and not a benefit to the radiologist. Don’t you think that if midlevels made money for radiologists that they would be widely adopted like they have in anesthesiology and primary care? The fact that they are scarce in radiology should give you some insight into the economics of the business of radiology. Remember that any person you hire into your practice, ie, radiologist, midlevel, or staff, should justify their cost. If the midlevel you hire cannot cover their costs, then why keep them? Or if a radiologist is too slow, why keep them?

 

[echobot3000]

Although, I can name a few departments that don't really care for the final read: neurosurg, ent, ortho, radonc, neuroIR, a lot of the surgeons, and probably a few others. I'm sure the list is growing too.

Just browsing SDN after a long time and forgot about some of the wild comments on this website back from my medical school days. As a senior radiology resident, who has just finished independent night call (as in no radiology attending overnight) and we cover a level 1 adult academic hospital and the only children's hospital in the state, I can say that every single one of those specialities that you listed, called me the most every single night to ask me about exams, excluding the ER and MICU teams, which obviously saw the most patients and ordered the most exams (not to mention the peds ER staff who call nonstop about plain films and US). Half the seniors for those specialties would call me after I read an exam, and already called the ER, to discuss the finding before they went to see the patient in the ER because they were consulted. The only reason you have the impression that they don't care about our reads etc, is because you're a medical student rotating and every speciality wants to make it seem like they're the best for anybody rotating through. Heck, during the day, after rounds the subspecialty attendings would come to the reading rooms to discuss cases with our neuro, body, peds, chest staff, etc...but in private so the other residents and students rotating wouldn't come thru. The neurosurgeons and neurorads, as well as the body and general/transplant surgery guys have each others numbers in their favorites and are always discussing complicated cases. It's a mutual beneficial relationship. As a medical student, the only thing to keep in mind is to know that you know very little about hospital and healthcare, regardless of how much you think you know. We've all been in your shoes as students, it's normal. Just enjoy the ride.

 

[medradthrowaway]

Just browsing SDN after a long time and forgot about some of the wild comments on this website back from my medical school days. As a senior radiology resident, who has just finished independent night call (as in no radiology attending overnight) and we cover a level 1 adult academic hospital and the only children's hospital in the state, I can say that every single one of those specialities that you listed, called me the most every single night to ask me about exams, excluding the ER and MICU teams, which obviously saw the most patients and ordered the most exams (not to mention the peds ER staff who call nonstop about plain films and US). Half the seniors for those specialties would call me after I read an exam, and already called the ER, to discuss the finding before they went to see the patient in the ER because they were consulted. The only reason you have the impression that they don't care about our reads etc, is because you're a medical student rotating and every speciality wants to make it seem like they're the best for anybody rotating through. Heck, during the day, after rounds the subspecialty attendings would come to the reading rooms to discuss cases with our neuro, body, peds, chest staff, etc...but in private so the other residents and students rotating wouldn't come thru. The neurosurgeons and neurorads, as well as the body and general/transplant surgery guys have each others numbers in their favorites and are always discussing complicated cases. It's a mutual beneficial relationship. As a medical student, the only thing to keep in mind is to know that you know very little about hospital and healthcare, regardless of how much you think you know. We've all been in your shoes as students, it's normal. Just enjoy the ride.

LOL, ain't no attending gives enough of a damn to make a false impression on some medical student rotating through. Everything you've just said...good for you, but it's definitely not the norm (as others on here have attested to, neurosurg is notorious for reading their own images and not caring or waiting for radiologist reads). And I don't blame them, because to be honest, there are a lot of garbage radiologist reports out there. There are some exceptionally good radiologists and there are a lot of bad ones that like to hedge on every single thing. "Correlate clinically" didn't just become a joke out of nowhere.

 

[echobot3000]

LOL, ain't no attending gives enough of a damn to make a false impression on some medical student rotating through. Everything you've just said...good for you, but it's definitely not the norm (as others on here have attested to, neurosurg is notorious for reading their own images and not caring or waiting for radiologist reads). And I don't blame them, because to be honest, there are a lot of garbage radiologist reports out there. There are some exceptionally good radiologists and there are a lot of bad ones that like to hedge on every single thing. "Correlate clinically" didn't just become a joke out of nowhere.

They care more than you think. I agree, there are "garbage" radiologists, as there are garbage neurosurgeons, ER docs, CRS docs, neurologists, IM, family etc. Every speciality has good and not so good physicians, like any occupation does. And yeah, a neurosurgeon doesn't need to wait for a read to see a GBM that needs to be resected, decompressive crani, whether a SDH got worse, etc...but when there's a large IPH on a 30 yr old with shift and neuro deficits and they order a CTV concerning for hypertensive bleed vs dural sinus thrombus and deciding whether to anticoagulate or not, they're calling rads the second that patient gets off the table.

 

[medradthrowaway]

They care more than you think. I agree, there are "garbage" radiologists, as there are garbage neurosurgeons, ER docs, CRS docs, neurologists, IM, family etc. Every speciality has good and not so good physicians, like any occupation does. And yeah, a neurosurgeon doesn't need to wait for a read to see a GBM that needs to be resected, decompressive crani, whether a SDH got worse, etc...but when there's a large IPH on a 30 yr old with shift and neuro deficits and they order a CTV concerning for hypertensive bleed vs dural sinus thrombus and deciding whether to anticoagulate or not, they're calling rads the second that patient gets off the table.

Good for you. It's not what I've seen. I see too much hedging with almost every report, CYA if you will. All that makes the report pretty much useless. I don't disagree that really good radiologists are a total asset. They're just not that many around.

 

[scoopdaboop]

Good for you. It's not what I've seen. I see too much hedging with almost every report, CYA if you will. All that makes the report pretty much useless. I don't disagree that really good radiologists are a total asset. They're just not that many around.

Nice jokester. The reliance of imaging on diagnoses has made radiologists probably the most important specialty in the hospital. You have it the other way around; there’s way more good radiologists than bad ones. I can probably say that a FM doc or Im doc half ass knows something then follows some algorithm to make decisions. That’s not happening in radiology.