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doepug

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Stuff like this really aggravates me.

Shouldn't these physicians lose their malpractice coverage since, by interpreting their own studies, they are not meeting the basic standard of care? What's really scary is that the patients probably have no idea that their doctor is reducing the quality of their care to make a quick buck.
 

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Well, I don't mean to ruffle anybody's feather's, but IMO, if specialists want to buy their own scanners and read them, I don't see why it's such a problem. I've noticed that a lot of times, the pulmonologists, neurologists, ENT, ID or orthopod doc has a different read on films then the radiologist's read because he or she has better clinical correlation, more experience in seeing these types of films with these types of patients, and is looking for more specific clinical things on the film then the radiologist is looking for. I've noticed this in academic centers where radiologists are sub-specialized, so I imagine that it must be even more prevalent in private practice settings where general radiologists are expected to look at all sorts of different types of films using different imaging modalities. If an orthopod wants to know whether or not to operate and has seen a ton of knee films, I don't see how having a radiologist give an official read of that knee film will neccessarily add anything to it. Some physicians like to look at their own films and are able to challenge "official" reads based on their experience or what they see clinically. It's all about experience IMO. Anyways, if anyone wants to correct me, I'd be happy to stand corrected, I'm only a med student.
 
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AlexanderJ

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As more and more formal imaging training is included in the training for various specialties, and doctor's fees continue to decrease, I suspect this trend is going to continue far into the future.
 

juddson

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Why aren't insurance companies playing a greater role in this issue? Two issues:

First, if the level of competence required to read these images is greater than that possesed the physicians who self-refer, shouldn't the health insurance companies be refusing (at some level) to cover what are probably ineffecatious imaging (due to a failure to read them well). In that case, this is a waste of insurance dollars that I would have guessed the insurance companies would be all over. Also, I gather from the article and some posts in recent threads that many of these images themselves are mnotivated by profit rather than medicine. That being the case, even if the physicians were good at reading them, many would not be necessary. Why haven't the insurance companies been all over that?

Second, IF the physicians who self-refer are not as good at reading images, why aren't the malpractice insurance companies raising the rates of these physicians for practicing outside of their traditional scope of expertise?

The answer to both of these questions may very well be that for whatever relative lack of competance a self-referring physician may have in reading films, it is not so low that there are "meaningful" (ie, so much that it effects insurance loss risk) differences in the standard of care being provided.

Perhaps radiologists - much like anesthesiologists, psychiatrists, etc. - are overqualified and overtrained to do "bread and butter" imaging, and that all of this self-referral imaging reflects a mere market correction in the provision of imaging in that these "bread and butter" cases can be handled effectively and cheaply by less qualified practitioners.

I guess I can add rads to my growing list (Gas, path, psych) of specialties to worry about.

Judd
ps, what kalel said (though I'm even less qualified than he).
 

MacGyver

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Originally posted by juddson
I guess I can add rads to my growing list (Gas, path, psych) of specialties to worry about.

Why do you put path and psych together with gas? Gas is in far greater danger than those other fields.
 

oldandtired

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Plenty of work for everyone to be busy. Most specialists will not take on the medicolegal risks and realize how difficult MR is to interpret accurately. To those that have enough patients that need MR and want to do it themselves, more power to them. We get physician and surgeon licenses. We can do whatever we want once were out of residency.

Outsourcing is not so bad as long as the reimbursements do not change. Better to keep studies within radiology, than have to clinician monkeys interpreting studies. Most studies that will be sent will be burdensome studies such as icu cxr, ortho films, etc. That would be great as these films are painful to read and have minimal management impact. I would rather have more time to read the complex CTs, MRs, US, do biopsies, etc.

No worries, the sky hasnt fallen yet. Radiology has fewer "problems" than most specialties.
 

droliver

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Originally posted by doepug
1. Shouldn't these physicians lose their malpractice coverage since, by interpreting their own studies, they are not meeting the basic standard of care?

2. What's really scary is that the patients probably have no idea that their doctor is reducing the quality of their care to make a quick buck.


Two comments:
1. there is no "basic" standard of care for image interpretation. Many different specialties routinely interpret their own studies & have for decades. Its not much of a stretch to incorporate newer modalities (CT,MR,NM,U/S,PET) into their practice & learn to read certain focused studies to proficiency

2. Radiologists were first in line with sacrifice of quality vs the $$$$ (non-contrasted CT body scans, open MRI centers,etc....) Nobody's hands are completely clean in that respect.
 

juddson

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Originally posted by MacGyver
Why do you put path and psych together with gas? Gas is in far greater danger than those other fields.

I mention path for the same reason that Rads is woried about outsourcing. If you can send images to India, you can certainly send snapshots of biopsy samples. It might be suggested that much of path is hands-on, and that the reading itself is only part of it. But it seems to me that a PA can work up the sample, take the picture, and wooosh, off it goes to another country. Just a guess.

I think psych is in even worse trouble than Gas. psychologists with scripts, in my opinion, is a HUGE problem, if for no other reason that the science is not as well understood in psych. Harder to determine M&M rates, which works to the advantage of a less qualified practioner.

Geez, I thought the OB/Gyn looked bad, but I have to say from this angle, it's starting to look the best. Look, midwifery has been around for a long time, and it does not seem to have had much effect on OB/GYN practice. Even the insurance premium issue seems like a non-issue as far as I am concerned. The average draw after expenses is STILL $240k - that's damned high no matter how you look at it. And quite frankly, the field is "primed" for men who are interested in it. It is my feeling that a field dominated by women will experience shortages of care because the careers tend to be shorter and the practice more sporadic. I feel there will be PLENTY of work for male OB/GYN's in the future.

Anyway, just some relatively uninformed feelings. I don't even start med school till august - I might learn a lot more about this in a few years.

for ME, the following areas look promising:
ob/gyn, urology, general surgery, FP (yes, FP - my informal research suggests people only tolerate NP's for so long), hospitalist IM.

Judd
 

Goober

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Originally posted by droliver
Two comments:
1. there is no "basic" standard of care for image interpretation. Many different specialties routinely interpret their own studies & have for decades. Its not much of a stretch to incorporate newer modalities (CT,MR,NM,U/S,PET) into their practice & learn to read certain focused studies to proficiency

2. Radiologists were first in line with sacrifice of quality vs the $$$$ (non-contrasted CT body scans, open MRI centers,etc....) Nobody's hands are completely clean in that respect.

1. I agree with you on your first point that many clinicians are reading their own studies and have been for a long time. This is mostly done in offices where the doctor owns the equipment. This almost never occurs in hospitals where they have to be certified to read and there are typically exclusive contracts for radiology ( although there certainly are exceptions). But most clincians have figured out that they can get the money from imaging without the liabilty.

This is why radiological reads by nonradiologists is rather small:

The general setup is a group of clinicians buys a MRI scanner or other imaging equipment. It collects on the technical component which is much higher than the professional component. It then pays a radiologist a small amount of for the read. The rad may not even get paid the professional component and get a even smaller reading fee if the owners bill globally. The rad takes on most of the liabilty but they (the owners) get most of the money. This is the setup in almost all cases I have seen of nonradiologist owned MRI scanners/imaging centers. Even xrays done in docs offices are routinely sent out to rads to read for incredibly low reading fees. The only routine exception is orthopods reading their own xrays. Now this obviously doesn't apply across the board. OB US done by OB, Nuc cardiology done by cards are examples.

2. As for your second point, I don't see how you can blame noncontrast body scans on radiologists. It has not been adopted by radiology as a whole. Ameriscan, the biggest bodyscan company in the nation, was in fact sued by the ACR for misrepresentation. In any group of physicians there are always a small number who are doing things on the fringe.

Open MRIs are of lower quality than high field closed scanners, but they fill a niche for either obese patients or claustrophobic patients. What do you propose for these patients? A open MRI of the brain is better than a CT of the brain. In fact, in patient demand has pushed for open scanner technology and now there are 1.0T scanners which nearly rival high field scanners. In the future it is very likely that open high field magnets will outnumber closed high field magnets.
 

juddson

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Goober,

I did not understand your explanation of how it works with non-rad owned machines. You said the rad gets a very small fee, but then say he gets most of the liability because he gets most of the money.

Can you explain this again - treat me like a 4 year old.
Judd
 

Goober

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Originally posted by juddson
I mention path for the same reason that Rads is woried about outsourcing. If you can send images to India, you can certainly send snapshots of biopsy samples. It might be suggested that much of path is hands-on, and that the reading itself is only part of it. But it seems to me that a PA can work up the sample, take the picture, and wooosh, off it goes to another country. Just a guess.

I think psych is in even worse trouble than Gas. psychologists with scripts, in my opinion, is a HUGE problem, if for no other reason that the science is not as well understood in psych. Harder to determine M&M rates, which works to the advantage of a less qualified practioner.

Geez, I thought the OB/Gyn looked bad, but I have to say from this angle, it's starting to look the best. Look, midwifery has been around for a long time, and it does not seem to have had much effect on OB/GYN practice. Even the insurance premium issue seems like a non-issue as far as I am concerned. The average draw after expenses is STILL $240k - that's damned high no matter how you look at it. And quite frankly, the field is "primed" for men who are interested in it. It is my feeling that a field dominated by women will experience shortages of care because the careers tend to be shorter and the practice more sporadic. I feel there will be PLENTY of work for male OB/GYN's in the future.

Anyway, just some relatively uninformed feelings. I don't even start med school till august - I might learn a lot more about this in a few years.

for ME, the following areas look promising:
ob/gyn, urology, general surgery, FP (yes, FP - my informal research suggests people only tolerate NP's for so long), hospitalist IM.

Judd


Judd,

Picking your specialty based on what you predict it will be like in the future is a pointless exercise. Every specialty has it's ups and downs and every single prediction that people were making when I was in medical school, turned out to be wrong. Since you won't be practicing for 8-10 years from now, anyone who tells you that specialty x will be like this 10 years from now is purely speculating. How about choosing a specialty based on what you ability and interest in?
 

Goober

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Originally posted by juddson
Goober,

I did not understand your explanation of how it works with non-rad owned machines. You said the rad gets a very small fee, but then say he gets most of the liability because he gets most of the money.

Can you explain this again - treat me like a 4 year old.
Judd

The owners get most of the money from their technical or global billing which is much higher than professional fees for reading by the radiologist. If an owner collects $500 for a MRI he may only pay the rad reading it $50. If it is something like an xray the rad may get only $5-10! The radiologist has almost all the liabilty because he is reading the case. If something is missed he is the one getting sued.
 
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juddson

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Rads ought to think about refusing to do reads without a fair cut of the total fee.

Judd
 

droliver

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Originally posted by Goober
As for your second point, I don't see how you can blame noncontrast body scans on radiologists. It has not been adopted by radiology as a whole. Ameriscan, the biggest bodyscan company in the nation, was in fact sued by the ACR for misrepresentation. In any group of physicians there are always a small number who are doing things on the fringe.

I don't mean to imply blame. I'm just contrasting the point that someone made that all these "other" specialties are the ones cheapening radiologic studies for profit. Everyone's looking for new revenue & as the NYT article points out, these centers have been very profitable for many.

The open MRI thing is somewhat of a sales gimmic. There really aren't that many people who can't be done in a conventional magnet. The images I've seen from many of these free-standing open MRI centers have been very poor
 

Goober

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Originally posted by droliver
I don't mean to imply blame. I'm just contrasting the point that someone made that all these "other" specialties are the ones cheapening radiologic studies for profit. Everyone's looking for new revenue & as the NYT article points out, these centers have been very profitable for many.

The open MRI thing is somewhat of a sales gimmic. There really aren't that many people who can't be done in a conventional magnet. The images I've seen from many of these free-standing open MRI centers have been very poor

Well most radiologists hate to read off low field open scanners. Most of these freestanding centers are more often than not, owned by businessmen or non-radiologists physicians.
 

AlexanderJ

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Hey NY SkinDoc, the original poster for this thread. I suspect you are a derm resident from your name. I think I might be a little worried if I were you. As primary care physicians continue to feel the financial squeeze, they are going to look for ways to supplement their income other than reading rads. Its not going to take people very long to figure out that BoTox injections, dermabrasion, and cosmetic laser treatments are not rocket science. In reality, these procedures are so simple that they can be performed by nursing staff (or a monkey for that matter). Also, an outsourced teledermatology model is not out of the questions (again, with nurses or technicians or monkeys performing any necessary procedures). Just my two cents.
 

Goober

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Originally posted by juddson
Rads ought to think about refusing to do reads without a fair cut of the total fee.

Judd


The problem is the owners will just shop around till they find a group of radiologists that will read at the lowest price. This is generally doable in any city with multiple groups. In a small town with a single rad group this may not work. But now with teleradiology it is possible.

The biggest problem with all of this is the Stark Laws don't have any teeth to them. There are just too many loopholes to exploit. Owners can still self refer cases which is driving buying of imaging equipment by non radiologists and driving up the overall cost of healthcare in this country.
 

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Regarding the open MRI issue, I had a patient last year with cauda equina symptoms with presumed metastatic breast ca to the spine. Neurosurgery wouldn't do anything without an MRI, and the patient experienced too much pain to lie down for any longer then a couple of seconds. We tried to give her a lot of narcotics and benzos, to the point where she would fall asleep sitting upright, but the second we tried to lean her back, she'd wake right back up. The hospital where I was at did not do MRI's under anesthesia, I don't even know how a hospital could get all that metal equipment in an MRI machine to tell the truth, so after calling around, we eventually had to send her to a place which did open-MRI's. I agree that they aren't the best for people who just have minor claustrophobic discomfort during the scan, but it seems to me that if all you want is a scan, it's better then subjecting someone to general anesthesia at times.
 

Mr.Tweed

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Originally posted by AlexanderJ
Hey NY SkinDoc, the original poster for this thread. I suspect you are a derm resident from your name. I think I might be a little worried if I were you. As primary care physicians continue to feel the financial squeeze, they are going to look for ways to supplement their income other than reading rads. Its not going to take people very long to figure out that BoTox injections, dermabrasion, and cosmetic laser treatments are not rocket science. In reality, these procedures are so simple that they can be performed by nursing staff (or a monkey for that matter). Also, an outsourced teledermatology model is not out of the questions (again, with nurses or technicians or monkeys performing any necessary procedures). Just my two cents.

:laugh:
 

eddieberetta

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Originally posted by Goober
Well most radiologists hate to read off low field open scanners. Most of these freestanding centers are more often than not, owned by businessmen or non-radiologists physicians.

Well... it turns out that scan quality is generally lower in imaging centers run by non-radiologists (this has really been shown for US and radiography--anecdotally it is also true for MRI) -- probably because radiologists have more knowledge about technique factors and are more on top of the latest tech.

With the current marked demand for radiologists, it has been easier for radiologists to negotiate to have an equity stake in the magnet (even magnets originally bought by others) which means more $$. To me however, the major benefit from rads having a stake in the center(to the patient) is that brought by the on-going imaging quality / protocols at the imaging center (but of course I'm biased).

I agree that radiologists entering into these agreements should try to negotiate for an equity stake. The other point is that when you don't have any say over the center, you are stuck interpreting whatever you get -- yet may be held liable for missed findings due to suboptimal images. Ultimately, as the radiologist, you are responsible for all aspects of the imaging process (and when other physicians do imaging, they are held up to the same standard as radiologists -- not their own standard). So it is important to have input into the image acquisition/protocols/etc.

The above is certainly an interesting medico-legal issue...
 

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judd,

I still say gas is in far greater danger than rads, path or psych.

I would rank the danger areas as:

gas >>>>>> rads > psych > path

There IS NOBODY doing outsourcing of path imaging yet. Could happen, but I put that last because there is NOBODY doing this yet in the United States.

As far as psychiatry, I am aware of only 2 states who allow psychologists to do scripts, and in both states, the response by the psychologists has been less than enthusiastic. Consider the fact too that in both states, the plan to increase rural access has been an abject failure.

Rads still has the outsourcing issue, but it hasnt taken full hold of rads yet.

Gas, on the other hand, is in crisis. CRNAs are already competing head up with MDAs, and they've got research to back their claims of equivalence with MDAs. Thats a lethal combination. CRNAs can own their own practices in most states, and in nearly all states, MDA supervision is not required. The "last bastion" for MDAs is that most states still require MDA supervision of CRNAs for Medicare procedures. However, this is rapidly changing. 12 states (in less than 2 years) have exercised their "opt out" clause in the MDA supervision of medicare procedures. I see no reason to suggest that all 50 states wont eventually opt out. When that happens, CRNAs will be functionally equivalent in every way to MDAs.
 

ny skindoc

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Originally posted by AlexanderJ
Hey NY SkinDoc, the original poster for this thread. I suspect you are a derm resident from your name. I think I might be a little worried if I were you. As primary care physicians continue to feel the financial squeeze, they are going to look for ways to supplement their income other than reading rads. Its not going to take people very long to figure out that BoTox injections, dermabrasion, and cosmetic laser treatments are not rocket science. In reality, these procedures are so simple that they can be performed by nursing staff (or a monkey for that matter). Also, an outsourced teledermatology model is not out of the questions (again, with nurses or technicians or monkeys performing any necessary procedures). Just my two cents.
I posted the article because I thought people here would find it interesting.I may be in the minority of dermatologists who enjoy treating people with medical derm problems.I'm happy to leave Botox to others.There are plenty of FPs,Internists,OBs who now offer all sorts of cosmetic treatments to their patients including Lasers,Botox etc.Hopefully the monkeys working in their offices are adequately trained and experienced.I would check into it before allowing someone to put a laser to your patients (or wife's) face. I'm confident enough about the skills I have to offer that I won't lose sleep over teledermatology treatments in India.(I dont think there are too many US board certified dermatologists residing in India at present anyway!)
 
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pathstudent

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I mention path for the same reason that Rads is woried about outsourcing. If you can send images to India, you can certainly send snapshots of biopsy samples. It might be suggested that much of path is hands-on, and that the reading itself is only part of it. But it seems to me that a PA can work up the sample, take the picture, and wooosh, off it goes to another country. Just a guess.

Pathologists work closesly with the doctors. Docs at a hospital are not going to want to discuss a case with some guy they don't know thousands of miles away.

Moreover, all the pathologists have to do to put a stop to it is refuse to provide any of their services to the hospital unless they can provide all their services.

Lastly, If some doc in India misses an important diagnosis, there would be no way for the patient to seek compensation.

I don't think it will happen.

As far as docs wanting to read their own x-rays and mris, that is one place where pathologists are one up on radiologists as no surgeon or GI guy or Urologist or Gynecologist wants to look at their own slides and put their name on the diagnosis. But everyone thinks they can read the chest x-ray or CT of the abdomen.
 

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Originally posted by pathstudent
As far as docs wanting to read their own x-rays and mris, that is one place where pathologists are one up on radiologists as no surgeon or GI guy or Urologist or Gynecologist wants to look at their own slides and put their name on the diagnosis. But everyone thinks they can read the chest x-ray or CT of the abdomen.

Good point. All the non-path docs I know would never want to read/interpret their own slides, although they love to do their own x-rays, CT, and MRIs without a moment's hesitation.
 

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Originally posted by MacGyver
Good point. All the non-path docs I know would never want to read/interpret their own slides, although they love to do their own x-rays, CT, and MRIs without a moment's hesitation.

Now why would this be? Is this because path is perceived to be a more difficult read to make? Why the risk aversion to doing a path read, but not a film read?

Probably, most of this has to do with the fact that the scan itself makes a ton or money for the doc, and the read is secondary. In path, there pretty much isn't anything else BUT the read, which is not as lucrative.

Somebody help me out with this.

Judd
 

pathstudent

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It is more than just money. Think about it back when you were in medical school. How many times when you did sugery did your team go look at CTs claiming they could see an adrenal tumor? Or how many times did your IM team read the chest x-ray to identify the nodule. All the time the surgeons and internists claimed to be able to read the radiology as well as a radiologists if it pertained to their field.

But did your IM team ever go look at the slides and try to diagnose the lung nodule as infectious or malignancy or as auto-immune?

And did your surgery team ever go get the slides and sit down on their own and try to diagnose the adrenal mass as malignancy?

No of course not. Pathology is much more precise as it is the final word as to what something is. In path, especially with breast biopsies, I can't tell you how many times the final diagnosis isn't even in the radiologist's differential.
 

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What an stupid thread. Nobody want to read their own slides because it is tedious and boring as ****. Breast biopsies? Our job is not to make pathological diagnosis... it is to determine is something looks ugly enough to warrant a biopsy, period.

As for radiology, I would be very suspicious of clinicians who claim they can read scans as well as radiologists. There are some subspecialist who are pretty good at reading studies covering a limited area, but most just think they can. I have seen so many absurd calls made by clinicians that I will not be losing much sleep over it. Besides, there is much more to being a radiologist than simple reading the study, you must understand the technology and how best to use it to benefit the patient and answer the clinical question.

In any case, there have been studies coming out showing how imaging costs are driving up health care costs, and how most of this is due to self-referral. It will not be long until those paying the bill realize that it is best to have radiologist run medical imaging, because we have the knowledge and skill to run it in an efficient, high quality and more cost effective manner.
 

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Originally posted by pathstudent


No of course not. Pathology is much more precise as it is the final word as to what something is. In path, especially with breast biopsies, I can't tell you how many times the final diagnosis isn't even in the radiologist's differential.

Radiologists rarely provide differentials for breast lesions, so I don't know what you're talking about. The standard reporting system for breast imaging which is called BIRADS, has six different numerical categories based on whether something is suspicious enough to warrant a biopsy or not, without mention of any specific histology. There is rarely, if ever, any specific differential or histology is favored, except sometimes to guide the pathologist and more importantly, to later decide whether the path report is concordant with the imaging findings or not. Nowadays, most breast biopsies are done by radiologists (US or stereotactic core) and they are the ones that follow the pathology results and initially discuss the findings with the patient. When the radiologist gets the biopsy results back, he/she has to decide whether the pathology result is concordant or discordant with the radiological findings. If the results are discordant (e.g., looks bad radiologically, but pathology suggests a benign histology), the pathology result doesn't matter and the patient will be referred to a surgeon to get an excisional biopsy/lumpectomy anyway despite the benign pathology report.

Also, pathology is not ALWAYS the final word. Pathologsists are notably inaccurate in diagnosis of certain osseous tumors, some interstitial pneumonitides, and also lower grade chondrosarcomas. We see it all the time in our monthly pulmonary and bone tumor conferences. Even in your own example, the breast, pathologists are sometimes inaccurate. Atypical ductal hyperplasia is treated like cancer, because it is a well-known fact that pathologist miss DCIS in these cases in up to 30% of cases. Biopsy an area of healing fracture, and many pathologists will call it an osteosarcoma. What are you going to do? Listen to the pathologist and amputate the leg? No, you correlate it with the patient's other info. There are many more examples that I can give that pathology is NOT the final word.

There are thousands of diagnoses that never come to pathology since clinical and radiological findings are good enough to direct the course of management and treatment. Also, with improvements in noninvasive imaging, less patients need tissue sampling than in the past to arrive at a pathologic diagnosis. Granted, pathology is the often the final confirmatory test, but you have to realize it is not infallible. With advances in immunohistochemistry, cell-surface markers, etc., pathologists are much better now than before in making histopathological diagnoses and they will continue to improve their diagnostic armamentarium.

All pieces of information about the patient's condition are important, including demographics, history, clinical findings, radiology, labs, and finally path. None of them is good enough in isolation.
 

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Nobody want to read their own slides because it is tedious and boring as ****.

And reading CTs all day long in a dark room is HEAVEN.
 

ny skindoc

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Pathology is often not the final word on exactly what something is. I admire the knowledge and skill of pathologists but I frequently read biopsy reports even from highly qualified pathologists which are very nebulous and not specific as to precise diagnosis-its not their fault its in the limitation of the science.They often point you in a certain direction but the rest is left to the experience and judgement of the treating physician.
 

bosky

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"In any case, there have been studies coming out showing how imaging costs are driving up health care costs, and how most of this is due to self-referral. It will not be long until those paying the bill realize that it is best to have radiologist run medical imaging, because we have the knowledge and skill to run it in an efficient, high quality and more cost effective manner."


RADRULES,

Do you have references for these studies? I would enjoy reading them and would find it re-assuring....
 
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Docxter

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Originally posted by bosky
"In any case, there have been studies coming out showing how imaging costs are driving up health care costs, and how most of this is due to self-referral. It will not be long until those paying the bill realize that it is best to have radiologist run medical imaging, because we have the knowledge and skill to run it in an efficient, high quality and more cost effective manner."


RADRULES,

Do you have references for these studies? I would enjoy reading them and would find it re-assuring....

Take a look at this one:

Levin, DC Rao, V. J Am Coll Radiol 2004; 1: 169-172 (March 2004)

Abstract
A recent report by the Medicare Payment Advisory Commission to Congress indicated that the utilization of diagnostic imaging is growing more rapidly than that of any other type of physician service. This has engendered concern among those who pay for health care. In this article, the authors review the role of self-referral in driving up imaging utilization.
A number of studies of the self-referral factor in imaging have been conducted over the past three decades. These have consistently shown that when nonradiologist physicians operate their own imaging equipment and have the opportunity to self-refer, their utilization is substantially higher than among other physicians who refer their patients to radiologists. It has also been shown that the vast bulk of the recent increases in imaging utilization are attributable to nonradiologists who self-refer. The authors estimate that the cost to the American health care system of unnecessary imaging resulting from self-referral by nonradiologists is $16 billion per year.
 

WaitingForJuly

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Originally posted by Docxter
Take a look at this one:

Levin, DC Rao, V. J Am Coll Radiol 2004; 1: 169-172 (March 2004)

I hope the ACR is forwarding a copy of this to every congressional office. Anyone here from Pete Stark's district? He'd probably be interested to see it, especially if it arrived with a letter from one of his constituents.
 

Docxter

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Originally posted by WaitingForJuly
I hope the ACR is forwarding a copy of this to every congressional office. Anyone here from Pete Stark's district? He'd probably be interested to see it, especially if it arrived with a letter from one of his constituents.

The problem is that Stark's law is useless. The non-selfreferral laws doesn't apply if the imaging equipment is in the doctor's "office". Now go define "office".
 

droliver

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Docxter,

do you have the full text of that article available. It sounds from the abstract that its just a review of some previous articles on the subject rather then fresh data. A number of those previous articles (I'm presuming he's looking @ some of the same ones I looked @ on Medline) identify some of the utilization trends cited, but do not come out and make the bold & very political conclusions that this author seems to in the abstract.

I'm curious to see the break down of exactly what the procedures (is this including nuclear med & cardiology studies? )were surveyed & whether you can break it down even further by specialty of the ordering physician (FP vs orthopod vs. Neurosurgeon vs Hand Surgery, etc.....). The $16 billion figure is pretty staggering. I'm curious as to how you reach that number & how unless they personally surveyed hundreds of thousands of charts & requisitions could they make a judgement about the appropriateness of a given study. That number is so ridiculously large as to raise some red flags about the methodology
 

Docxter

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Originally posted by droliver
Docxter,

do you have the full text of that article available. It sounds from the abstract that its just a review of some previous articles on the subject rather then fresh data. A number of those previous articles (I'm presuming he's looking @ some of the same ones I looked @ on Medline) identify some of the utilization trends cited, but do not come out and make the bold & very political conclusions that this author seems to in the abstract.

I'm curious to see the break down of exactly what the procedures (is this including nuclear med & cardiology studies? )were surveyed & whether you can break it down even further by specialty of the ordering physician (FP vs orthopod vs. Neurosurgeon vs Hand Surgery, etc.....). The $16 billion figure is pretty staggering. I'm curious as to how you reach that number & how unless they personally surveyed hundreds of thousands of charts & requisitions could they make a judgement about the appropriateness of a given study. That number is so ridiculously large as to raise some red flags about the methodology

I only have the printed text. You can go to the ACR.org website and get the article from the JACR online site. The article reviews the previous studies but also looks at the medicare database as well. The 16 billion figure is a calculated and projectional figure based on the medicare data. It does include cardiac imaging and nuclear studies. This particular article doesn't have much in terms of breaking it down by specialty.

Actually, the greatest increase in utilization of imaging is by cardiologists (39% vs. 7%). I'm not surprised, even with my own limited experience. During my internship, the cardiologists made us do every imaging study under the sun, even ones with overlapping info for every single patient, whether indicated or not. We had to get a regular echo, a separate stress echo, stress MIBI, and a gated-blood pool study for every patient. I was once severely reprimanded when I raised the question that my patient may not need all these exams. It's no wonder that the majority (>65%) of all cardiac caths are stone cold normal as I have been told, not even counting insignificant minimal narrowings. Nowadays a calcium scoring CT and a CT coronary angiogram and a MR viability study is being added to the rest.
 

droliver

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Originally posted by Docxter
Actually, the greatest increase in utilization of imaging is by cardiologists (39% vs. 7%).

Interesting. There's an article in the Sunday NY Times yesterday about how a number of cardiologists are challenging the traditional wisdom & culture of the cardiac cath lab. I didn't realize it but it was explained that most lethal MI's are from rupture of plaques of non-flow limiting stenoses that wouldn't be stented in the first place rather then the areas routinely tx. by cardiologists. It seems that ASA & the statins are the tx. that is often overlooked & will save more lives in a more cost-effective pattern
 

bosky

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I read that article - this will probably make them go after cardiac imaging even more. There was a thing on 60 minutes a year or so ago about this guy in california doing stents and bypasses on perfectly healthy people. He eventually got found out, but not until after he had made a ton of money for the hospital.

I'm not in a position to really know, but is the field of cardiologists just significantly contaminated with greed?
 

WaitingForJuly

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Originally posted by Docxter
The problem is that Stark's law is useless. The non-selfreferral laws doesn't apply if the imaging equipment is in the doctor's "office". Now go define "office".

That was my point. The current Stark laws are meaningless. With both political parties promising to reign in health care costs, unneeded (and unethical) self-referral is a politically tenable way to do that. The politicians now have a peer-reviewed published article to support such a move. It sure beats across the board medicare reductions.
 

Voxel

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This is an interesting thread. But even in my limited experience across several instituations, cardiology self-refers many questionable and overlapping tests. Not only that, but there are less invasive tests out there that can give you more and better definied information but are not being used because (I suspect) cardiologists do not currently perform them. The stark laws are a joke. If only medicare and private insurance realized how much extra studies ($) are ordered when they can be self-referred vs when they are not would anyone start to listen. I think it happens with other specialities as well but to a lesser extent.
 
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