Neuroimaging - where do we stand?

[doctorlarry]

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Has anyone here recently completed a Neuroimaging fellowship? Will you be reading/billing for these studies?

 

[doctorlarry]

bump

 

[Astrocyte]

Has anyone here recently completed a Neuroimaging fellowship? Will you be reading/billing for these studies?

Don't count on it...even if you finished a fellowship. It might make you more attractive to any given neurology group, but you will essentially still be a clinical neurologist.

Neuroimaging "research" is another matter.

 

[bonran]

Not true.... Yes you will be able to read & bill for the studies. Whether you can survive just reading films is another matter, as you will not be able to read general radiology & so it wont be a big practice. Also, you wont be working in a big place where neuroradiology will ease you out.

But neuroradiologists are not available everywhere. General radiologists usually have very poor neuro reads. You will fill in their place in a medium to small hospital in the periphery.

 

[typhoonegator]

Some big research centers are actually having a hard time hanging on to their neurorads fellows; many leave to join private groups to make more cash. One of the Boston hospitals where I work is training two of my former co-resident neurologists in a formal neuroradiology fellowship, with the goal that they will remain at the medical center with dual appointments in neuro and neurorads. They will read and bill, and do crossover research, and have clinical responsibilities. To me, that sounds like a lot to balance, but it certainly sounds like an interesting opportunity.

 

[Astrocyte]

I think that's an except, not the rule. The clinical neuroimager path is relatively uncharted.

 

[typhoonegator]

I think that's an except, not the rule. The clinical neuroimager path is relatively unchartered.

Absolutely true. However, I do now know several practicing neuroradiologists who were trained first as neurologists.

The path for neurology into INR was similarly uncharted until a few years ago.

 

[Yoyomama88]

Can someone comment on the status of neuroimaging work performed by neurologists today. Is it still unlikely for a neuroimaging fellowship trained neurologist to read/bill for their own scans in a hospital?

 

[typhoonegator]

Well I wouldn't say it is at all common. But here in Boston we have a neurologist from my residency class who did neuroimaging fellowship and splits his time between neuro and neurorads. He bills. But he also stayed at the institution where he trained, so they radiologists were receptive to having him around in the first place.

But many, many groups would not let this happen. Why would they? You're hiring less than one neurologist, because some of her/his time will be spent reading. You're hiring less than one neuroradiologist, because some of her/his time will be spent seeing patients. And many neuroradiologists would not consider the training to be equivalent (whether this is true or not is something I don't want to get into).

 

[Yoyomama88]

I feel like it is important for any neurologist to become an expert in neuroimaging. At the end of the day, neurologists have to make decisions on a patient's care based off of these scans. In theory, isn't it possible, if the capital existed, to purchase an MRI or CT machine for a group practice of neurologists who are also fellowship trained in neuroimaging and then read/bill their own scans?

 

[typhoonegator]

First of all, yes, neurologists should have some degree of facility in imaging interpretation. But are you able to diagnose all manner of incidentally discovered salivary gland and thyroid lesions on MRI when you finish training? I'm not. Nor do I know the complete Ddx for a cystic non-enhancing bone lesion in the T1 vertebral body. You can't just wing it.

Sure, you could set up that practice environment, and bill all you want. But someone is going to have to pay the bill. Unless this is a boutique private practice, and you're self-insured, then somebody is going to have to underwrite your medical insurance policy for your neuroradiologic proclivities (with little data to support the notion that your image interpretation for your level of training is equivalent to a neuroradiologist), and payors are going to have to be willing to reimburse you for your efforts. So yeah, if all those stars aligned, then I suppose you could try that.

 

[Strokeguy]

In general it will be hard for a neurologists (with fellowship training in neuroimaging) to get credentialled in most hospitals to read and bill for neuroimages. Several factors come into play including the ones mentioned in prior posts. Radiologists (neuro or gen) are the ones that approve this credentialling and they will simply not allow this. Secondly how good the overall training would be to identlfy lesions outside the skull and spine is highly debatable. The criteria to get UCNS certification in neuroimaging are far less stringent than to get a 'board certification thru ACGME accredited training'.
This trainign could be useful for research.
Neuro subspeciality fellowships like MS, Stroke, Epilepsy etc provide ample/adequate training in imaging interpretation for clinical decision making as well as for research. In many fields as MS or stroke the clinical and imaging correlation goes a long way in therapeutic decision making and could be as good as a neurorad (but only for that disease aspect). The neurorad may not be better at MS imaging per se than an MS fellowship trained neurologist, but will still be superior to neurologists at overall neuroimaging. Same for stroke, neuroonc, etc.

 

[Strokeguy]

The arguement radiologists have against credentialling a fellowship trained neuologist in any hospital or including them within their rad group is 'who will cover for their malpractice' since there is a high chance they will miss extracranial/extraspinal lesions as lymphomas, chest nodules...

 

[Yoyomama88]

Just curious. What about a neurologist who completes a fellowship in INR, would they technically be a "neuroradiologist", who could easily be employed by a hospital for the sole purpose of reading scans?

 

[typhoonegator]

Neurointerventionalists are not neuroradiologists, and cannot sit for neuroradiology or radiology boards.

 

[neurodoc]

I feel like it is important for any neurologist to become an expert in neuroimaging. At the end of the day, neurologists have to make decisions on a patient's care based off of these scans. In theory, isn't it possible, if the capital existed, to purchase an MRI or CT machine for a group practice of neurologists who are also fellowship trained in neuroimaging and then read/bill their own scans?

Good points. Clinical neurologists should develop skills to read neuroimaging studies, for the reason you mentioned. I've been practicing for over 20 years and I have learned that we cannot always rely on the official radiologists' reports of brain and spine MRI's. I don't expect to be able to bill for such studies, nor do I want to. But I do always want to review the actual scans rather than rely just on the reports. This is because as the treating neurologist I know what's going on with my patient and I have a pretty good idea of where and what the lesion is when I order the scan. Radiologists who interpret the scans typically don't have this information. They can and do miss "subtle" but significant abnormalities. You'd think that radiologists with a "neuroradiology" emphasis would be better than generalists, and by and large they are, especially those who had training in neurology.

Nonetheless, being able to read the scans yourself is a very useful skill to have. I learned this very early on in my residency training during a neuroradiology case conference about a 2 year-old southeast Asian girl who presented with seizures. I admitted the patient to the Peds Neuro service. Her MRI showed a frontal lobe lesion that the neuroradiologist felt was some sort of glioma, for which a biopsy was planned. I opined that the audience should look more closely at the images, because this presumed glioma had what appeared to be an organized internal structure, namely a larval scolex...Given the girl's ethnicity, cysticercosis was a likely diagnosis, and she didn't need a biopsy to prove that.

The neuroradiology professor who was moderating the case conference was not pleased with these comments of a mere neuro resident, and I suppose I may have exacerbated the situation by quoting Goethe's admonition Mann sieht wass Mann wiess, i.e., we see what we know...I couldn't resist saying something like that...

Anyhow, this Prof was so offended by my cheekiness that he complained to my program director. My PD advised me to meet with this Prof., which I did. I apologized if I offended his ego, but bluntly refused to admit any wrongdoing and suggested that if he wanted to he could refer me for discipline by whatever review agency was applicable...but that my defense would be that: 1) My diagnosis was absolutely correct; 2) He and his radiology staff had missed the diagnosis; and, 3) The patient had been spared an unnecessary and risky surgical procedure, and both he and the hospital should thank me for this, or the least keep their mouths shut...That was the end of it. I took the liberty of ordering cysticercin antibody titers, which were positive. The patient was treated with albendazole and did well.😀

 

[Yoyomama88]

awesome post above 🙂

 

[neurodoc]

awesome post above 🙂

Thanks. My post accurately described the case of the girl with cysticercosis. And this occurred at a major UC teaching hospital, not at some backward facility in the boonies.😳

 

[Strokeguy]

Completely agree. And very important for all those in training. You must look at and interpret neuroimaging yourself. The time to start doing is when you are in training (otherwise you will miss learning opportunities). I always tell the residents and fellows that you need to look at images yourself before reading the radiology report. It does happen that either there is an error in the official read or it is irrelevant; or ambiguous (can be this vs that vs as well as ..). As the clinician you have to make treatment decisions.
I also advice them to read the official read after your own interpretation (Reason - we aren't trained to interpret patterns outside the vasculature/skull/spine). But neurologic decision making is always done based on your interpretation of the overall pt (clinical + imaging).
So many times (in the last few yrs) I have seen errors being made when clinicians (neurologists/non-neurologists) simply read the official report without taking a look themselves.

 

[07mcattaker]

so then to return to the original post - is anything being done or what could be done to make more legitimate the UCNS neurorads fellowship in the eyes of payers/underwriters/hospital management/rads colleagues?

by way of an example i have learned that cardiac MRIs are read by cardiologists in many institutions, how were they able to carve out this practice? i would imagine its because cardiac MRI is of the heart only so there is no opportunity to miss incidental findings elsewhere (in contrast to a head MRI)

thx,
interested PGY2

 

[Strokeguy]

We can read carotid US and TCDs and bill for these (in vascular neurology). Again this imaging is purely neurovascular, just like echo is for cardiologists. I am curious to see wha people think about fMRIs (though it mostly for research as of now) and MEG (I think epileptologists should bill for this).

 

[phonyreal98]

We can read carotid US and TCDs and bill for these (in vascular neurology). Again this imaging is purely neurovascular, just like echo is for cardiologists. I am curious to see wha people think about fMRIs (though it mostly for research as of now) and MEG (I think epileptologists should bill for this).

fMRI is difficult because there's such a great overlap between healthy controls and clinical groups that it's difficult to tell an impairment of function by scanning just one person (ie while group differences can be quite statistically significant, this doesn't mean that there's necessarily a difference on an individual level). Additionally, establishing the ideal type of paradigm to recruit various neural structures in different groups to see these differences is a matter of intense debate itself (task-based or resting state? looking at functional connectivity or one region? and so on and so forth).

 

[cerebral edema]

Any updates to this? Interested in pursuing this fellowship vs. vascular.

 

[sailor jerry]

Any updates to this? Interested in pursuing this fellowship vs. vascular.

I've been in Child Neuro practice 26 years. I look at my own images, most of the time the neuroradiologists do a good job with neuroimaging, but sometimes the mis stuff, and there are some that are lazy or rushed or just not so good, I guess, and mis more than the average.
The general radiologists that read brain mri's do mis quite a bit of findings, so, a fair ammount of my work is doing consults due to a scary mri reports. Some clinically relevant, but many are incidental findings of no relevance, or normal variants.
So my consults are sometimes, a neuroradiology 2nd opinion with clinical correlation-rationale- explanation, "defuse the anxiety" type of thing.
For a cuple of years I did dictate a
" second mri report" and tried to bill for an mri reading... after all, they got the diagnosis wrong, I got it right, I know more, any way, very seldomly was I succesful in getting any reimbursement, so I stoped spinning my wheels, and I now include the whole "corrected mri explanation" in my consult. That works fine, everyone is happy, specially the flunky radiologist that mised the dx, got paid, and did not even hear about it... 🙂
any way, back in the peak of my daydreaming with my neuroradiological superiority, I called the head honcho at a local radiology facility to "offer" an arrangement where I would send my mri's to them, they bill the technical fee and I interpret it and bill my reading fee... he politely said NO WAY!!!!
I have moved on.
We are good clinicians and know more neuroradiology than some, or many radiologists, even more than some neuroradiologists, specially in my field, child neuro, but that is life.
Pick your battles.
I think there is even a non ABMS type of certification that you can get ( pay some fees and jump some hoops) but I dont think it would get you very far in what pertains to reading and billing for neuroradiological studies.
Neurovascular stuff, that may be more of an open field for the vascular neurologists.
...Got to be goodlookin' cause is so hard to see

 

[kchan99]

For your " 'second MRI' " how did you know that you were correct? Did you have pathological, genetic, or biochemical data, or was it something completely obvious? We were to trained to develop habits in reading scans from day one in residency, but when I rotated in outlying clinics, I was appalled to learn that there were neurologists who did not look at scans at all, and relied on reports, including those from non-neuroradiologists.

I've also been bothered by (neuro)radiologists who write MRI reports like pathologists. A frequent scenario that comes to mind is an older adult with vascular risk factors, white matter hyperintensities and an impression on the MRI report that includes "gliosis." How does a radiologist know that there is gliosis? The neuropathological correlate of white matter hyperintensities in a distribution that looks like small vessel disease is white matter rarefaction or ischemic demyelination. Although I have research projects in neuroimaging, I'm actually skeptical of many neuroimaging findings. I'm biased because I'm interested in rad-path correlation.

 

[oopsy]

How does a radiologist know that there is gliosis? The neuropathological correlate of white matter hyperintensities in a distribution that looks like small vessel disease is white matter rarefaction or ischemic demyelination. Although I have research projects in neuroimaging, I'm actually skeptical of many neuroimaging findings. I'm biased because I'm interested in rad-path correlation.

And hence, "lesion could be consistent with demyelination, microvascular angiopathy, neoplasm, or atypical infection. Clinical correlation recommended."

 

[NWwildcat2013]

Are there any novel neuroimaging modalities starting to be used that neurologists could capture and bill for?

 

[kchan99]

Are there any novel neuroimaging modalities starting to be used that neurologists could capture and bill for?

Neuromuscular ultrasound