Neuroimaging

[Bonobo]

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I don't accept the ASN certificate of neuroimaging--and I doubt most hospitals would either. I think there should be a neuroradiology CAQ within neurology, much as there is in radiology (i.e. certified by the American Board of Psychiatry and Neurology) that should take 2 years. This is precisely the accreditation that is being blocked. The analogous situation in cardiology would be a cardiologist reading cardiac CT's and MR's which is going to be commonplace. If we can do this, why not the former?

The fact that Bhakshi (sorry that I mixed up BW and MGH, but that doesn't change the point) does mostly MS work gets to my second point about neuroimaging in neurology. An MS expert should be allowed to be a neuroimager for MRI's that are monitoring the progress of an MS patient. I suspect that this entire issue is going to blow-up into a large turf war very soon as MRI becomes the defacto standard in evaluating acute stroke. Who will evaluate the PWI-DWI images, the HARM images, etc to figure out when a patient needs a particular treatment versus another? And who will bill for this evaluation? What if someone invents an MR based "brain stress test"? Or how about using fMRI to monitor rehabilitation? As far as I can tell, most of the major academicians studying the clinical use of fMRI are neurologists.

It is this latter scenario that I am really interested in hearing thoughts on from radiology residents. I sense a very defensive tone from the newer posts above, making me think that this is more of a political, money driven turf issue that has gotten many of the radiology residents worried about the future. I don't intend to move neuroradiology into neurology, but trust that in certain scenarios, we might be better off having the neurologists read MR's and CT's. If you still think that all neuroimages should only be officially evaluated by radiologists in all situations, then please plead your case.

B

 

[f_w]

I think there should be a neuroradiology CAQ within neurology, much as there is in radiology (i.e. certified by the American Board of Psychiatry and Neurology) that should take 2 years. This is precisely the accreditation that is being blocked.

On what level ? Has the ABPN proposed such a CAQ to ACGME ?

Who will evaluate the PWI-DWI images, the HARM images,

A radiologist (in the ideal case a neuroradiologist).

to figure out when a patient needs a particular treatment versus another?

The neurologist who has examined the patient, has discussed the treatment options with the family/patient and is willing to bear responsibility for the treatment decision.


This whole discussion about neuroimaging by neurologists is not about who reads the stroke-MR at 5am. There is no money in off-hours stroke imaging. This discussion is about self-referred imaging of marginally symptomatic patients during office hours (the cardiology way). Stroke imaging is the camels nose, self-referred imaging at a facility the neuro group owns a share is the camel.

The folks at your professional society are a bit more honest about this. They want to get the additional income from imaging into neurologists pockets so they can attract the cream of graduating medschool classes into the specialty.

 

[eddieberetta]

If you still think that all neuroimages should only be officially evaluated by radiologists in all situations, then please plead your case.

B

(First of all, we are not pleading -- in reality any licensed physician in the US can do any procedure they feel like. These are reasons I feel non-radiologists should consider.)

We have given you many reasons why we feel that neuroradiology should be a part of radiology. Radiologists receive the most training and experience in the performance (including physics, artifact etc), and interpretation of these tests. We have expereince with all pathologies encountered by region of the body and across all organ systems (which is what gets imaged) rather than by specialty (surgical, neurological, endocrine etc. etc.) which is how clinicians are trained.

Furthermore, I feel that cherry picking cases will erode the ability of radiologists to maintain competence, which I feel is a valid issue.

I also feel that if a radiologist is available, then hospital should utilize their expertise to interpret imaging tests. Just like if a hospital has a vascular surgeon, they usually will avoid having their general surgeons perform vasc. surgery.

As for the idea of a full length 2-3 y fellowship in neuroimaging for neurologists, this is feasible but will not I suspect be popular due to the length. Most specialty groups are talking about doing imaging without additional training, claiming that they are already well trained in imaging, which is not true. I also am concerned that by training non-radiologist neuroimagers, the supply of radiologists available to provide on-call services will be reduced (these imagers can only provide neuroimaging). I am much more in favor of training neurologists in 3 years to get full BC in radiology, but that will be even less popular.

 

[Bonobo]

We may disagree on the 2-year neuroradiology question leading to a CAQ accepted by the ACGME for neurologists (and despite neurologists being allowed to do neuroimaging, a board sanctified CAQ is very important for several reasons as I have mentioned above), but I appreciate your comments. I agree that most neurologists will find an additional 2 years to be unpopular--but as neuroimaging becomes even more important in the management of many common neurological illnesses, I suspect that there may be several neurology residents who would be interested in this plan.

The 3 year BC in radiology post internship and further clinical training is a great idea for those who want to be full neuroimagers but maintain clinical interest as well. However, spending 7 years (and most likely another 1-2 more to develop specific expertise in neuroradiology and a subspecialty of neurology) would be prohibitive to many. Nevertheless, I know of 2 neurology residents that have done this (one spent 10 years to become a double-board certified interventional neurologist!), and have heard of few others as well. I personally think this a great path for academic neuroimagers, and may consider it myself, but is obviously too much to ask for someone interested in private neurology.

You have all made me question my beliefs about neurologists doing their own neuroimaging, but I still wonder if there couldn't be some easier way of certifying stroke neurologists to read (and bill for) their own MRI's and CT's in the setting of acute stroke. Am I wrong, or are stroke neurologists still not able to bill for their own interpretations of head CT's during acute stroke at most institutions and hospitals? I doubt that this would hurt the supply of radiologists out there, and think that the analogous situation is the cardiologist reading a patient's EKG to evaluate their treatment of AMI.

B

 

[eddieberetta]

I doubt that this would hurt the supply of radiologists out there, and think that the analogous situation is the cardiologist reading a patient's EKG to evaluate their treatment of AMI.

B

I don't know if that is a typo or what, but the analogous situation would be an ED of FP doc reading a patient's EKG and billing for it. In most hospitals, the EKGs are saved and read by a cardiologist days or weeks later (in my experience, it is much worse than xrays now), and the ED and FP do not get paid for their interpretation. However, hospitals credential the cardiologists to provide the final reads.

I do not wish to comment on how useful this is in the ECG realm.

In the x-ray world, we now usually read the ER films within 3-12 h, and there is a healthy mix of missed pathology picked up by us, and the odd fracture that the ED picks up that honestly I would have missed (of course sans history) (I am willing to admit it, but I am also confident that that is the exception rather than the rule, even without clinical info, and I am still in residency).

Back to head CTs -- you are correct that most hospitals do not let the stroke neurologist bill for it. I believe this is appropriate, because as I have said before, many pathologies can present clinically as a stroke, not all are familiar to the stroke neurologist. And I feel it is patently unreasonable to expect the radiologists to stand around as a "back-up" in case something pops up that the ordering physician is uncomfortable with interpreting, but otherwise forego the billing in "straightforward" cases.

And very importantly, even if a stroke neurologist were to undergo the training to read head CTs (all pathologies, "medical-neurological" and otherwise), in the day-to-day imaging of his own patients, I do not think he would see enough cases to maintain good competence. And let's remember that in terms of professional development, he is going to focus on stroke, and stroke imaging, not neuroimaging. To be a good film-reader, he would have to devote a significant part of his practice to reading films, many more films than patients he could possibly see -- which is what radiologists do! And is the busy clinician who reads a few scans per week going to ensure that the radiology department is properly equipped, that the images are of top quality, and that the latest techniques are being used?

I think we should tread carefully. Imaging could easily be carved up, but I believe quality would suffer.

 

[Bonobo]

As someone who is willing to train for 10 years, I appreciate your arguments in favor of radiology--I might have to use them to explain why I put myself through that much residency time. But allowing a stroke neurologist to bill for stroke imaging has important advantages that you should still consider:

First, I don't think the analogous situation is an IM or FP (or ED) doc reading an EKG. The critical and detailed treatment decisions will be made by a cardiologist for AMI's, not the other doctors. Similarily in stroke, the critical decisions will be made by the neurologist, not any other doctor. Regardless of whether they bill for it or not, the neurologist will be trained and will proceed to read the CT or MRI immediately in the setting of acute stroke to plan their treatment--I doubt they will wait for the radiologist in most settings. This is due to the practical need to treat as soon as possible in order to secure better outcomes ("time is brain"). This situation will be especially important in places that don't have neuroradiologists on call (and even more in places that don't have radiologists on call!). So a stroke physician will likely need to be well trained to read the imaging to manage their patients acutely.

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke. Suddenly, stroke physicians would be willing to spend 2 years in fellowship post residency securing far more training in CT and MRI than they would have gotten from their typical 1 year fellowship (I argue that one needs only 1 additional year to learn stroke imaging rather than the 2 for complete neuroradiology training). This would likewise translate to far better care of stroke patients given above. The billing structure might simply be a extra fee in the compensation to a stroke neurologist when reading a head CT or MRI in the setting of acute stroke--not a difficult thing to add. Without this, I fear that neurologists will not get this training, keep stroke imaging dependent on radiologists and lead to increased time to thrombolysis or other treatments. Even an extra 30 minutes makes a difference in outcomes, and this is likely to be even more true as the time window for treatment of stroke extends to 12 hours in the coming years with many more options than simple IV tPA.

The analogous situation again is the cardiologist determining the treatment for an AMI patient and being able to read all, bill for, and interpret all the necessary data available him or herself. Such a situation is not necessary at large academic institutions with their own comprehensive stroke centers, but will be in community hospitals.

B

 

[f_w]

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke.

You seem to have an unrealistic expectation about the professional fee for the interpretation of a head-CT.

If you want the stroke neurologist to bill the imaging, he should also be obliged to interpret all the other CNS imaging studies obtained by the ED (all the head CTs for 'AMS' and other results of CYA medicine).

 

[Bonobo]

Last I checked, professional fees for head CT's and brain MRI's range from around $50 per scan to $200 per scan depending on whether one uses contrast, does 3-d reconstructions, looks at angiography, checks perfusion images, etc. While right now all we typically do is a non-con head CT (fee ~$50), I think there is a good chance that we will be doing MRI's with PWI/DWI images and probably angiography in the future with fees of around $200 each instead. Add another fee for follow up imaging which may also become standard of care in the future. This would all be in addition to fees for consultation, thrombolysis if used, ultrasound/dopplers if used, and post-care management.

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

B

 

[f_w]

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

Enjoy !
(and look forward to be called 10-20 times per night to read another 'usually delusional, now paranoid delusional, r/o stroke' CT)

 

[eddieberetta]

And by the way, I wouldn't mind if a neurologist (who has had adequate training--see above) were required to read other brain scans in the ED when they were on call in the ED for stroke and other neurological issues.

B

Firstly I doubt many fellowship trained stroke neurologists are that interested in doing another lengthy fellowship.

Secondly, if your hospital hires a general surgeon and then tells them "our FPs and EPs do all the appys and choles" (ct heads), we just need you to do the colostomies and bowel resections (necks, temporal bones) and help out the FPs and EPs if they have a question" they will tell you to take a hike. As a condition of signing on, they will take over the procedures that traditionally fall in their expertise. You want to provide your hospital/ED with imaging? You had better be prepared to do it all I mean barium enemas all) because your radiologists will leave.

 

[Docxter]

Last I checked, professional fees for head CT's and brain MRI's range from around $50 per scan to $200 per scan depending on whether one uses contrast, does 3-d reconstructions, looks at angiography, checks perfusion images, etc. While right now all we typically do is a non-con head CT (fee ~$50), I think there is a good chance that we will be doing MRI's with PWI/DWI images and probably angiography in the future with fees of around $200 each instead. Add another fee for follow up imaging which may also become standard of care in the future. This would all be in addition to fees for consultation, thrombolysis if used, ultrasound/dopplers if used, and post-care management.

B

You must not know much about reimbursement. These fees are what is on paper. The amount that you will actually be able to collect in the end usually varies between 35% to 70% of the published fees. Plus you mentioned the repeat studies, the majority of which will be done for free since the third party payors and their DRGs have a limit on what they will pay. So for the 10 CT/MRIs that a patient gets in the hospital, you'll be probably be paid for 2-3 of them. The rest is pretty much done for free. Income often comes from well-insured outpatients.

BTW, perfusion MRI and perfusion CT are NOT reimbursable. You only get paid as much as a regular contrast MRI or CT. Depending on your carrier, you may be able to get a very small reimbursement for postprocessing. Spectroscopy is NOT reimbursable either in any form.

 

[INR]

I am not trying to reopen the original debate...I am just wondering if there are alot of neurologists in private practice who are reading their own films (without getting sued.) I know that there are Neuroimaging fellowships for Neurologists, which I believe are different than fellowships for neurointerventional. For someone like me, whose only interest in Radiology is neuro, and who also wants patient interaction, this seems like a dream come true.

Any thoughts from those in the know? Thanks!

You can check out the ASN website - asnweb.org for additional info. There is plenty to go around, and you should have no difficulty doing neuroimaging after a neuro residency - your opportunities are more plentiful in private practice though. Except for the Buffalo group and Dr Bakshi at Harvard, I don't know of anybody else in neurology that does the CT/MRI stuff in academic setting. There is a better market for neurologists to do angio/endo work in the academic setting

 

[INR]

Now imagine if a stroke doctor could bill for neuroimaging in the setting of acute stroke. Suddenly, stroke physicians would be willing to spend 2 years in fellowship post residency securing far more training in CT and MRI than they would have gotten from their typical 1 year fellowship (I argue that one needs only 1 additional year to learn stroke imaging rather than the 2 for complete neuroradiology training).
B

Why the extra-training? Some neurology residencies are structured that they get plenty of neuro-imaging even at the resident level. You need to do extra-time if you want to learn the endovascular procedures - one to two years at most.

 

[eddieberetta]

Why the extra-training? Some neurology residencies are structured that they get plenty of neuro-imaging even at the resident level. You need to do extra-time if you want to learn the endovascular procedures - one to two years at most.

This is exactly what I mean. The discussion of advanced training is almost moot because while there is no standardization of imaging training at the residency or board level in these specialites, people will claim they have all this expertise just from doing a non-radiology residency. There is no standardization, and it is a guarantee that these people have little or no experience with pathologies outside the realm of neurology. Reviewing the results of your patients' scans does not constitute a radiology residency. This is whay hospital credentialling committees, and now some insurance payors won't buy it.

 

[Bonobo]

The thing about my hope for a 1 (for particular applications) vs 2 (for all neuroradiology) year neuroradiology fellowship for neurologists is that it was a way for them to have to endure the standardized, rigorous training that radiologists get. It is part of vision for American medical training that allows multiple specialties to get training in the fellowship programs fighting the constant turf wars out there. The leaders of INR had this vision and the results have been fairly impressive to me so far. Diagnostic neuroradiology could take a similar route. Note that this is not just a problem in neuro. Currently EM docs are not allowed to get boarded in critical care, though they get quite a bit of relevant training and would likely get the remainder via their critical care fellowship.

Saying that a neurologist could simply do neuroimaging from their residency training is like saying that a neurosurgeon could do endovascular procedures without ever doing an interventional fellowship. The problem is simply that errors are dependent on an operator/imager's experience and training. To best minimize errors, one has to train an operator/imager with a sufficient number of cases in a standardized format.

B

 

[Koil Gugliemi]

Most neurologists do zero training in head and neck/ENT radiology. These things are on every head MR, and bad stuff often lives in the spaces of the neck. Also, while I agree that neurologists see alot of images in their training, the average rads resident probably sees more images on their first neurorad month than the average Neuro resident sees in their residency. (by time you do your 1 hour history and physical, and look a the images, I'm through a wide range of studies...and so on for ever hour)

 

[bugmenot]

Most neurologists do zero training in head and neck/ENT radiology. These things are on every head MR, and bad stuff often lives in the spaces of the neck. . .

which is why gastroenterologists shouldn't be doing virtual colonoscopies . . . but ultimately it falls on the the lack of public exposure by radiologists so that the general public demands a trained professional interprets imaging