Other Mds Reading Images?

[medstud721]

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APPARENTLY, UNDERCOMPENSATED PRIMARY CARE PHYSICIANS ARE ATTEMPTING TO INCREASE THEIR COMPENSATION BY VIEWING, INTERPRETING AND BILLING FOR CERTAIN X-RAYS, ETC THAT THEY ORDER. IT IS NOW LIMITED TO SOME SMALL PCP GROUPS IN CALIFORNIA(I'VE SEEN IT FIRST HAND).

ALSO, WORD IS SOME ORTHOS ARE DOING THIS WITH MUSCSKEL MRI, AS WELL AS NEUROS/NEUROSURGEON WITH BRAIN/NEURO MRI. THESE GROUPS VERY OFTEN DISAGREE WITH RESPECTIVE RADS ON INTERPRETATION AND APPARENTLY THEY FEEL AS QUALIFIED TO READ THEIR OWN FILMS--UH, AND BILL FOR THEM.

GREED?

WHO KNOWS

 

[Rads Resident]

It happens and it's ill-advised. I'm admittedly biased, but consider this. Mistakes will happen (they always do) and legal defense is based on "standard of care". The standard of care is clearly to have a board-certified radiologist perform the studies. Without that, the clinician is asking to be hung out to dry.

 

[droliver]

Sure sounds like a lot of liability for the PCP's reading CXR's. A delay in diagnosis for a lung CA you miss on xray could be very expensive. I don't know if their malpractice carriers will cover them for this or no.

As far as some of the other specialties...... I think its pretty well established that a number of them can safely interpret their own speciality imaging without 3rd party interpretations (OBGYN-pelvic ultrasound, orthopedists- plain films & some musculoskeletal MR/CT, Plastic Surgeons - hand films/craniofacial CT/MR, trauma surgeons- FAST ultrasound, cardiologists- ultrasound/arteriograms, Vascular surgeons- ultrasound/arteriograms). I would defend the right of neurologists & neurosurgeons to do their own reads as it is included as part of their accredited training process.

 

[eddieberetta]

General plastic surgeons, the same guys doing boob jobs and lipo doing primary reads on craniofacial CT and MR??? You have to be kidding. I have never heard of this in N. America. What hospital are you talking about?

As for neuro, it is impt to recall that ENT, neorological / systemic and neurosurgical pathologies must all be covered. Other training programs by themselves do not cover the full spectrum of clinical neuroradiology. Just my opinion, as a future radiologist -- ignore it if you like.

Also, note that in many cases, when other specialists do imaging, they become imaging specialists themselves, much like limited (anatomically) radiologists (i.e. echo guys, some OB guys). What I really object to is people trying to read the VERY LIMITED number of scans done on their own patients. The volume is very limited, as is the person's experience. There is inappropriate self-referral. And these people do not keep up with the state of the art. Leave it to the pros... it is in patients' and practitioners' best interests.

 

[droliver]

eddie,

craniofacial imaging for planning the repair of fractures, congenital palate defects, etc.. is routinely interpreted by the plastic surgeons who do those kind of operations. You don't really need a 3rd party diagnostic read for them for that purpose (they actually all do get read out b/c they're almost uniformly done in the hospital, but that information is not much use in this context). In point of fact, many plastic surgeons no longer do facial fractures or pediatric/adult cranifacial work (there's not much money in it), the ones that do however tend to be very fluent in the imaging of these abnormalities.

I certainly agree with your point about how the volume of studies interpreted is important as a benchmark for non radiology trained specialists. Most of these studies I refer to in the general surgery fields (plastics, hand, vascular) actually do get radiologist read outs (with the possible exception of hand films if you have a machine in your office - a very rare setup for plastic or general surgeons who do hand). I was refering to the point that these subspecialists get to the point where someone else's read of their study gets to be superfluous for the clinician.

 

[eddieberetta]

Hi droliver,

Your point is well taken about surgical planning scans (especially those done after the lesion was already spotted on other imaging) are lower yield in terms of the radiologist's report. But cases where the added expertise makes a difference are impossible to predict. If you have access to the experts, may as well use them I think. Also, the high quality imaging coming from the radiology department -- the latest sequences etc. -- is because the radiologists have kept on top of the latest advances in imaging protocols/technique/technology.

Although other clinicians often become very fluent in imaging related to the pathology they generally treat, it isn't their focus. I feel that their training is not as standardized especially in regards to other pathologies (i.e. those "covered" by a different specialist) that must be considered.

In my own experience, I have seen very collegial relationships between radiologists and other doctors (esp. surgeons) -- something I hope will continue as I become a Rads resident and someday an attending.

 

[MacGyver]

From what I understand, chiropractors also read their own x-ray films.

Most of them choose to pass them on to radiologists, but technically they are allowed to do it on their own if they want to.

 

[oldandtired]

Private insurance will in most cases only allow a board certified radiologist to bill for an imaging procedure.

 

[QuietSylph]

I considered entering rads for awhile but ultimately opted for pathology instead. My reasons were many, but I wanted to bring up one of the issues that resonated with me.

In particular, I felt uncomfortable with the endemic attitudes about the accuracy of radiologists at my large, well-known teaching hospital. There, no one waited for the radiologist to dictate a report. The vast majority of the time, films were read by whatever doctor ordered them, and treatment decisions were then made on the spot. Once the radiology reports came in, I was usually the only one to actually read them. Frequently I couldn't conclude anything because of the verbal hedging, and rarely was any sort of differential dx proposed. I know this has become a shield of sorts for medicolegal reasons, but it was still frustrating to encounter.

Often there were arguments between specialists - e.g., an ENT attending and the Neuroradiologist on whether or not a cribriform plate fracture was evident in a patient with known CSF leak (the Neuroradiologist hadn't noticed it, but then finally agreed that it was there). Or the general surgeon who came downstairs to prove a point; he hand-selected a radiologist he felt was competent to re-read an abdominal CT, because he was tired of having clear cases of appendicitis being misread as normal by other radiologists. He became so angry he discussed this with the chief of staff. I was (and am) no expert, but when the pivotal details on each of the above images were pointed out to me, it did seem like stuff was being missed. The very thought gave me chills. Our radiologists are sharp people with solid training and decades of experience. The sheer volume they see is incredible. So how could this happen? (And no, I don't have an answer.)

During noon conference, I also found it unnerving that many radiology residents identified anatomy on images less well than I did. I've excelled over the years in certain medical arenas, but anatomy was not my high point. Why aren't these former gunners with a couple years of rads under their belts impressing me with a solid foundation in the basics?

Don't get me wrong. I think radiology is a great field, and an intensely important one too. But I worry that as our technologies improve and images become easier to decipher, docs will be even LESS interested in having radiologists read the images because the non-rads docs will grow increasingly confident in their own abilities. This could eventually have a serious impact on the demand for radiologists, and I could see the future "standard of care" being modified to reflect this.

What say you? Have any of you noticed these sorts of attitudes at your teaching hospital?

 

[wundabread]

I have noticed the vexing and freqently useless dictation reports, but I would also say there is a tendency to over-read questionable tiny areas of pathology while missing the one important finding on the film, or not even commenting on the indication for ordering the film in the first place.

When I see a list of 5 clinically insignficant or highly unlikely pathologies that "may be present" and the laundry list of recommended follow-up studies, not to mention the ever present "clinical correlation of findings is recommended," I get really annoyed. It is good to be thorough, but it's just by nature such a wishy-washy document that I can see why it wouldn't be too hard to ignore. Not to mention that the same film read by 2 radiologists will frequently get conficting readings.

This is not to downplay the amazingly tiny findings that can end up being significant. We have some excellent radiologists, but the above problems have recently been discouraging me from persuing radiology despite my enthusiasm for the topic.

 

[oldandtired]

In response to the above two posters.

Clinicians have a very narrow focus when they look at films. Radiologists inspect the films globally regardless of what the clnical presentation is. They are responsible for every detail on the film. They are trained in detecting pathology across organ systems and modalities.


As technology advances imaging studies become much more complex and detailed. You need knowledge of pathology and the principles of how the particular imaging modality works. You need to be able to distinguish artifact from real pathology.


I do not know why the radiologists are missing so much at your institution. Perhaps giving them a more detailed history would help. Frequently imaging findings can be very subtle and without an appropriate history they can be ignored.

Hedging may seem like the radiologist is not confident or is covering his ass. Remember that radiology is very sensitive at detecting pathology but poor at specifically defining it. Therefore frequently confirmatory tests are needed. In clinical medicine you rarely make the diagnosis with one lab test.