Radiologist assistants?

[Steve_Zissou]

Under new legislation, Medicare would cover radiology assistants’ services in all settings

Absent passage of HR 3657, the profession is “in peril,” with RAs losing their jobs and left unable to practice to the full extent of their training, advocates said.

www.radiologybusiness.com

Perhaps I’m misunderstanding what radiologist assistants do, but this sure sounds like opening up the midlevel can of worms for DR.

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[maxxor]

Under new legislation, Medicare would cover radiology assistants’ services in all settings

Absent passage of HR 3657, the profession is “in peril,” with RAs losing their jobs and left unable to practice to the full extent of their training, advocates said.

www.radiologybusiness.com

Perhaps I’m misunderstanding what radiologist assistants do, but this sure sounds like opening up the midlevel can of worms for DR.

It is. It’s a very bad idea. The ACR is being extremely stupid.

 

[Cognovi]

Under new legislation, Medicare would cover radiology assistants’ services in all settings

Absent passage of HR 3657, the profession is “in peril,” with RAs losing their jobs and left unable to practice to the full extent of their training, advocates said.

www.radiologybusiness.com

Perhaps I’m misunderstanding what radiologist assistants do, but this sure sounds like opening up the midlevel can of worms for DR.

The midlevel can of worms for what this proposes is already opened for PAs and NPs who can already do radiological procedures under direct supervision, which is mostly light IR procedures. I suppose this would also apply to doing diagnostic procedures like a barium swallow. Essentially take the model from the status quo of ultrasounds (the sonographer takes the images) and apply it to fluoro studies. This legislation applies it to hospitals (beyond the current application to outpatient non-hospital settings).

 

[Steve_Zissou]

It is. It’s a very bad idea. The ACR is being extremely stupid.

The midlevel can of worms for what this proposes is already opened for PAs and NPs who can already do radiological procedures under direct supervision, which is mostly light IR procedures. I suppose this would also apply to doing diagnostic procedures like a barium swallow. Essentially take the model from the status quo of ultrasounds (the sonographer takes the images) and apply it to fluoro studies. This legislation applies it to hospitals (beyond the current application to outpatient non-hospital settings).

Seems like the ACR and big academia are pushing for it. Looks like there’s going to be a talk tomorrow at 8PM about it. Do radiologists really have to try to go the way of ER and anesthesia? I thought DR would be mostly free from this creep, but looks like I’ll be having to fight it still once I become an attending.

 

[maxxor]

The midlevel can of worms for what this proposes is already opened for PAs and NPs who can already do radiological procedures under direct supervision, which is mostly light IR procedures. I suppose this would also apply to doing diagnostic procedures like a barium swallow. Essentially take the model from the status quo of ultrasounds (the sonographer takes the images) and apply it to fluoro studies. This legislation applies it to hospitals (beyond the current application to outpatient non-hospital settings).

There’s more to it than that. The RRAs would be able to bill and final sign many procedures. A careful reading between the lines of the MARCA legislation creates a new mid level with the ability to independently bill Medicare. Their reimbursements would be redirected to the “supervising” radiologist, but that can be changed at any time. It literally just changed for PAs as a class this past year.

Sonographer model is what they want you to think it is.

 

[maxxor]

There’s more to it than that. The RRAs would be able to bill and final sign many procedures. A careful reading between the lines of the MARCA legislation creates a new mid level with the ability to independently bill Medicare. Their reimbursements would be redirected to the “supervising” radiologist, but that can be changed at any time. It literally just changed for PAs as a class this past year.

Sonographer model is what they want you to think it is.

If you are an ACR member, there are many threads on Engage about it.

 

[Taurus]

Not a problem as long as radiologists do not preferentially hire a particular midlevel group and become beholden to them like anesthesiologists have with CRNA’s.

 

[maxxor]

Not a problem as long as radiologists do not preferentially hire a particular midlevel group and become beholden to them like anesthesiologists have with CRNA’s.

Disagree.

The risk here is corporate employers hiring the mid levels and expecting you to work with / teach them. This happens in anesthesia where the hospital employs the crnas but expect the anesthesia group to supervise.

Once the precedent has been set that an imaging interpretation mid level can exist and is sanctioned by the ACR, expect to be reading out 4 mid levels all day long. Maybe you will be lucky and your group hires and fires.

Private equity buying practices wasn’t enough. The ACR has decided to sell the entire specialty.

 

[Taurus]

As I’ve said in other threads, midlevels are used in radiology for scut work and low level procedures. They’re not economical to read imaging studies. Most practices would not feel comfortable having them do advanced procedures like TIPS. To further minimize their threat to radiology, don’t rely on any one group. My group would not consider hiring RA’s. There’s no significant benefit to hiring them over PA’s. At least with PA’s, they are a proven product and you pretty much know what you are getting. I wouldn’t lose any sleep if RA’s getting more Medicare coverage similar to PA’s and NP’s. Groups are not knocking down the door to hire them. If PA’s or NP’s become a threat to radiology like CRNA’s, I have no problem hiring RA’s instead and vice versa.

That was the great mistake of anesthesiology. They supported and empowered a single midlevel group for so long because anesthesiologists couldn’t imagine that CRNA’s would stand up one day and say we don’t you need you anymore. The anesthesiologists are trying to dig themselves out of that hole by throwing their support behind AA’s but it’s a slow, hard slog because CRNA’s are entrenched and well-connected, well-funded politically.

All medical groups need to learn the lessons of anesthesia and vow to never repeat it.

 

[maxxor]

As I’ve said in other threads, midlevels are used in radiology for scut work and low level procedures. They’re not economical to read imaging studies. Most practices would not feel comfortable having them do advanced procedures like TIPS. To further minimize their threat to radiology, don’t rely on any one group. My group would not consider hiring RA’s. There’s no significant benefit to hiring them over PA’s. At least with PA’s, they are a proven product and you pretty much know what you are getting. I wouldn’t lose any sleep if RA’s getting more Medicare coverage similar to PA’s and NP’s. Groups are not knocking down the door to hire them. If PA’s or NP’s become a threat to radiology like CRNA’s, I have no problem hiring RA’s instead and vice versa.

That was the great mistake of anesthesiology. They supported and empowered a single midlevel group for so long because anesthesiologists couldn’t imagine that CRNA’s would stand up one day and say we don’t you need you anymore. The anesthesiologists are trying to dig themselves out of that hole by throwing their support behind AA’s but it’s a slow, hard slog because CRNA’s are entrenched and well-connected, well-funded politically.

All medical groups need to learn the lessons of anesthesia and vow to never repeat it.

Scope creep is a thing. Now it’s scut. Next it’s “radiographs”, then it’s nodule follow up.

once you open the door to interpretation, it’s never getting closed.

The RRA will have imaging training. Other mid levels don’t currently.

 

[Ho0v-man]

As a former rad tech, I can’t imagine any tech feeling remotely comfortable interpreting imaging. There is literally zero education on this in their schooling. Rad techs aren’t nurses. They’re not brainwashed into thinking they’re just as good as doctors. In fact, there’s a huge emphasis in school that they’re NOT qualified to interpret imaging. I imagine the common sense of this bill is just for them to be able to interpret the normal fluoro studies they do and run the abnormals by the doc.



But we should all realize where this is going. Wouldn’t be surprised if the long term plan here is to get AI to generate a garbage report and have the RRA sign off on it. Yeah it’ll be garbage care and lots of people will die, but at least admin will make money. That’s all anyone cares about anyway smh.

 

[Taurus]

Scope creep is a thing. Now it’s scut. Next it’s “radiographs”, then it’s nodule follow up.

once you open the door to interpretation, it’s never getting closed.

The RRA will have imaging training. Other mid levels don’t currently.

I’m not going to repeat what I’ve said in earlier threads. You can do a search. People can believe whatever they want. If someone is that worried about midlevels or AI, then don’t go into radiology. I’m a practicing radiologist with more than 6 years of private practice experience now. I am actively involved in our AI initiative. I’m not worried about either. I’m more worried about the corporatization of radiology and medicine in general. I would still recommend medicine and radiology to most people. It’s a great career.

 

[Tiger100]

I’m not going to repeat what I’ve said in earlier threads. You can do a search. People can believe whatever they want. If someone is that worried about midlevels or AI, then don’t go into radiology. I’m a practicing radiologist with more than 6 years of private practice experience now. I am actively involved in our AI initiative. I’m not worried about either. I’m more worried about the corporatization of radiology and medicine in general. I would still recommend medicine and radiology to most people. It’s a great career.

Agree with above.

The biggest threat to radiology and medicine in the next decade will be decreased reimbursements and corporatization of medicine.

Decreased reimbursements is a real thing especially giving current level of inflation. With a hospitalist level salary most people could afford a nice house in nice neighborhood in 2000s. Not anymore.

This is my prediction: The reimbursements will stay unchanged or slightly increased in the next decade but the inflation will be on average 3-4% (or even more). So 10 years from now the real salaries of physicians will be about half of current numbers. The government doesn't need to cut our salaries. Just the inflation will take care of everything.

 

[maxxor]

I’m not going to repeat what I’ve said in earlier threads. You can do a search. People can believe whatever they want. If someone is that worried about midlevels or AI, then don’t go into radiology. I’m a practicing radiologist with more than 6 years of private practice experience now. I am actively involved in our AI initiative. I’m not worried about either. I’m more worried about the corporatization of radiology and medicine in general. I would still recommend medicine and radiology to most people. It’s a great career.

I’m also an attending and have 14 publications on AI and a patent. I’m not talking about AI. I’m talking about the sudden drop in labor needs when you can hire 4 mid levels for the prior price of 1 radiologist. Even more when they don’t even need to be read out! I know now you don’t think it’s necessary but should they drop our RVU conversion factor to $20, I can see groups seeking it out as a short term bridge until AI matures.

I’m not as far out as you (2 years) but have a more dismal view of the future of the specialty.

I fear corporate VC/PE backed destruction of the field. Interpreting mid levels play so perfectly into their strategies that it’s almost too good to be true. The ACR has become beholden to these forces much like ACEP has.

I’ve seen PE destroy previously very desirable groups. I’ve seen groups that swore up down left and right that they’d never sell, suddenly drop it on their associates that they are selling and lose contracts, have layoffs, and cause people to leave.

The biggest threat to a newly acquired practice is being unable to staff the new place due to turnover. Well, pack a bunch of mid levels in, and it’s not so hard to staff now is it.

 

[Taurus]

I’m also an attending and have 14 publications on AI and a patent. I’m not talking about AI. I’m talking about the sudden drop in labor needs when you can hire 4 mid levels for the prior price of 1 radiologist. Even more when they don’t even need to be read out! I know now you don’t think it’s necessary but should they drop our RVU conversion factor to $20, I can see groups seeking it out as a short term bridge until AI matures.

I’m not as far out as you (2 years) but have a more dismal view of the future of the specialty.

I fear corporate VC/PE backed destruction of the field. Interpreting mid levels play so perfectly into their strategies that it’s almost too good to be true. The ACR has become beholden to these forces much like ACEP has.

I’ve seen PE destroy previously very desirable groups. I’ve seen groups that swore up down left and right that they’d never sell, suddenly drop it on their associates that they are selling and lose contracts, have layoffs, and cause people to leave.

The biggest threat to a newly acquired practice is being unable to staff the new place due to turnover. Well, pack a bunch of mid levels in, and it’s not so hard to staff now is it.

I’m not losing any sleep about midlevels reading imaging studies. Since you’re an attending, why don’t you suggest to your group to hire midlevels and allow them to read imaging studies independently with the aid of AI? Then come back and let us know what your group’s response is.

 

[maxxor]

I’m not losing any sleep about midlevels reading imaging studies. Since you’re an attending, why don’t you suggest to your group to hire midlevels and allow them to read imaging studies independently with the aid of AI? Then come back and let us know what your group’s response is.

I have no desire to let midlevels read.

But if reimbursements get cut and my group decides to sell (which they did during covid and is why I left that place), the temptation to boost revenue at the cost of quality may no longer be their decision to make if they no longer own the practice.

 

[Taurus]

I have no desire to let midlevels read.

But if reimbursements get cut and my group decides to sell (which they did during covid and is why I left that place), the temptation to boost revenue at the cost of quality may no longer be their decision to make if they no longer own the practice.

This sounds more like paranoia than reality. I’ve already mentioned in prior threads why midlevels reading independently is not economically or medicolegally viable for any practice. AI does not change that equation.

 

[Tiger100]

I’m also an attending and have 14 publications on AI and a patent. I’m not talking about AI. I’m talking about the sudden drop in labor needs when you can hire 4 mid levels for the prior price of 1 radiologist. Even more when they don’t even need to be read out! I know now you don’t think it’s necessary but should they drop our RVU conversion factor to $20, I can see groups seeking it out as a short term bridge until AI matures.

I’m not as far out as you (2 years) but have a more dismal view of the future of the specialty.

I fear corporate VC/PE backed destruction of the field. Interpreting mid levels play so perfectly into their strategies that it’s almost too good to be true. The ACR has become beholden to these forces much like ACEP has.

I’ve seen PE destroy previously very desirable groups. I’ve seen groups that swore up down left and right that they’d never sell, suddenly drop it on their associates that they are selling and lose contracts, have layoffs, and cause people to leave.

The biggest threat to a newly acquired practice is being unable to staff the new place due to turnover. Well, pack a bunch of mid levels in, and it’s not so hard to staff now is it.

I don't think midlevels are any threat at all. Midlevels are not capable of interpreting most imaging studies.


20 years ago people used to say that an American board certified radiologist will hire 10 radiologists from India (telerad) to prepare prelim reports for him and will sign all those reports in a short period of time so it will result in dramatic decease in need for radiologists. Never happened.

What I see is the opposite. As more and more midlevels staff the primary care clinics and EDs, the number of imaging studies go higher and higher.

 

[maxxor]

I don't think midlevels are any threat at all. Midlevels are not capable of interpreting most imaging studies.


20 years ago people used to say that an American board certified radiologist will hire 10 radiologists from India (telerad) to prepare prelim reports for him and will sign all those reports in a short period of time so it will result in dramatic decease in need for radiologists. Never happened.

What I see is the opposite. As more and more midlevels staff the primary care clinics and EDs, the number of imaging studies go higher and higher.

The thing that stopped foreign telerad was CMS. If the “American soil” rule goes away, the telerad threat returns.

This is the equivalent of the ACR starting a telerad company overseas and lobbying to remove the requirement that CMS work is done on American soil.

Technically, MARCA as written does not require cosignature.

 

[Taurus]

The thing that stopped foreign telerad was CMS. If the “American soil” rule goes away, the telerad threat returns.

This is the equivalent of the ACR starting a telerad company overseas and lobbying to remove the requirement that CMS work is done on American soil.

Technically, MARCA as written does not require cosignature.

That’s good that you identified the barrier that foreign-based teleradiology couldn’t overcome and therefore it withered. Seriously, if CMS did allow teleradiology on foreign soil, do you think that it’s only radiology would be affected? The argument I made to people back then and the same argument applies today is “telemedicine”. They would try to ship every clinical field they possibly could overseas, ie, primary care, neurology, etc. Hospitals would hire a midlevel to staff onsite and the doc would be in India via video. They would even try telesurgery. Telemedicine has taken off because of the COVID pandemic. It’s not only radiologists in the future who would be against CMS changing policies.

So are there barriers to midlevels and AI in radiology? Yes. Economic and medicolegal ones that I discussed in length in prior posts. Just like what CMS did to foreign-based teleradiology, these economic and medicolegal barriers are too great to overcome for midlevels or AI to be serious threats. People who claim the sky is falling for radiology because of midlevels and AI don’t make any convincing arguments on how they can overcome these barriers. You may have published all these papers on AI, but I’m the one who actually evaluates AI in clinical practice and trying to determine if it’s worth the investment for my large group. It’s not cheap. Many companies want close to $1M. So far, I’m unimpressed for the price they want.

 

[Kuratz]

The fox is already in the hen house. Private equity groups don’t give a damn about quality. If they can hire an RA to read out X-rays or heck even CTs, ultrasounds and maybe select MRs they will. They will test the limit in the name of profit. Docs don’t control the paradigm anymore, the suits do. This is why it’s a big deal. It’s not like an employee radiologist can choose not to hire an RA. No. RadPartners or whomever will effectively replace one radiologist and hire an RA to fill the gap. They’ll push that to the limit and get away with as few radiologists as they can. They don’t care about the patients and they certainly don’t care about you. “Oh it’s no big deal, it’s just barium” is a shortsighted way to tank the job market for Rads and end up cranking out the complex, highest liability cases for a minimal amount more than those who have vastly less training than you taking the easy cases, just like the CRNAs. “Oh but in Rads any case could be tough”. Ah but see the second you open up a case you can tell if it’s a complex disaster or near-normal. Nothing to stop an RA from just leaving the ones that look like a clusterF to the rad. Quickly reading normals is what makes Radiologist money, not slogging through a disaster abdomen. So that’ll result in lower RVUs as the normals get read out by the midlevel. And the occasional miss? Well as long as the money saved outweighs the lawsuits then it’s a net profit.

These woke leaders who throw their own profession under the bus, and devalue years or training and expertise are infuriating. It totally has the potential to **** over this generation of radiologists. I would love to come back to this post in 10 years and be wrong but if this passes I am extremely skeptical the profession will remain financially solvent for those of us who had to pay our own way in med school.

 

[Tiger100]

The fox is already in the hen house. Private equity groups don’t give a damn about quality. If they can hire an RA to read out X-rays or heck even CTs, ultrasounds and maybe select MRs they will. They will test the limit in the name of profit. Docs don’t control the paradigm anymore, the suits do. This is why it’s a big deal. It’s not like an employee radiologist can choose not to hire an RA. No. RadPartners or whomever will effectively replace one radiologist and hire an RA to fill the gap. They’ll push that to the limit and get away with as few radiologists as they can. They don’t care about the patients and they certainly don’t care about you. “Oh it’s no big deal, it’s just barium” is a shortsighted way to tank the job market for Rads and end up cranking out the complex, highest liability cases for a minimal amount more than those who have vastly less training than you taking the easy cases, just like the CRNAs. “Oh but in Rads any case could be tough”. Ah but see the second you open up a case you can tell if it’s a complex disaster or near-normal. Nothing to stop an RA from just leaving the ones that look like a clusterF to the rad. Quickly reading normals is what makes Radiologist money, not slogging through a disaster abdomen. So that’ll result in lower RVUs as the normals get read out by the midlevel. And the occasional miss? Well as long as the money saved outweighs the lawsuits then it’s a net profit.

These woke leaders who throw their own profession under the bus, and devalue years or training and expertise are infuriating. It totally has the potential to **** over this generation of radiologists. I would love to come back to this post in 10 years and be wrong but if this passes I am extremely skeptical the profession will remain financially solvent for those of us who had to pay our own way in med school.

We are chasing our tails here.

Answer this question:
Why telerad companies, Radpartners or these private equities haven't used foreign Radiologists so far? Afterall nobody cares about quality and only cares about money.

If you think a PA can interpret a CT abdomen-pelvis well, you don't have enough medicine or radiology knowledge.

I always hear this argument that they(whoever) will read easy and normal cases and leave complex cases to rads. It is a very dumb argument. Really dumb that probably comes from some engineer who has no clue what's medicine about. "You don't know what you don't know". Unless you are a sophisticated radiologist, you don't know what is easy and what is hard. Differentiating a normal versus abnormal exam is a very hard task.

Let me talk you something. Most Radiologists' screw ups happen when they read an abnormal exam, normal. Otherwise, when there are 10 different sites of metastasis nobody will cause any harm to the patient by missing a few of them.

At the end of the day if you really feel uncomfortable, go to a different field.

 

[Steve_Zissou]

We are chasing our tails here.

Answer this question:
Why telerad companies, Radpartners or these private equities haven't used foreign Radiologists so far? Afterall nobody cares about quality and only cares about money.

If you think a PA can interpret a CT abdomen-pelvis well, you don't have enough medicine or radiology knowledge.

I always hear this argument that they(whoever) will read easy and normal cases and leave complex cases to rads. It is a very dumb argument. Really dumb that probably comes from some engineer who has no clue what's medicine about. "You don't know what you don't know". Unless you are a sophisticated radiologist, you don't know what is easy and what is hard. Differentiating a normal versus abnormal exam is a very hard task.

Let me talk you something. Most Radiologists' screw ups happen when they read an abnormal exam, normal. Otherwise, when there are 10 different sites of metastasis nobody will cause any harm to the patient by missing a few of them.

At the end of the day if you really feel uncomfortable, go to a different field.

Alternatively, you could feel uncomfortable with introducing midlevels into the field, lobby/voice your opinions against it, and stay in the field.

 

[Kuratz]

Answer this question:
Why telerad companies, Radpartners or these private equities haven't used foreign Radiologists so far?

To work as a teleradiologist for US hospitals you must have a state medical license for each state you interpret for. The only foreign radiologists who could do tele for these companies are American Rads abroad or ex-pats. Source: ACR State Teleradiology Licensure Requirements | American College of Radiology

If you think a PA can interpret a CT abdomen-pelvis well, you don't have enough medicine or radiology knowledge.

I very explicitly don't think a PA can interpret images appropriately. Go re-read my post. The whole point is that the PE firms don't care about quality as long as it is passable enough and the increased cost of malpractice doesn't outweigh the savings. It doesn't matter what we as Rads think; it is no longer within our control once legislated.

I always hear this argument that they(whoever) will read easy and normal cases and leave complex cases to rads. It is a very dumb argument. Really dumb that probably comes from some engineer who has no clue what's medicine about. "You don't know what you don't know". Unless you are a sophisticated radiologist, you don't know what is easy and what is hard. Differentiating a normal versus abnormal exam is a very hard task.

Nope. Sufficient experience on my end to know that Radiology is a humbling profession. As above, it doesn't matter what we think. It's a matter of what employers can get away with. Don't underestimate the hubris of noctors, either.

I'm sure the anesthesiologists thought the idea of CRNA's staffing cases independently, let alone staffing entire departments, was a pipe dream. Things can and do change. Burying your head and just calling the idea dumb doesn't prevent it from happening. Making a ton of noise about it and letting the ACR know this is a bad idea though might actually make a difference.

 

[maxxor]

We are chasing our tails here.

Answer this question:
Why telerad companies, Radpartners or these private equities haven't used foreign Radiologists so far? Afterall nobody cares about quality and only cares about money.

Because it currently won’t get paid by CMS. Academic centers are using radiologists in foreign countries who only read private payers.

If you think a PA can interpret a CT abdomen-pelvis well, you don't have enough medicine or radiology knowledge.

It’s not that we think they *can*, it’s that we think they will try. The current barrier is that they themselves don’t feel comfortable to do it. Even so, NPs have tried repeatedly to get interpretation privileges at the VA. It will happen sooner or later.

Enter the ACR which is proposing to create an imaging trained mid level. Stop thinking in terms of now but a new reality where they will have imaging training.

 

[Tiger100]

IWhy CMS banned foreign Radiologists from getting paid if the system doesn't care about quality at all and any yahoo can read CTs and MRs?

You are contradicting yourselves.

 

[Ho0v-man]

If you think a PA can interpret a CT abdomen-pelvis well, you don't have enough medicine or radiology knowledge.

No one in this thread thinks they can interpret…anything. They also can’t practice EM, anesthesiology, derm, intensive care, etc. But they definitely think they can. And PE has no interest in discouraging them.

It’s ludicrous to think that they would try this today. It was the same with the other fields, too.

 

[qxrt]

With many radiologists especially in community practice churning out sh***y reads, ignoring comparisons, skipping windows, etc., I would say today's practice of radiology is more radiologists reading at the level of midlevels than midlevels trying to read like a radiologist.

In my former group out in community practice, I had colleagues whose impressions are just a laundry list of findings with no attempt at interpretation. Or chest radiographs where every non-normal exam is a non-descript variation of "infiltrates."

If that is the standard for radiology in community practice, then midlevels will have no problem interpreting chest radiographs at the level of the radiologist. Don't need a 4-year medical school education and 5-year residency to call out "infiltrates" on chest radiograph.

I only single out community practice because that crap wouldn't fly in most academic centers. I do not mean to imply that there aren't excellent radiologists in community practice.

 

[Tiger100]

people are overreacting here big time.

While there are some bad reports out there, most reports are good quality and specialized.

Also Anesthesiologists, ER and derm and ophtho are not out of job because of midlevels.

It's better for ACR to have supervision on their scope of practice rather than letting them open their own societies.

 

[Gadofosveset]

As someone who has seen techs and RAs trained to interpret (not trained them myself, so don’t get punchy)… it’s a really mixed picture.

They can eventually get to the level of a low level radiologist. This is the truth.

BUT

- They have no range. They interpret only one kind (or a small set) of studies and cannot cover anything else
- It takes them a long long time to get to a point of weak independence. The talent pool is different. Some of these RAs are motivated to learn. Some just are not, period.
- they can’t read cross sectional at all and are basically limited to plain films. They can’t do cross modality comparisons. Cross sectional imaging is much harder to read, even if it’s second nature to trained rads. Could they do it eventually? Sure, but it will take a lot of time and effort to get to a minimum level of a basic radiologist.
- They can’t interpret EMR histories very well and certainly with not a lot of insight. This important “extra” stuff takes years and years of experience. Could you train them to do this eventually? Yes. But it will take a long long time and may not even work (depending on the individual, high school grads are not just gonna drop in and interpret an oncology note).
- The length of training for cross sectional makes it kind of unfeasible for OJT. You would need to set up an “alternate pathway” of training for these folks with constant training so they could simulate an MD looking at imaging. That really would be sealing one’s doom. I’m sure the creeps at RadPartners are working on a “TopGun” “academy” for RAs.
- Many referring subspecialists will not tolerate an RA read of cross sectional. They’re not going to go consult with the RA about the differential for a chest wall mass. Referring docs understand the quality argument even if hospital admins won’t. Referrers are our allies here.
- The more of these RAs you need, the weaker the talent pool will become. Right now it’s just super motivated RAs who have some talent so are drawn to the idea of interpreting. But this “bell curve” is skewed and the mean is going to be way way lower than this.
- AI w/ midlevel is a bit of a deceptive concept, because it sort of implies that the human will QA the mistakes that the AI makes but this requires a level expertise which a midlevel will almost certainly not have. “AI + midlevel” means “AI reads and some poorly trained human is tacked on to absorb liability / increase public acceptance / do physical scut a computer cannot do” If the RAs of the future are anything like the RAs of today, they will just sign off on the AI and “idgaf”.

Couple other thoughts.

As tempting as it is to think that — because of forums and such — your individual voice is powerful, the individual radiologist is powerless here. It will be foisted upon you or not by someone more powerful than you and your only recourse is quitting in a blaze of indignation. Good luck. Firm polite collective action at the ACR level from concerned rads (and ally referring docs) is the way to make a difference - if a difference can be made.

Also, qxrt has it right on the money. Some radiologists read like trash. A midlevel can replicate trash much much MUCH more easily than they can add value. So for trashcan rads, the midlevel objections are clearly a case of radiologist guild mindset and no one important really cares about that. If you’re going to make a compelling argument here it can’t be only on the basis of cost or guild sentiment, genuine quality has to play a role — in the medical world this is minimized by corporate interests (or the term is used deceptively), but it is *always* compelling to the ultimate consumer and it needs to be played that way.

 

[qwerty89]

people are overreacting here big time.

While there are some bad reports out there, most reports are good quality and specialized.

Also Anesthesiologists, ER and derm and ophtho are not out of job because of midlevels.

It's better for ACR to have supervision on their scope of practice rather than letting them open their own societies.

At least for ER, the ACEP had a recent discussion of the topic back in March. Bad job market largely due to residency expansion (which itself is partly driven my for profit entities like HCA) and increased use of midlevels.

On slide 39, they make it clear that they could have a surplus of 9413 EM physicians in 2030.

 

[Dave1980]

if the midlevels want x-ray, fluoro, US, and minor procedures i would be happy to give them up.

i would also like to see a midlevel try to read a CT. it would be a disaster from day 1

 

[Tiger100]

if the midlevels want x-ray, fluoro, US, and minor procedures i would be happy to give them up.

i would also like to see a midlevel try to read a CT. it would be a disaster from day 1

I don't agree with this one.

US pays relatively well for the amount of time we spend.

We still make money from x-rays. They outnumber any other modality by a big margin.

 

[Cognovi]

I find x-rays harder to read than CTs. Important findings are subtler.

 

[Tiger100]

I find x-rays harder to read than CTs. Important findings are subtler.

While your statement may be true, there is a huge difference here. When it comes to X-rays the expectations are very low and when it comes to CT the expectations are very high. Even if you miss a lobar pneumonia on an X-ray, most likley nothing will happen. They will order a CT. At times, even if you call it on an Xray, still they order a CT. On the other hand, many referring physicians order a CT abdomen and pelvis without contrast and expect you to tell them why the patient has abdominal pain for 20 years.
- Is there an aortic dissection?
- I can't tell that since it is a non-contrast CT.
- Really? Why you can't tell that. Blah blah.

CT has become the workhorse of medical diagnosis in 21st century.

 

[Dave1980]

I don't agree with this one.

US pays relatively well for the amount of time we spend.

We still make money from x-rays. They outnumber any other modality by a big margin.

X-rays are a loss leader. There is no way any rad can pay their salary if they only did x-rays.

I agree that US pays pretty well for the amount of time they take.

 

[Cognovi]

I agree that US pays pretty well for the amount of time they take.

US pays well for the time they take because the technologist made nearly all the findings for you; you just look at the images to double-check the call is justifiable. Returning to the original point of this thread, what if it could be like that for other modalities?

 

[maxxor]

US pays well for the time they take because the technologist made nearly all the findings for you; you just look at the images to double-check the call is justifiable. Returning to the original point of this thread, what if it could be like that for other modalities?

This is what MARCA proponents want you to think the law creates.

It actually creates a new mid level that can independently bill medicare for imaging interpretation services. For now, the payments are redirected to the “supervising” radiologist, but that can end in a CMS rule change.

Ultrasound techs perform a prescribed series of image captures and if anything weird sticks out, they take pictures of the findings. If the place is serious about ultrasound, they include sweeps for you to review. At no point do they interpret anything, write anything in the report, nor bill it. Ultrasound is great rvu/time because it’s essentially a screening exam. Anything funky: get a CT or MR for definitive diagnosis.

 

[Tiger100]

This is what MARCA proponents want you to think the law creates.

It actually creates a new mid level that can independently bill medicare for imaging interpretation services. For now, the payments are redirected to the “supervising” radiologist, but that can end in a CMS rule change.

Ultrasound techs perform a prescribed series of image captures and if anything weird sticks out, they take pictures of the findings. If the place is serious about ultrasound, they include sweeps for you to review. At no point do they interpret anything, write anything in the report, nor bill it. Ultrasound is great rvu/time because it’s essentially a screening exam. Anything funky: get a CT or MR for definitive diagnosis.

That's how Ultrasound has become in this country. A screening but not a diagnostic tool. In other parts of the world, US is performed by radiologists themselves and they rely on the findings a lot as a diagnostic tool.

Agree that ultrasound techs don't interpret anything. They don't have the knowledge to interpret the US findings in the clinical context or to correlate US findings with other imaging modalities to give a correct interpretation.

 

[Dave1980]

That's how Ultrasound has become in this country. A screening but not a diagnostic tool. In other parts of the world, US is performed by radiologists themselves and they rely on the findings a lot as a diagnostic tool.

Agree that ultrasound techs don't interpret anything. They don't have the knowledge to interpret the US findings in the clinical context or to correlate US findings with other imaging modalities to give a correct interpretation.

US techs definitely interpret things and in many places put in a prelim sheet in PACS.

 

[fun8stuff]

Not much to add but it’s kind of fun to come here and hear non-rads thoughts.

Radiology is somewhat protected from midlevels because it’s much more cerebral than basic anesthesia, ER, and primary care… and AI for that matter. There’s a reason why it’s a long residency with a mandatory fellowship… and even then, many of us will admit it’s difficult. It’s not a profession like the above where you can give them a crash course and expected t them to do an even adequate job at…. Not that the NP’s in the ERs are doing that great.

 

[fun8stuff]

Not much to add but it’s kind of fun to come here and hear non-rads thoughts.

Radiology is somewhat protected from midlevels because it’s much more cerebral than basics anesthesia, ER, and primary care… and AI for that matter. There’s a reason why it’s a lo g residency with a mandatory fellowship… and even then, many of us will admit it’s difficult. It’s not a profession like the above where you can give them a crash course and expected t them to do an even adequate job at…. Not that the NP’s in the ERs are doing that great.

 

[vm26]

US techs definitely interpret things and in many places put in a prelim sheet in PACS.

US is a strange bird. With the right tech, these exams can be a breeze to read/dictate. With the sub-optimal tech, these exams are a freakin nightmare and I have to spend a ridiculous amount of time/band-width explaining away the nonsense images the tech saved and the "info" they scribbled on a work sheet. Then of course I have to recommend the cross-sectional f/u that they cannot botch (though both the pt. and the system get stuck with the bill when it comes to time/$/radiation exposure etc.

While I am no fan of P/E, it's easy to forget that our individual colleagues are the ones that sold out for golden parachutes. No one put a gun to their head. We live in an uber competitive materialistic society that is conducive to this unfortunate trend.

While no one particular challenge to the field keeps me up at night, the combo that could /would is: AI + mid-level + decreasing CMS reimbursements + P/E.

As a side note, I am cautiously hopeful that the ACR is starting to pay attention to it's paying membership.

 

[maxxor]

As a side note, I am cautiously hopeful that the ACR is starting to pay attention to it's paying membership.

I'm not. The MARCA "town hall" was a farce.

 

[vm26]

I'm not. The MARCA "town hall" was a farce.

Agree on that...Dr. Lexa came out with the Building the Foundation of the ACR Strategic Plan. So guess we will see.