The economics of reading images work against midlevels. I can send a finalized report electronically for a normal chest plain film within 5 seconds and for a normal CT abdomen and pelvis within 5 minutes. How does adding a middleman to that process increase my productivity? It doesn’t. If a midlevel prereads an exam and I have to review the same images before the report can be finalized, then my productivity will be significantly impacted negatively. It will often double or triple or more the time to finalize the report for that study. That’s why training residents is so time-consuming. Furthermore, if you have a train wreck of a study or a subtle but critical finding, you need the knowledge and experience from going to medical school, residency, and often fellowship. Midlevels don’t possess that knowledge base. Every time you open a new study to read, it can fall into any category. This is an extremely important point. Unlike other medical fields like primary care, anesthesia, and EM that can triage cases and assign the easier, less complex cases to midlevels, you can’t do that in reading imaging studies. Midlevels can’t cherry pick easy, normal studies from the complex studies or ones with critical findings. Male or female. Old or young. Black or white. It doesn’t matter. That million dollar lawsuit can be hiding in any study. Images don’t change and can be preserved indefinitely. This is another extremely important point. Imaging is unlike most clinical fields where the condition of the patient in retrospect is inferred based on documentation and diagnostic tests. You don’t know the exact condition of the patient unless you were there in person. Using a retroscope, a good lawyer can look at the exact same images as you did and point out where you missed that critical finding. Hence, these are some major reasons why midlevels in radiology are primarily used to do minor procedures and scutwork and not reading images. If a midlevel places a drain or does a biopsy, they can more or less function independently and in that case they can help the bottom line of the group.
Other medical fields like primary care, anesthesia, and EM widely adopted midlevels because they improved the bottom lines of groups. They allowed midlevels to run rampant and to function more or less autonomously with physician backup because it helped make the partners in the groups more money. These fields loved midlevels until the midlevels revolted and demanded their independence. These fields didn’t have the foresight to see what would happen if you don’t limit what midlevels can do and to establish clear boundaries and to unequivocally differentiate the roles of physician and midlevel. These fields allowed the boundaries to become fuzzy, roles to be interchangeable more or less, and made it very difficult for the lay public and politicians to see independent midlevels as a risk to public health. That’s why I keep harping on the point that it is critical for the long term health of your field to maintain a large moat separating the roles of physician and midlevel. Because of economics (and probably a lot of dumb luck), radiology has done this. Surgery too.
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