Disturbing Article or Hot Air??

[glc549]

Is the future of neurology really as bleak as these two authors seem to indicate? I'd like to get a second opinion from current residents, docs, and/or those on the interview trail. My whole purpose for entering medicine at 40 was to practice neurology, a dream I've had since high school. I haven't even considered other options (as yet). Should I?

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[swedcrip]

Little of what I read there seems to be specific to neurology. Most of the complaints seem to be about what's hitting medicine in general.

Extinction? That idea went a little too far. But things seem to be changing and might continue to change.

One of the biggest complaints seems to be that they're concerned about their salaries slipping. That might be true, but that hardly means there won't be jobs for neurologists.

 

[Bonobo]

The article, I sense, is really a cry to arms before the situation gets much worse. Neurology is at a point of revolution right now. Acute stroke treatment is finally here and will likely require greater and greater interventional skills (e.g. TCD's, stenting procedures, and intra-arterial thrombectomies). Major hospitals are scrambling to recruit neurointensivists due to their ability to bring money through ICU care (via ICU procedures, repeat radiography, and surgeries). Away from the hospital, neurologists are beginning to learn the cost-efficiency of subspecializing. "Boutique" practices can bring in a considerable income. As neurology salaries are squeezed even further, the concept of subspecializing will become more and more the norm.

It is true that fewer top applicants are entering neurology. I believe that this is largely due to the historical lack of money-making procedures in the field, coupled with an overall declining affluency of medicine in general. However, I suspect this will change as neurologists fight for interventional turf and neurointensivists at major institutions are around to help attract more top applicants (who tend to prefer procedural specialties).

Neurology will survive--it must given the increasing age of the population, the new found treatments for stroke, movement disorders, epilepsy, etc.-- but as future neurologists, we must fight and advocate for our profession. This is critical if we would like neurology to develop the stature of cardiology and similar specialties as I believe it rightfully deserves. Neurologists and neurology patients clearly know how important the field is, but why don't physicians understand this? What about the public? Neurologists are poor at advocating their field. We need to be at the frontlines, extolling the virtues of early stroke recognition, encouraging other physicians to refer epileptic patients until it is to late, and demonstrating the breadth of our knowledge and skills. We need to be lobbying at state and federal institutions to increase the renumeration for our time-intensive exams. Why don't we get paid for reading head-CT's when patients have strokes?

I am actually excited about neurology as I feel that it is finally entering the path that cardiology took some 20 years ago. I wonder how others think about this...

 

[bustbones26]

Ten years ago anesthesiologist were making squat and it was a horrible specialty filled with FMG's. Today, you have to almost kill your neighbor to get a residency spot in gas and they are making well over 300K

How does this relate to neuro?

Just to show that all specialties wax and wane.

Let's face it, right now, neuro is not making the big bucks and they are not living the cush lifestyle, which is why getting that neuro spot is not competitive.

However, if this whole interventional neuro, and neurointensevist thing takes off, those guys will make some serious dollars. Then ironically, the number of neuro applicants will spike. The only thing I find amusing about that, is all of those applicants will think that just because they did a general neuro residency they will get handed a fellowship in invasive neuro or intensive care neuro. By that time, I will already be a neuro attending and will be having a good time weeding out those idiots at interview time.

 

[stroke]

The article, I sense, is really a cry to arms before the situation gets much worse. Neurology is at a point of revolution right now. Acute stroke treatment is finally here and will likely require greater and greater interventional skills (e.g. TCD's, stenting procedures, and intra-arterial thrombectomies). Major hospitals are scrambling to recruit neurointensivists due to their ability to bring money through ICU care (via ICU procedures, repeat radiography, and surgeries). Away from the hospital, neurologists are beginning to learn the cost-efficiency of subspecializing. "Boutique" practices can bring in a considerable income. As neurology salaries are squeezed even further, the concept of subspecializing will become more and more the norm.

It is true that fewer top applicants are entering neurology. I believe that this is largely due to the historical lack of money-making procedures in the field, coupled with an overall declining affluency of medicine in general. However, I suspect this will change as neurologists fight for interventional turf and neurointensivists at major institutions are around to help attract more top applicants (who tend to prefer procedural specialties).

Neurology will survive--it must given the increasing age of the population, the new found treatments for stroke, movement disorders, epilepsy, etc.-- but as future neurologists, we must fight and advocate for our profession. This is critical if we would like neurology to develop the stature of cardiology and similar specialties as I believe it rightfully deserves. Neurologists and neurology patients clearly know how important the field is, but why don't physicians understand this? What about the public? Neurologists are poor at advocating their field. We need to be at the frontlines, extolling the virtues of early stroke recognition, encouraging other physicians to refer epileptic patients until it is to late, and demonstrating the breadth of our knowledge and skills. We need to be lobbying at state and federal institutions to increase the renumeration for our time-intensive exams. Why don't we get paid for reading head-CT's when patients have strokes?

I am actually excited about neurology as I feel that it is finally entering the path that cardiology took some 20 years ago. I wonder how others think about this...

Well-said Bonobo and w/passion. I actually disagree w/the article that less and less people go into the neurology. this year, neuro applications are up significantly (don't have overall stats but from my own program and program i've interviewed, the number of applications grew by 30-50% and most of the increase is accounted by US grads not FMG's (granted i've interviewed only in the northeast and can't speak for the rest of the country).

Why don't we get paid for reading head-CT's when patients have strokes?

Actually, we can -- if you read over 200 films and get a neuroradiologist write a "letter of support" for you you can get a certificate and get the right ot bill for this. It's hard to do b/c u take away neurorad "bread" so to speak, but it's not impossible. So start wining and dining your local neuroradiolgists

Regarding procedures in neurology: EMG and Video EEG are the two that belongs to neuro. ALthough, more and more rehab PMNR's doctors are allowed to be certified in EMG's as long as they get the necesseary quota to be certified. THe interventional procedures involved in stroke, icu and neuro rehab are done by neurologists but it's a turf war and there are a few places were striclty neurogists are being trained to do them, not neuroradiologists -- but they do exist.

Finally, neurologists are not the only one poor at advocating their field. Medicine and doctors in general are poor at that -- that's why we allow bunch of NP's and MBA's running insurance company tell us what to do. Until doctors realize that they "are not above this" we'll always play a 2nd fiddle to insurances

 

[Whisker Barrel Cortex]

The article, I sense, is really a cry to arms before the situation gets much worse. Neurology is at a point of revolution right now. Acute stroke treatment is finally here and will likely require greater and greater interventional skills (e.g. TCD's, stenting procedures, and intra-arterial thrombectomies). Major hospitals are scrambling to recruit neurointensivists due to their ability to bring money through ICU care (via ICU procedures, repeat radiography, and surgeries). Away from the hospital, neurologists are beginning to learn the cost-efficiency of subspecializing. "Boutique" practices can bring in a considerable income. As neurology salaries are squeezed even further, the concept of subspecializing will become more and more the norm.

It is true that fewer top applicants are entering neurology. I believe that this is largely due to the historical lack of money-making procedures in the field, coupled with an overall declining affluency of medicine in general. However, I suspect this will change as neurologists fight for interventional turf and neurointensivists at major institutions are around to help attract more top applicants (who tend to prefer procedural specialties).

Neurology will survive--it must given the increasing age of the population, the new found treatments for stroke, movement disorders, epilepsy, etc.-- but as future neurologists, we must fight and advocate for our profession. This is critical if we would like neurology to develop the stature of cardiology and similar specialties as I believe it rightfully deserves. Neurologists and neurology patients clearly know how important the field is, but why don't physicians understand this? What about the public? Neurologists are poor at advocating their field. We need to be at the frontlines, extolling the virtues of early stroke recognition, encouraging other physicians to refer epileptic patients until it is to late, and demonstrating the breadth of our knowledge and skills. We need to be lobbying at state and federal institutions to increase the renumeration for our time-intensive exams. Why don't we get paid for reading head-CT's when patients have strokes?

I am actually excited about neurology as I feel that it is finally entering the path that cardiology took some 20 years ago. I wonder how others think about this...

Maybe your program is different, but after seeing how poor even the upper level residents at my hospital are at looking at CTs and MRIs, its scares me to think of them actually interpreting them. As for interventional, that requires a whole different personality than the majority of neurologists. Its more of a neurosurgical field.

 

[Fantasy Sports]

Maybe your program is different, but after seeing how poor even the upper level residents at my hospital are at looking at CTs and MRIs, its scares me to think of them actually interpreting them. As for interventional, that requires a whole different personality than the majority of neurologists. Its more of a neurosurgical field.

Perhaps that was because the neurologist actually had to go out on a limb and make the diagnosis, as opposed to being able to hedge a meaningless statement onto his report and move on to the next case?

Unless fellowship-trained, a radiologist is just dead (paper)weight on the neurology service anyway. And its amazing how slow the turnaround times are on studies. I can't wait to outsource the easy stuff (and yet it comes back to me faster than dropping it off a floor below!), and then get a real fellowship-trained neuroradiologist to consult on the harder stuff. That seems to be the way the field is progressing, especially since radiologists at many local hospitals here refuse to work normal doctors hours, leading to a backlog for everyone else. And think of all the money patients will save too, with no loss in their standard of care.

 

[Whisker Barrel Cortex]

Perhaps that was because the neurologist actually had to go out on a limb and make the diagnosis, as opposed to being able to hedge a meaningless statement onto his report and move on to the next case?

Unless fellowship-trained, a radiologist is just dead (paper)weight on the neurology service anyway. And its amazing how slow the turnaround times are on studies. I can't wait to outsource the easy stuff (and yet it comes back to me faster than dropping it off a floor below!), and then get a real fellowship-trained neuroradiologist to consult on the harder stuff. That seems to be the way the field is progressing, especially since radiologists at many local hospitals here refuse to work normal doctors hours, leading to a backlog for everyone else. And think of all the money patients will save too, with no loss in their standard of care.

When a neurostroke fellow tells me she thinks there is calcification in a guys eye on a head CT (pre-MRI) and points to a LOW attenuation area near the eye, I don't call that not making a call. I was the one that made the call that it was the OPPOSITE of calcification so the guy got his MRI. Its amazing how many times I've had to explain to upper level neurology residents and an attending or two the basics of MRI. It has nothing to do with them having to "make" a call. It has to do with lack of knowledge of the technologies of CT and MRI and lack of experience in imaging interpretation.

Are you serious that radiologists aren't working doctor's hours? In private practice, radiologists hours are just under those of general surgeons. The days when radiologists went home at 3pm ended 20 years ago man.

I'm curious what your current level is. I'm geussing med student going into neurology.

Never mind, I just looked it up, you are a 1st year med student. Please refrain from inserting your opinion in such matters unless you have a clue what the hell you rae talking about.

 

[PainDr]

Hmmm...I wonder which program you're at. It sounds like your neurologists are pretty worthless! I'm a pgy-4 neuro resident and can tell you that is NOT the norm. Any neurologist worth their salt should be able to read CTs and MRIs. At this point I rarely ever consult our neuroradiologists and most of the time, don't even read their reports. Believe it or not, specialists in many fields do their own reading.

 

[Bonobo]

It seems that neurologists and neuroradiologists are headed into a deep turf war. The turf battle seems to be primarily over two things: can and should neurologists be trained in interventional neurology/neuroradiology? and can and should neurologists be compensated for reading their own head CT's and brain MRI's?

It seems that whenever this battle comes up, both sides are quick to criticize and provide ample subjective arguments claiming that one type of physician is better than the other in reading CT's or doing interventions, etc. The goal seems to be that one side should maintain control over the field in general and the system should not change as it is or should revolutionize as it has in cardiology.

I think the best solution for patient care is somewhere in the middle. As stroke becomes more and more commonplace, and acute (< 1 hr) care is necessary to convert good outcome rates from 15% to 50%, we cannot depend on having two physicians trained and on call for every set of community hospitals out there. The supply is simply not available, and the end result is far too costly for the US health care system (remember that the biggest cost in US health care next to pharmaceuticals are physicians...)
So for *stroke* it seems smart and optimal for patient care to have a single physician trained in almost all acute aspects of stroke, i.e. a neurologist who can read and bill for his or her own head CT's, perform both IV and IA-tPA, and basic stenting procedures. Imagine, a stroke patient in southern Illinois getting such advanced care for his thrombus in the MCA... the reduction in neurological disability burden itself would save the US considerable money.

The radiologists do not like this idea for obvious reasons. Their arguments are that neurologists cannot adequately read brain MRI's and head CT's. There however have been a few studies showing that neurologists are as good as *neuroradiologists* in reading head CT's. See here: Telemed J E Health. 2003 Fall;9(3):227-33. There are other examples of this, but this is most recent. I am not suggesting that neurologists be allowed to bill for brain MRI's. Reading these for AVMs, brain tumors, etc. should be a joint process with the neuroradiologist in charge of the reading. Remember, we can use anecdotes all we want to claim we are better at reading a particular scan than others... but let's look at the evidence first.

They also argue that neurologists do not have the "personality" to do interventions. If you've ever met a neurointensivist, you know that this is completely incorrect. Furthermore, many students with 'interventional' personalities are going into neurology now and so this old stereotype will certainly be changing. Finally, I think neurologists should only be limited to a few interventional procedures required for acute care in stroke (angiography, ia-tPa, carotid stenting, possible thrombectomy). Thus, they can have excellent training in a few procedures while being able to refer more complicated cases (coiling, sinus vein thrombectomy, etc.) to full-time INR people. Note that stroke neurologists will also probably have to rekindle their training in TCD's if the CLOTBUST trial holds out.... leading to yet another important intervention in the stroke doc's armamentarium.

A healthy compromise like this should lead to greater volume for both stroke physicians and neuroradiologists, so don't worry about income. It will also provide far better care for stroke patients than we have currently. Stroke is *the* leading cause of disability in the US. As Sherwin Nuland has elegantly argued several times, the US healthcare system needs to focus on reducing disability, not death, and needs to do this soon before the US goes bankrupted. Proper acute stroke care is the obvious first step and us physicians must work together, not against one another, in making this happen.

B

 

[bustbones26]

Okay first off, I am not trying to start a pissing contest here, but I did both neuro and neurosurgery rotations at the same hospital. Both the neurologist and neurosurgeon I worked with agreed that the radiologist at their hospital just plain sucked, they NEVER trusted anything, and both the NEUROLOGIST and neurosurgeon constantly were picking up things on CT/MRI that the residency trained/board certified radiologist at this hospital were missing.

Now, the ONLY reason I bring this up, is NOT because I want to pick on rads, or even say something stupid like neurologist are better at reading films, yadda yadda yadda. I only bring this up to point out that on both ends of the spectrum, from rads, to medical neurology, to neurosurgoen, you will find some people that are really good at reading films, and some people that are really bad, and it really does vary from institution to institution, unfortunately were I was at, the rads were very bad! So it is NOT fair for anybody to state that "so and so has no business reading films because---".. I suppose it all boils down to this, no matter what you do, rads, neuro, neurosurg, etc. we all know who at out home institution is good and bad, trust those that arae good. Oh, and one more comment too, just like any radiologist can sit here and tell some story of how a neurologist did something stupid, we can sit here and list stories of how a radiologist did something stupid too, they do make mistakes when reading films.

 

[Whisker Barrel Cortex]

It seems that neurologists and neuroradiologists are headed into a deep turf war. The turf battle seems to be primarily over two things: can and should neurologists be trained in interventional neurology/neuroradiology? and can and should neurologists be compensated for reading their own head CT's and brain MRI's?

It seems that whenever this battle comes up, both sides are quick to criticize and provide ample subjective arguments claiming that one type of physician is better than the other in reading CT's or doing interventions, etc. The goal seems to be that one side should maintain control over the field in general and the system should not change as it is or should revolutionize as it has in cardiology.

I think the best solution for patient care is somewhere in the middle. As stroke becomes more and more commonplace, and acute (< 1 hr) care is necessary to convert good outcome rates from 15% to 50%, we cannot depend on having two physicians trained and on call for every set of community hospitals out there. The supply is simply not available, and the end result is far too costly for the US health care system (remember that the biggest cost in US health care next to pharmaceuticals are physicians...)
So for *stroke* it seems smart and optimal for patient care to have a single physician trained in almost all acute aspects of stroke, i.e. a neurologist who can read and bill for his or her own head CT's, perform both IV and IA-tPA, and basic stenting procedures. Imagine, a stroke patient in southern Illinois getting such advanced care for his thrombus in the MCA... the reduction in neurological disability burden itself would save the US considerable money.

The radiologists do not like this idea for obvious reasons. Their arguments are that neurologists cannot adequately read brain MRI's and head CT's. There however have been a few studies showing that neurologists are as good as *neuroradiologists* in reading head CT's. See here: Telemed J E Health. 2003 Fall;9(3):227-33. There are other examples of this, but this is most recent. I am not suggesting that neurologists be allowed to bill for brain MRI's. Reading these for AVMs, brain tumors, etc. should be a joint process with the neuroradiologist in charge of the reading. Remember, we can use anecdotes all we want to claim we are better at reading a particular scan than others... but let's look at the evidence first.

They also argue that neurologists do not have the "personality" to do interventions. If you've ever met a neurointensivist, you know that this is completely incorrect. Furthermore, many students with 'interventional' personalities are going into neurology now and so this old stereotype will certainly be changing. Finally, I think neurologists should only be limited to a few interventional procedures required for acute care in stroke (angiography, ia-tPa, carotid stenting, possible thrombectomy). Thus, they can have excellent training in a few procedures while being able to refer more complicated cases (coiling, sinus vein thrombectomy, etc.) to full-time INR people. Note that stroke neurologists will also probably have to rekindle their training in TCD's if the CLOTBUST trial holds out.... leading to yet another important intervention in the stroke doc's armamentarium.

A healthy compromise like this should lead to greater volume for both stroke physicians and neuroradiologists, so don't worry about income. It will also provide far better care for stroke patients than we have currently. Stroke is *the* leading cause of disability in the US. As Sherwin Nuland has elegantly argued several times, the US healthcare system needs to focus on reducing disability, not death, and needs to do this soon before the US goes bankrupted. Proper acute stroke care is the obvious first step and us physicians must work together, not against one another, in making this happen.

B

While I aplaud your efforts to improve stroke care, there is a large chunk of neurologists who would like in on imaging for less altruistic purposes. In a recent Neurology journal (I don't remember the name but it was a throwaway journal focused more on practical day to day issues), there was an article called "Cashing in on Imaging" with a big dollar sign sitting in front of a CT image.

 

[scm]

isn't Harvard outsourcing their overnight preliminary XR reading to India? i seem to remember many articles about this awhile back. as technology improves, I really doubt Rads will remain as lucrative(and given the above comment, please dont even try to argue that a good number of Rads people dont chose this field mostly because of the $ and/or they don't want to touch a patient)..as far as I'm concerned, I'd be happy to purge medicine of people motivated to go into the field mostly because of income/earning potential...i think this has happened to some degree already(vs 30 yrs ago)..

 

[Fantasy Sports]

While I aplaud your efforts to improve stroke care, there is a large chunk of neurologists who would like in on imaging for less altruistic purposes. In a recent Neurology journal (I don't remember the name but it was a throwaway journal focused more on practical day to day issues), there was an article called "Cashing in on Imaging" with a big dollar sign sitting in front of a CT image.

And radiologists are attempting to fit much longer jobs into a 9-5 mold and trying to read films from home because? (Doesnt have to do with improving healthcare, that's for sure).

Turf wars have two components to them:

1. The superficial "we are providing better healthcare layer" which, if you can prove an increase in quality of care by Party A over Party B in a large study, you can likely enact legislative reform.

and 2. The concommitant increase in reimbursement, if and only if you can prove #1

Ultimately, it all boils down to who can clinch the diagnosis in the most cost effective manner. If that means neuroradiologists only, fine. If that means neurologists + neuroradiologists or neurologists + some dude in India, that's what it will be.

Cash cows have a way of getting busted. And now that Bush wants to bust up Medicare (even over the objections of some Republican governors), radiology will probably be the first specialty to have its fee services modified if Bush succeeds.

 

[Whisker Barrel Cortex]

isn't Harvard outsourcing their overnight preliminary XR reading to India? i seem to remember many articles about this awhile back. as technology improves, I really doubt Rads will remain as lucrative(and given the above comment, please dont even try to argue that a good number of Rads people dont chose this field mostly because of the $ and/or they don't want to touch a patient)..as far as I'm concerned, I'd be happy to purge medicine of people motivated to go into the field mostly because of income/earning potential...i think this has happened to some degree already(vs 30 yrs ago)..

Very self-righteous of you. So then you are a proponent getting the proportion of neurologists (however small a percentage you think it is) that are greedy out of the profession. The article described above very clearly implies that there are plenty of neurologists that are in it for the money. How is this helping to "purge" medicine of people who are in it for the money?

 

[scm]

Very self-righteous of you. So then you are a proponent getting the proportion of neurologists (however small a percentage you think it is) that are greedy out of the profession. The article described above very clearly implies that there are plenty of neurologists that are in it for the money. How is this helping to "purge" medicine of people who are in it for the money?

huh? i was speaking of all of medicine when i said "field"- sorry you misunderstood, neurologists/your article included..i wasnt making a rads vs neuro comparison in that regard, though honestly perhaps it's kinda silly for anyone to assert that more folks go into neuro for $/lifestyle than rads..but i was thinking more about people choosing to go into medicine as undergrads and so on..most dont have a field in mind at that point.. self-righteous? i dunno. i guess ive encountered enough students/doctors who clearly didnt go into medicine to help people out, and ultimately do not wind up doing so....or maybe they got lost along the way(perhaps the fault of how things are right now I'll admit)..our healthcare system is broken, in one of the wealthiest nations in the world 40 million people are uninsured..among many other problems. we need national healthcare, and set salaries(vs people billing for procedures/tests, abovementioned "turf wars" mostly generated by income and so on), i think, to avoid perpetuating the mess we're in..but thats another discussion/debate.

 

[Whisker Barrel Cortex]

And radiologists are attempting to fit much longer jobs into a 9-5 mold and trying to read films from home because? (Doesnt have to do with improving healthcare, that's for sure).

Turf wars have two components to them:

1. The superficial "we are providing better healthcare layer" which, if you can prove an increase in quality of care by Party A over Party B in a large study, you can likely enact legislative reform.

and 2. The concommitant increase in reimbursement, if and only if you can prove #1

Ultimately, it all boils down to who can clinch the diagnosis in the most cost effective manner. If that means neuroradiologists only, fine. If that means neurologists + neuroradiologists or neurologists + some dude in India, that's what it will be.

Cash cows have a way of getting busted. And now that Bush wants to bust up Medicare (even over the objections of some Republican governors), radiology will probably be the first specialty to have its fee services modified if Bush succeeds.

I have no doubt that radiology will be the first thing to get reimbursements decreased and it doesn't really bother me much. I am not in this for the money and plan on going into academic radiology, which means I will earn half as much as private practice radiologists (and probably on par with most neurologists).

Given that, do you expect me to be happy as clinicians attempt to take away my business with no formal radiologic training? I am spending 4 years of my life learning the intricacies of imaging of all parts of the body in all ages. I have taken and passed a board exam specifically on the physics of imaging. I will pass a written as well as an oral examination, specfically on imaging. I will do a fellowship. This means I will have a total of 6-7 years of training, 1 year in clinical medicine and 5-6 years of radiology (depending on if I do a 1 or 2 year fellowship). Forgive me if it pisses me off when people that have a fraction of that training and no formal training in imaging try to encroach on my field.

 

[Whisker Barrel Cortex]

huh? i was speaking of all of medicine when i said "field"- sorry you misunderstood, neurologists/your article included..i wasnt making a rads vs neuro comparison in that regard, though honestly perhaps it's kinda silly for anyone to assert that more folks go into neuro for $/lifestyle than rads..but i was thinking more about people choosing to go into medicine as undergrads and so on..most dont have a field in mind at that point.. self-righteous? i dunno. i guess ive encountered enough students/doctors who clearly didnt go into medicine to help people out, and ultimately do not wind up doing so....or maybe they got lost along the way(perhaps the fault of how things are right now I'll admit)..our healthcare system is broken, in one of the wealthiest nations in the world 40 million people are uninsured..among many other problems. we need national healthcare, and set salaries(vs people billing for procedures/tests, abovementioned "turf wars" mostly generated by income and so on), i think, to avoid perpetuating the mess we're in..but thats another discussion/debate.

I apologize if I misunderstood. When you start off a post mentioning outsourcing in a postive way when it wasn't even part of the debate, it will bias me toward the rest of your post.

 

[Bonobo]

While I aplaud your efforts to improve stroke care, there is a large chunk of neurologists who would like in on imaging for less altruistic purposes. In a recent Neurology journal (I don't remember the name but it was a throwaway journal focused more on practical day to day issues), there was an article called "Cashing in on Imaging" with a big dollar sign sitting in front of a CT image.

Thanks for bringing this up. I think, however, that both radiologists and neurologists want to 'cash in on imaging' for self-serving reasons. The point of my statement is simply to encourage people to consider altruistic reasons for deciding where to stand in this turf battle. Neurologists want to be interventional neuroradiologists *completely*. I think a more "altruistic" neurologist would realize that this idea is somewhat inconsistent with their training and that rather, a few interventional procedures that need to be done in the acute setting (where interventional neuroradiologists may not always be around) makes more sense.

Also, I think that when neurologists are looking for more money, it isn't just for selfish reasons. Neurology departments always receive a smaller budget in hospitals than most other departments, often because much of their time involves teaching and talking to patients--activities that the US foolishly hasn't learned to compensate adequately yet. Without a change to this system (lobbied against by non-clinicians such as anesthesiologists and radiologists--no offense intended), neurologists are forced to look for money elsewhere to fund what they believe--that talking to patients and teaching students are inherently important activities in our society. The US is way behind many countries in providing effective medical care, many patients turn to alternative medicine, and the costs of US healthcare are obscene not b/c of simply misguided medical practice. A lot of it, in fact most of it as far as I am concerned, comes from how the US allocates its funds in healthcare. If talking to patients and caring for them was compensated more, we would be better at it.

Take the high road even if it hurts you. Life will be sweeter.

B

 

[scm]

ah no worries. i didnt mean to imply outsourcing was positive either, just that it will likely ultimately make the field less lucrative and change the nature of rads a bit, when people, to some degree, can do it from home/outside the US..and noone had mentioned this in regard to the neuro vs rads imaging discussion which ultimately is in some ways also about reimbursement..so i threw it in there and then i suppose kinda went off on a tangent..

 

[Bonobo]

Given that, do you expect me to be happy as clinicians attempt to take away my business with no formal radiologic training? I am spending 4 years of my life learning the intricacies of imaging of all parts of the body in all ages. I have taken and passed a board exam specifically on the physics of imaging. I will pass a written as well as an oral examination, specfically on imaging. I will do a fellowship. This means I will have a total of 6-7 years of training, 1 year in clinical medicine and 5-6 years of radiology (depending on if I do a 1 or 2 year fellowship). Forgive me if it pisses me off when people that have a fraction of that training and no formal training in imaging try to encroach on my field.[/QUOTE]

How much of that is spent on head CT's acquired at the time of stroke? Even with a neuroradiology fellowship? Compared now to a neurologist with 1-2 years of training in stroke? Remember that recent study arguing that surgeons who specialize in a couple procedures, are *way* better at them? I think the idea is true for most of medicine. For stroke patients, I believe that neurologists, particularly stroke neurologists, have far more training than any radiologist, even most neuroradiologists, in reading and understanding head CT's as they pertain to stroke. This is why neurologists feel so strongly about the issue. Not simply b/c they want to make an extra buck or two.

I hope this doesn't feel like we are all bashing you directly. Maybe you can echo some of our thoughts to your colleagues though.

B

 

[Whisker Barrel Cortex]

Given that, do you expect me to be happy as clinicians attempt to take away my business with no formal radiologic training? I am spending 4 years of my life learning the intricacies of imaging of all parts of the body in all ages. I have taken and passed a board exam specifically on the physics of imaging. I will pass a written as well as an oral examination, specfically on imaging. I will do a fellowship. This means I will have a total of 6-7 years of training, 1 year in clinical medicine and 5-6 years of radiology (depending on if I do a 1 or 2 year fellowship). Forgive me if it pisses me off when people that have a fraction of that training and no formal training in imaging try to encroach on my field.

How much of that is spent on head CT's acquired at the time of stroke? Even with a neuroradiology fellowship? Compared now to a neurologist with 1-2 years of training in stroke? Remember that recent study arguing that surgeons who specialize in a couple procedures, are *way* better at them? I think the idea is true for most of medicine. For stroke patients, I believe that neurologists, particularly stroke neurologists, have far more training than any radiologist, even most neuroradiologists, in reading and understanding head CT's as they pertain to stroke. This is why neurologists feel so strongly about the issue. Not simply b/c they want to make an extra buck or two.

I hope this doesn't feel like we are all bashing you directly. Maybe you can echo some of our thoughts to your colleagues though.

B[/QUOTE]

Although I would disagree that any neurologist will be better at interpreting CT than a neuroradiologist, I could see how this could be true for some general radiologists. Keep in mind, that it is much easier to interpret a CT when you have an accurate clinical history. But at the same time, this may bias the clinician into missing other significant findings.

At this point in my training, after only 2 months of neuroradiology and several months of call, I feel that I am much better at image interpretation than any of the neurology residents and probably similar to the neurostroke fellow. Part of the deficiency of the neurology residency here may be due to the fact that our neuroradiology department is so good that they rely on them too much. They also rely on the on call radiology resident at night.

On a side note, I called a basilar artery thrombosis vs aneurysm on a patient in the ER on call on Christmas day and recommended a CT angio. It turned out he did have a thrombosis. The neurointerventional radiologist attempted to thrombolyse but was unsuccessful. Satisfying case in that I identified what is often a very subtle finding on non contrast CT (most people I showed weren't sure if they would call it). Very unsatifying in that it made no difference in the final outcome.

 

[bustbones26]

Not too many post in the past here, it was pointed out that neuro guys are reading to cash in on taking business away from the rads. It was also pointed out that perhaps these neuro guys are not being altruistic in their stroke care, but are ready to cash in.

First off, allow me to be the one to point out that as the salary of radiologist has nicely increased over the past few years, we have ironically seen a nice spike in the number of rads applicants?? Perhaps rads are ready to cash in too??

yes, there is no doubt that if interventional neuro takes off, it will be a money generator, and yes, there will be a turn battle with it over rads vs. neuro, etc. etc. But it is not fair for anyone to come here and state that interventional neuro gusy are in it for the money, just like it is not fair for a neurologist to state that a radiologist does intervention for the cash too.

I think anybody here who has seen me post in the past knows that I am highly against anybody persuing a specialty JUST BECAUSE they can cash out!! I think those people, although they will amke a nice salary, are not happy at what they do and make medicine in general a miserable place to practice. My original post here was to point out that I myself am excited about stroke intervention becoming a new possibility with neurologist, but at the same time, I am also looking forward to weeding the "cash seekers" out at interview time in the future as I will become an attending neurologist.

Last comment, and I have said it before, it is very stupid of any radiologist or neurologist to think they are going to get handed one of these big cash making fellowships just because they did a basic residency. This to me is a huge concern because what this leads to is a number of residency trained/board certified general radiologist and neurologist that never got the big interventional fellowship and will be "STUCK" practicing as an non-fellowship trained attending in complete misery

 

[Finally M3]

Not too many post in the past here, it was pointed out that neuro guys are reading to cash in on taking business away from the rads. It was also pointed out that perhaps these neuro guys are not being altruistic in their stroke care, but are ready to cash in.

Interesting discussion y'all are having here.

Quick question on the business side of neurologists who get certification reading CTs. How much do you think this will add to the liability burden neurologists are facing? You guys already face pretty steep malpractice rates.

 

[Bonobo]

On a side note, I called a basilar artery thrombosis vs aneurysm on a patient in the ER on call on Christmas day and recommended a CT angio. It turned out he did have a thrombosis. The neurointerventional radiologist attempted to thrombolyse but was unsuccessful. Satisfying case in that I identified what is often a very subtle finding on non contrast CT (most people I showed weren't sure if they would call it). Very unsatifying in that it made no difference in the final outcome.

Interesting..., I did a rotation once at a place where the neurologists got CT angio's on most stroke patients in order to catch basilar artery thromboses. Not to add fuel to the fire, but in most cases, it was the neurologist calling the basilar artery thrombosis on the angio, not the neuroradiologist. But that was mostly b/c the neurologists making the call had specialized in making this diagnosis (and calling a bat on CT angio is a lot easier than on a non-con CT). In fact, they published an article on this some time ago in Neurology arguing that if the facilities are available, a CT angio is often a good idea. But I know many who would disagree...

I want to highlight your point about the clinical correlation--this is precisely why I think neurologists will tend to be better at reading head CT's as they pertain to stroke. Now, clearly, at some places the neurorad guys will be better, at other places the neurologists, but this is no reason to *deny* a neurologist from being qualified to read the head CTs. This is also why I think it is appropriate that a neurologist who reads some 200 scans and gets the approval of a neurorad guy can get certification to read head CTs.

B

 

[oldandtired]

"This is also why I think it is appropriate that a neurologist who reads some 200 scans and gets the approval of a neurorad guy can get certification to read head CTs."

I cant believe someone can get certified to interpret CTs after 200 cases? During a radiology residency, you will see thousands of head CTs and even more during a neuro fellowship. Also, many findings are outside the expertise of the typical neurologist- sinuses, orbits, bones, extracranial soft tissues, skull base, etc.

A stoke may be obvious in some cases on a CT however would a neurologist know how to work up or even see the lytic skull lesion? Would he miss the subtle CP angle mass? How about the subtle subarachnoid? Do neurologists study CT scanners and how they work? All the artifacts?

Do you guys want to share call duties with ER coverage and stay up all night with us?

 

[neuro kid]

My 3 cents worth.

cent 1:
A couple of decades ago, we knew as little about MI as we today know about stroke. I feel that the growth of cardiology (esp. interventional cardiology) and the field of coronary artery disease are mutually dependent phenomena. We could not have had the field of CAD grow so well if the cardiologists hadnt seized control over everything related to the disease. Hence, the same team recieves an MI patient in their service, does all the relevant investigations, puts in the catheter, and follows the patient after he goes back home. This encourages development of the field by eliminating petty turf wars that create obstacles in patient care.

I predict a similar future for neurology, and other branches of medicine. It would be wonderful if one team of doctors could look at all aspects of a patient, rather than depend on others for each little thing.

cent 2:
I refuse to believe that a certain field has a personality trait attached to it. I have seen surgeons who are very polite and soft-spoken, and neurologists who skateboard to work (my present hospital has one). I do agree that for generations, neurologists have been passive, and end up doing little about their patients. But this is changing. With our armamentarium of drugs increasing each day, neurologists are being percieved as being more active.

Just wait for us to get a complete hold of imaging and interventions (cath, pain), we will be the cool kids on the block. .

cent 3:
I actually forgot. So I am substituting it for what has already been said by my brethren bustbones and bonobo.

I am in neuro for the fun of sitting and scratching my head in a conference room, and not for the *bling*. I admit that we are medicine's poor cousins. We just have no *bling*. I wouldnt mind some, and would appreciate if the richer brothers from bel air could throw some our way, but the truth remains that as of today (and the recent future) we dont have any.

We do have a life, and I would recommend that those who dont, should get one.


PS: I am a little kid, and i make mistakes all the time. Please dont bust my balls if I offended anyone. .

 

[Fantasy Sports]

Do you guys want to share call duties with ER coverage and stay up all night with us?

I think this is the point though, the types of radiologists that neurologists would replace are the lazy general ones that you end up sending images to which they read from home.

We're not talking about the fellowship-trained neuroradiologists, or even the excellent general radiologists that might study the brain predominantly and are available for consult.

I think its absolutely embarassing that in some hospitals, the turnaround time is oftentimes a full day for a radiology consult, when some guy in India could read the film and have it back to me in an hour or two (and in both cases, Ill be doing most of the read anyway)

Once again, experts never have to worry about being outsourced or replaced... they're experts and are always required. But in terms of reading scans, its doubtful medicare is going to keep "double" reimbursing both a neurologist and a radiologist on a stroke patient, especially since several studies have shown equal competency. And this is even more true now that Bush plans on cutting medicare bigtime to balance the budget.

And to be honest, I think neurologists are willing to pay the extra malpractice to read scans, and many neurologists do work night shifts (I mean, strokes happen all the time). So I think that point is moot.

Just like cardiology has taken over a lot of the heart imaging and interventional procedures to create a "one stop shop" for heart problems, it seems neurology is headed that direction over the next decade in terms of brain problems. As more money gets squeezed out of the health system, the need to provide one efficient specialist will increase, especially considering the exorbitant radiologist salaries. There will still be a place for expert neuroradiologists, but neurologists are going to have to become more involved in imaging as the market is slowly squeezed for money by the government.

 

[Whisker Barrel Cortex]

I read about 15-40 head CTs per night (4:30pm-7am) at my hospital, probably averaging about 20. Thats how many I see every singe call night. With about 80 overnight calls in residency, that equals about 1600 CTs before I even hit neuroradiology fellowship. It probably even more if you include weekend calls. And that is not including the 5 months, at least, of neuroradiology I will get during residency, which probably adds up to another 1000-1500. The vast majority are normal and the ER sends the pt home without even consulting neurology. You're saying that a neurologist who has reviewed 200 scans with a neuroradiologist is as qualified as a general radiologist who has seen close to 3000 in residency alone?

I will also see hundreds of neck CTs, sinus CTs, temporal bone CTs, maxillofacial CTs during residency. This helps me have an understanding of the anatomy and pathology of these areas, which neurologists do not have. And believe it or not, you can see many of these things on head CTs. Since the findings do not relate directly with the acute neurologic situation, the neurologist will be blinded by the clinical situation and will (not may or could, but will) miss significant findings more frequently than the radiologist. Even if he/she does see it, what further work up will they recommend. Is it benign or is it malignant? Oh, yeah, now we better ask for the radiologist, who we are talking business away from, for help.

As for Fantasy Sports assertions of delayed reporting, the majority of that is due to the sheer volume of studies that are ordered. We'll often have clincians call from clinic 1 hour after a study to see if we'd read it yet and get pissed off if we haven't. Its not cause we're sitting there chatting. We are working our asses off while we're in that reading room. It is because of the sheer volume of work we are expected to do continues to increase. Add to that the fact that radiology practices are understaffed due to a shortage of radiologists, add that leads to delay.

 

[PainDr]

I don't know where the number 200 came from but I can assure you that the average neurology resident sees at least 10 times that amount and probably nearly as many as you. What you don't seem to realize is that we usually look at several CTs and MRIs a day...EVERY DAY...for the length of our residency. You do the math. And yes, we do have formal neuroradiology training. We have weekly conferences with our neuroradiologist and competency in neuroradiology is required for board certification. Regarding slow turn around times, we could care less. We read our own studies and treat accordingly. In the past year I've consulted our neuroradiologist exactly twice and both times he concurred with my diagnosis. In one breath you whine about neurologists reading studies because it takes work away from you, in the next breath you whine about being overworked. Pleeeease stop the whining and get off your high horse. There's plenty of work for everyone.

 

[Whisker Barrel Cortex]

I don't know where the number 200 came from but I can assure you that the average neurology resident sees at least 10 times that amount and probably nearly as many as you. What you don't seem to realize is that we usually look at several CTs and MRIs a day...EVERY DAY...for the length of our residency. You do the math. And yes, we do have formal neuroradiology training. We have weekly conferences with our neuroradiologist and competency in neuroradiology is required for board certification. Regarding slow turn around times, we could care less. We read our own studies and treat accordingly. In the past year I've consulted our neuroradiologist exactly twice and both times he concurred with my diagnosis. In one breath you whine about neurologists reading studies because it takes work away from you, in the next breath you whine about being overworked. Pleeeease stop the whining and get off your high horse. There's plenty of work for everyone.

There was no mention of complaint about being overworked. I was just telling you how much I see. No whining at all in the above post. So pleeeeease go away.

Your contention of lack of neuroradiology consult seems completely at odds with neurologists at both my current hospital and my med school. Maybe your program is just full of geniouses or maybe you are just arrogant and will get burned. Time will tell.

 

[bustbones26]

First off, to Whisker Barrel Cortex. Don't get cocky!!! To me, I give radiologist credit, for how many films they look at per day, they have to get the right diagnosis 100% of the time or they do not have a leg to stand on in court. Would you honestly tell everybody here that for how many films you read per day, you never screw up? Radiologist are not infallable!! In fact, some are downright awful! And we all know who they are and always second guess their readings. This is just not in the field of neuro but in other fields as well. In my Third year of medical school, the OB/GYN I worked with made his patients travel 30 miles to get mammos done because, get this, the board certified, breast imaging fellowship trained radiologist at his home hospital had a high rate of missing breast cancer???

Neurologist do look at films, yes, many per day. Are they board certified radiologist, no. But it is the responsibility of the neurologist to walk down to the radiologist reading room, preferably grab one of the rads that likes to read head films or is a neuroradiologist, and say, "Hey, Dr. X, what do you think? Do you agree with me, disagree, what is your opinion, after all, you are the expert?" Why can't we all work as a team??? I have never seen a neurologist or neurosurgeon ask an opinion of a radiologist that was followed by a barrage of insults?

In my opinion, it is just my opinion, a neurologist damn better know what he/she is looking at on a CT/MRI. But at the same time, they need to know their limitations and know when to curbside consult their rad colleagues.

 

[Whisker Barrel Cortex]

First off, to Whisker Barrel Cortex. Don't get cocky!!! To me, I give radiologist credit, for how many films they look at per day, they have to get the right diagnosis 100% of the time or they do not have a leg to stand on in court. Would you honestly tell everybody here that for how many films you read per day, you never screw up? Radiologist are not infallable!! In fact, some are downright awful! And we all know who they are and always second guess their readings. This is just not in the field of neuro but in other fields as well. In my Third year of medical school, the OB/GYN I worked with made his patients travel 30 miles to get mammos done because, get this, the board certified, breast imaging fellowship trained radiologist at his home hospital had a high rate of missing breast cancer???

Neurologist do look at films, yes, many per day. Are they board certified radiologist, no. But it is the responsibility of the neurologist to walk down to the radiologist reading room, preferably grab one of the rads that likes to read head films or is a neuroradiologist, and say, "Hey, Dr. X, what do you think? Do you agree with me, disagree, what is your opinion, after all, you are the expert?" Why can't we all work as a team??? I have never seen a neurologist or neurosurgeon ask an opinion of a radiologist that was followed by a barrage of insults?

In my opinion, it is just my opinion, a neurologist damn better know what he/she is looking at on a CT/MRI. But at the same time, they need to know their limitations and know when to curbside consult their rad colleagues.

Of course we miss things too. Of course there are good radiologists and there are bad ones, just as there are good neurologists and there are bad ones.

Your post is basically saying the same thing I was. The poster before you says she has consulted a neuroradiologist 2 times in the last year. Does she read the reports? Is it wise to ignore the neuroradiologist in your opinion? That is the arrogance I am referring to and it will cause her problems in the future.

 

[Bonobo]

"A stoke may be obvious in some cases on a CT however would a neurologist know how to work up or even see the lytic skull lesion? Would he miss the subtle CP angle mass? How about the subtle subarachnoid? Do neurologists study CT scanners and how they work? All the artifacts?

Do you guys want to share call duties with ER coverage and stay up all night with us?

I don't think the point is to exclude the radiologist from reading CTs. The point is that when a CT is required to rule out hemorrhage or to figure out where the thrombus is causing the stroke, a trained *stroke* neurologist should be compensated for this activity. While a radiologist sees thousands of head CTs in a dark room with five words of clinical correlation, a stroke neurologist sees at least hundereds that *correlate with full neurological exams and clinical presentation*. Thus the neurologist is likely to get at least as good if not a better sense of how to read a CT in its relation to stroke.

Incidental findings are simply that: they imply a finding that is not related to the purpose of the study in the first place. Why should neurologists be expected to discover such incidental findings? Why even, should a hospital that gets a head CT to rule out hemorrhage or mass effect during an acute stroke pay for an extra read by a radiologist to additionally rule out an incidental finding? In economic terms of marginal benefit versus marginal cost, radiologists should be paid according to how their discovery of incidental findings outside the brain (e.g. in the sinuses) significantly affects patient care. (They may also be paid if they significantly add to the diagnosis of the cause of the neurological problems, but we have already made our point that this type of added value is minimal at best given the quantity and *quality* of experience of stroke physicians.) In economic terms, then, radiologists must prove that they are not a cost burden. Has such an analysis been done before?

B

 

[oldandtired]

"Incidental findings are simply that: they imply a finding that is not related to the purpose of the study in the first place. Why should neurologists be expected to discover such incidental findings?"

Hey, we are dealing with people here. One potential life threatening oversite out of a million cases is one too many. The probability of a radiologist missing a finding is significantly less than other specialists.

Although neurologists do see a significant number of imaging studies, many of them concern medical neurology. You dont see the full gamut of neuropathology like radiologists.

 

[Bonobo]

Hey, we are dealing with people here. One potential life threatening oversite out of a million cases is one too many. The probability of a radiologist missing a finding is significantly less than other specialists.

Respectful idealism 'oldandtired'. However, let us consider the cost of having 1,000,000 head CTs read by a radiologist to prevent one oversight. Let's assume that the cost of a radiologist reading is about $50 (~1.75 RVUs) per head CT. Then it will cost about $50,000,000 to catch one oversight. Imagine what medicare could do with another $50,000,000? This is obviously an oversimplification, but should raise the point that when healthcare resources are limited, having a radiologist read a head CT for stroke evaluation just in case the neurologist missed an incidental finding is simply not economical. I am not sure, of course, how often a "life-threatening oversight" would occur. However, given that many many studies of screening head CTs have failed in showing any benefit for such a procedure without some relevant clinical presentation, I highly doubt that such oversights will occur frequently enough to justify the extra $50 per head CT. (Just to make this clear, I do not equate "oversight" with "incidental finding". An "incidental" intracranial neoplasm should be found by a neurologist. An "incidental" unruptured aneurysm should also be found by a stroke neurologist as often as a radiologist since both should have expertise with this type of neuropathology. In fact, exactly what type of "life-threatening oversights" are likely with a neurologist reading a head CT instead of a radiologist? Radiologists may find sinus disease or empty sellas more frequently... but life-threatening findings? Show me the study!)

B

 

[Fantasy Sports]

As for Fantasy Sports assertions of delayed reporting, the majority of that is due to the sheer volume of studies that are ordered. We'll often have clincians call from clinic 1 hour after a study to see if we'd read it yet and get pissed off if we haven't. Its not cause we're sitting there chatting. We are working our asses off while we're in that reading room. It is because of the sheer volume of work we are expected to do continues to increase. Add to that the fact that radiology practices are understaffed due to a shortage of radiologists, add that leads to delay.

But as you report a shortage, you have a number of radiologists working from home (or as Dr. Cuts insists, from their yachts in the Carribbean). My comments are not directed towards people such as yourself WBC, but rather, the growing number of radiologists who have gone into the field strictly for financial and lifestyle reasons that ARE slowing down everyone else. And the fact of the matter is, the reason each of you have so many films to read is because your specialty organization wants to maintain that level of demand as to keep salaries artifically high.

For that reason, the combination of wanting a good lifestyle (reading films from yachts/home) and wanting higher pay (keeping a low number of radiologists) is great for you guys now. The problem is, specialists hate having to wait for something that they can do themselves. And laws that increase cost and waiting time for patients have a way of getting changed (so I wouldnt count on legal protection, as the number of studies showing specialists are just as adept at reading films for their own specialty as radiologists are).

In any case, the solution to your problem of being overworked (though you dont say you're overworked, Im saying that most radiologists in general will claim that as the reason for a film read delay) is either:

1. Having the specialists read the films, thus decreasing your volume of films to read and increasing turnaround time. This has the added bonus of lowering costs for patients and filtering out all the mundane reads.

2. Outsourcing the basic film reads, keeping the complex reads in-house. This has similar benefits to #1

3. Train more radiologists, especially fellowship trained radiologists. The problem with this is that it will lower your pay (something that has driven your specialty enrollment over the past decade). But the bonus to you guys is you will have a better overall lifestyle.

But aside from the issues with radiologists, there are positive reasons for letting neurologists read films. Aside from the fact that a general neurologist will be better at reading CTs/MRIs for the brain than a general radiologist (fellowship trained neuroradiologists are immune to this discussion, as their expertise ensures their utility for the distant future), the ability to have a one-stop-shop for neurological services without having to wait for the radiology dept to simply sign a report will have a huge benefit to patient care. Combine that with the direct clinical correlations that neurologists make, and the fact that oftentimes general radiologists hedge their reports so much as to make a study a waste of time, you can see that most specialties are going to start taking back imaging within their fold-- much like cardiology has done.

There is a place for all of us in the medical field, and the optimization of resources to better serve patients is not mutually exclusive to either radiology or neurology controlling imaging studies. But like most markets, there is a tendency towards equilibrium and generating economics of scale, and even though medicine is insulated from those effects by its highly regulated nature, it is only a matter of time before cost cutting from the federal government forces hospitals to rework neuroimaging reimbursement such as to compensate neurologists as part of the "general neurological exam."

 

[Fantasy Sports]

Respectful idealism 'oldandtired'. However, let us consider the cost of having 1,000,000 head CTs read by a radiologist to prevent one oversight. Let's assume that the cost of a radiologist reading is about $50 (~1.75 RVUs) per head CT. Then it will cost about $50,000,000 to catch one oversight. Imagine what medicare could do with another $50,000,000? This is obviously an oversimplification, but should raise the point that when healthcare resources are limited, having a radiologist read a head CT for stroke evaluation just in case the neurologist missed an incidental finding is simply not economical.

Oldandtired,
Where exactly are these studies that show radiologists (especially of the general variety) catch more on head CTs than neurologists? If anything, the studies seem to indicate equal efficacy (as a few studies posted on this thread indicate).

 

[neurologist]

"Incidental findings are simply that: they imply a finding that is not related to the purpose of the study in the first place. Why should neurologists be expected to discover such incidental findings?"

Hey, we are dealing with people here. One potential life threatening oversite out of a million cases is one too many. The probability of a radiologist missing a finding is significantly less than other specialists.

"One out of a million is too many"? You are, of course, familiar with the studies that consistently show about a 30% misread rate among radiologists? Cmon, don't sit here trying to convince us you're perfect. I'm better at reading head and spine (and yes, I do know about lytic bone lesions and sinuses) than any general radiologist I've ever met, and (after residency and 4 years practice) probably as good as a neuroradiologist, with the exception of interventional angio, which I don't see much. My gut feeling on this is that any medical or surgical specialist should be able to read rads related to their specialty with a proficiency at least equivalent to a good general radiologist.

Although neurologists do see a significant number of imaging studies, many of them concern medical neurology. You dont see the full gamut of neuropathology like radiologists.

What is this supposed to mean? What do you think I've been doing for the last 8 years? If you mean surgical vs nonsurgical, just remember that most neurosurgeons get their patients because a neurologist has sent them there, and the only way the neurosurgeon will see them is if the MRI is already done.

In closing, remember the sign off on most radiology reports: ". . .Clinical correlation is suggested." Until you guys are interested in seeing the patient and correlating the findings clinically, spare me the complaining. I'm pretty tired of getting reports back from radiologists saying "the patient has findings consistent with multiple sclerosis" (guaranteed to freak out the patient) when what they really have is white matter changes secondary to their migraines and MS was never even a remote consideration. I can generate a more meaningful differential than any radiologist, because I know the context; the radiologist operating in a clinical vacuum can do nothing more than point out anatomic abnormalities. Frankly, in many cases, the imaging is a CYA "defensive medicine" maneuver anyway -- the huge majority come back normal or with minor abnormalities not relevant to anything.

 

[oldandtired]

Obviously we all have our own biased opinions. I will not convice anyone here that I am right, just interesting to hear other opinions on the matter.

Neurologist, it is clear that you have an interest and high level of competency in imaging. Unfortunately, many of your colleagues do not. In my practice, I have noticed a broad range of comfort level with imaging amongst the various subspecialists. Also dont forget that less specialized physicians frequently order neuro studies before they make their way to your office.

 

[play274]

Dr. Orly Avitzur is a very bright lady and, not only is she a strong headache neurologist in the New York area, but she has an MBA. Knowing a bit about the author, (as mentioned previously by another poster) it appears as if this article is a semi-"call-to-arms" for neurologists. More than simply winning the so-called turf wars via staking claim to reading imaging, it is evident that neurologists - as a whole - need to become more proactive, business-minded, protective of our own field.

Why should we become more business savvy? Because we need to survive as a profession.

Are we just money-hungry? The answer is in-between yes (everyone would like a 'better income') and no (in order to continue to see great cases and help people, we need to be monetarily smart - as a group).

Interventional neuroradiology appears to be something that is in for a show-down. For example, the SAPPHIRE study (on carotid stenting) was obviously skewed; although results do show some equivalent and (in one case) improve with stenting, we all know that this is based on supposed "high-risk patients," and we likely would not tolerate an overall risk of intervention at 10% (which is much higher that that seen in the NASCET and ACAS trials). Nonetheless, there is already a war between the neurosurgeon, vascular surgeons, interventional radiologists, and cardiologists as to who should do these procedures (stent or CEA) and to which patients (70% stenosis? high risk patients? intracranial stenoses only? all patients?). So ... you may ask: where do neurologists stand in this scheme? Up to this point, we have usually served as non-partisan bystanders.

In the future, however, I believe that more neurology residents will find their way into interventional neuroradiology; unfortunately, it will a very long road, and relative competitve. At this point, I know a number of a couple neurology stroke fellows gaining this experience via three-year fellowships w/NICU training at institutions ranging from the caliber of Michigan State and New Jersey to Columbia. As long as the interventional neurologist is able to form a niche at a proper institution (this is the key), they should be able to routinely perform these well-reimbursed procedures. In the future, new rules may be placed against neurologists training in this manner, but - until formal rules are made - neurologists graduating from these fellowships would likely be able to have 'grandfathered' status and continue their procedures.

But, are we all going to become interventionalists? I believe that the answer is a resound NO. Rather, if you look around the community, it is evident that we have already begun to see the sproutings of neurology becoming more economically-sound.

In academics, we succeed via the fruits of strong research and allies - grants and publication; this approach is obvious and well-known.

In the private world, we have become more subspecialized. For example, we have found EMG (a procedure w/excellent pay-back - which is shared w/PM&R to an extent but - in most larger markets - studies performed by ABEM certified neurologists are considered to be the 'gold standard') to become one of our most popular fellowships, sleep (shared w/pulmonologists) has become popular, and epilepsy remains part of our bread and butter (especially w/the boon in medication therapies and 24-hour video-EEG monitoring). Not only that, but relatively lucrative interoperative opportunities exist at larger institutions and botox is on the rise. Thus, it is not a surprising that neurophysiology (which qualifies one to be subspecialty-boarded to perform EMG, EEG, and sleep studies) is - for the most part - our most competitive, traditional fellowship.

Moreover, we have found a number of neurology practices buying MRI machines. The majority of these neurology practices have made profit from having the scans done with their property - with community radiologists making the official readings on their films (nd the beginnings of outsourcing the readings to physicians in places such as India); we do not necessarily need to read these films ourselves and, as mentioned, liability/malpractice insurance is always an issue.

In addition, we all know of the lucrative headache clinics and specialists. Thus, it is unsurprising that Dr. Silberstein's headache fellowship at Jefferson is highly sought out by a number of graduating neurology residents. As mentioned previously, Orly Avitzur (MD, MBA) is a headache specialist herself ... and that should speak volumes of the author "survivability" and where private neurology with subspecialization is headed.

I do not believe that neurologists are doomed to fall by the waste-side. I strongly feel that articles such as these should encourage neurologists to better define their practices and disciplines. It is evident that fellowships are currently the "way to go," academicians will continue to strive to have strong grant support, and private neurologists will work within their own groups and with other specialities to truly form their niche. In my opinion, the future should be bright ... as long as we (neurologists as a whole) maintain focus.

From the figures that I have seen, the competition to get into neurology residency has actually risen over the past few years (although not to the extent of anesthesia and - in the past - radiology and rad-onc), and it's evident that this will likely continue to rise. Fellowships will become more and more competitive (especially neurophysiology, headache, and - for the masochists - neurointerventional), and I believe that the laissez-faire market will demonstrate a resurgence in neurology over the next few decades. As mentioned on this thread, specialities wax and wane ... and it seems as if we're passing a recent nadir (mid-1990's).

-274

 

[Whisker Barrel Cortex]

Here is a scan of a very tasteless article from Practical Neurology. I'm sure patients would love to read this in the waiting room.

 

[Fantasy Sports]

Here is a scan of a very tasteless article from Practical Neurology. I'm sure patients would love to read this in the waiting room.

A radiologist preaching to neurologists about the monetary aspects of medicine? Good one.

Seriously though, if patients saw how incompetent the radiologists reading their scans were, and how the most common type of post in radiology forums is "how much am I going to make," I wonder what they would think too.

I just love when radiologists, who you couldn't pay enough to enter the field a decade ago, think they can criticize REAL medical specialties (read: actually interact with patients) for wanting to be reimbursed as well.

Oh well, it'll be much better in ten years when just about every subspecialty will take back its imaging and outsource whatever is left. Then not only do we get to avoid the incompetent radiologists wasting our time with 2-3 day turnaround reports that hedge so much as to be useless, but we don't have to listen to their bullcrap about wanting to practice by reading images from the beach anymore (when of course, some Asian dude will do it for 1/20th the cost and with essentially the same accumen).

 

[Whisker Barrel Cortex]

A couple of points.

1. FantasySports contention that the radiology establishment has limited the number of radiology resident in order to increase income is far from the truth. In the early nineties, reports that there would be less need for radiologists caused many programs to be downsized. In the past few years, the number of spots has increased. It is not easy to get more spots, since funding for residency spots is from medicare, and money is limited. So your assesment is incorrect.

2. Some neurologists can interpret imaging equivalent to general radiologists, especially when it comes to things that are in the realm of the neurologist. However, there are fewer and fewer general rads out there. Most of them are older rads. More and more practices require subspecialization, especially in metropolitan areas and the majority of rads are doing fellowships, even with the lure of big money job offers prior to completing residency. While I respect that you (neurologist) are confident of your neuroradiology skills, I truly doubt that your abilities are equivalent to a neuroradiologist.

3. Your knowledge of the clinical picture is actually a weakness in some respects, since it will bias your interpretation and blind you to important alternative and ancillary findings.

4. Many studies have shown that the amount of imaging performed when a physician self refers to a scanner they own or to studies they interpret increases anywhere from 2 fold to 8 fold as compared to when they refer to a radiologist. Even if monetary concerns are not the conscious driving force, there is no doubt that self-referral leads to overutilization of imaging.

5. By the way, do you have any formal training in radiation biology, radiation safety, MRI physics. And I don't mean a weekend course.

6. Neurointerventional radiology requires a skillset that begins with general interventional radiology, which radiologists learn in residency and is honed during neuroradiology fellowship and neurointerventional radiology fellowship. Vascular surgeons have taken over a great deal of peripheral vascular procedures, but in the early years, we watched in horror as poorly trained vascular surgeons used 90 minutes of flouro time (enough to cause radiation changes in the skin), flogged cases due to lack of cather skills, and other such misadventures. I geuss the patients had to pay for the vascular surgeons training with their health.

7. Stop with the corrolate with clinical findings bs. This is included in a small percentage of reports and only when there is finding that could mean multiple things. It is not part of "most" radiology reports as you suggest. You just notice it when its there. I'd say I dictate this in about 5% of positive studies maximum, usually when the clinician decided to include no real clinical history.

 

[Whisker Barrel Cortex]

A radiologist preaching to neurologists about the monetary aspects of medicine? Good one.

Seriously though, if patients saw how incompetent the radiologists reading their scans were, and how the most common type of post in radiology forums is "how much am I going to make," I wonder what they would think too.

I just love when radiologists, who you couldn't pay enough to enter the field a decade ago, think they can criticize REAL medical specialties (read: actually interact with patients) for wanting to be reimbursed as well.

Oh well, it'll be much better in ten years when just about every subspecialty will take back its imaging and outsource whatever is left. Then not only do we get to avoid the incompetent radiologists wasting our time with 2-3 day turnaround reports that hedge so much as to be useless, but we don't have to listen to their bullcrap about wanting to practice by reading images from the beach anymore (when of course, some Asian dude will do it for 1/20th the cost and with essentially the same accumen).

Hmm. I've been on two different radiology boards and on neither is the most common question how much money will I make. On the first page of the neurology forum, there are 3 threads about money. On the radiology forum, there are 2.

Your hatred for radiology is evident. I am sorry that you are so bitter.

Oh yes, we are not REAL doctors. Good one. Oh, now the majority of radiologist are incompetent. Nice one. You wish ill upon my chosen profession. How very altruistic and kind of you. I am glad you are into such mature discussion.

edit: A few more points:

1. A 2-3 day turnaround time for reports is not the norm. The vast majority of practices will have reports dictated the same day. As technology advances this time is getting shorter and shorter. Our reports are in the computer as soon as they are dicated (voice recognition software) and 90% are signed off as final by attendings within 24hours. There are many factors to delays, the rate limiting usually being trascription. You can usually listen to a report much quicker. I'm geussing Fantasy Sports isn't clever enough to figure out how to do this. Or maybe he/she will learn it once out of medical school.

2. Very few radiologists are currently reading from home. Those "lazy radiologists" you keep referring to work longer hours on average than neurologists according to some studies. The ones making a lot of money often work much longer hours. There is a private practice radiologist I know of who is in solo practice because he can't recruit a partner. He works from 7 am to 6 pm in the hospital. Goes home and eats. Then works from 7 pm to 10 pm at home to keep up with the volume. He repeats that every day. While this is extreme, most of those "high paying" positions in radiology involve pretty impressive work loads. So please stop commenting on things you really have no first hand knowledge of.

3. Radiologists make as much impact on patient care as neurologists. Even if you are not impressed with the neurologic study reads, you have no idea how many patients we impact on a daily basis. And since you are obviously clueless about the practice of radiology, many general radiologists have a great deal of direct patient contact through biopsies and other procedures (this is not limited to interventionalists). Just because we don't see a stroke patient in clinic and prescribe aspirin and speech therapy doesn't mean we don't help patients.

4. The neurology residents at my hospital have less call on average than the radiology residents (I have discussed this with them) and their call is not as brutal as ours.

5. Radiology was always a very competitive field until a brief period in the nineties when projections were made of poor job prospects. Again, your ignorance is showing.

6. If you are so into Fantasy Sports, shouldn't you be watching the exciting Jets/Steelers game instead of being online.

 

[neurologist]

By the way, do you have any formal training in radiation biology, radiation safety, MRI physics. And I don't mean a weekend course.

Yeah, I really need courses in radiation biology and safety to read MRIs!!!!!!

7. Stop with the corrolate with clinical findings bs. This is included in a small percentage of reports and only when there is finding that could mean multiple things. It is not part of "most" radiology reports as you suggest. You just notice it when its there. I'd say I dictate this in about 5% of positive studies maximum, usually when the clinician decided to include no real clinical history.

Why on earth would you want us to include a "real clinical history"? After all, "Your knowledge of the clinical picture is actually a weakness in some respects, since it will bias your interpretation and blind you to important alternative and ancillary findings." YOUR words, dude.
Step 1: Open mouth
Step 2: Insert foot

 

[Whisker Barrel Cortex]

Yeah, I really need courses in radiation biology and safety to read MRIs!!!!!!

Why on earth would you want us to include a "real clinical history"? After all, "Your knowledge of the clinical picture is actually a weakness in some respects, since it will bias your interpretation and blind you to important alternative and ancillary findings." YOUR words, dude.
Step 1: Open mouth
Step 2: Insert foot

The sentance refers to radiation biology and MRI physics as separate entities. Please read more carefully next time and maybe you won't be confused. In case you didn't know, CT scans have radiation. Now where is the answer to the question? Do you have any formal training in MRI physics (which is necessary to understand artifacts and true findings in MRI as well as to make sure the correct sequences are performed) or raditaion safety/biology (which pertains to CT scans). I take it the answer is no.

And please read my sentence again regarding clinical history. What I said is that when there is no clinical history, we may be forced to include a statement that clinical corrolation is recommended (and this is in a small proportion of cases). A brief clinical blurb is a far cry from biasing the interpretation compared to a neurologists full clinical history. Plus, if you noticed I said in some respects it was a weakness. Of course in making the final diagnosis, the onus is on you, the neurologist, to put together all of the information to reach a diagnosis. (foot not in mouth, now the said foot is kicking neurologist's ass)

Man, that was the easiest rebuttal I've had in a while.

Until you have completed a two year training program dedicated to neuroimaging that a neuroradiologist has and until you have been through a radiology residency, you will not know how truly limited your imaging knowledge is. I interact with many clinicians daily, and can confidently tell you that the vast majority are very limited in their knowledge of imaging. The ones that think they are the best are often the most dangerous.

 

[suburbanite]

Hi.

How did I know, when I saw the number of posts in this thread, that a rads-neuro turfscrum was involved? And that there would most likely be reams of bullet-pointed diatribes from Dr. Oldandtired and colleagues, who seem to go more on the defensive every year?

From a lot of what I've seen around the country on the interview trail, neuro can be 9 to 5 if that's what you want, it can be lucrative if this is your goal, it can certainly be intellectually and spiritually fullfilling regardless.

Most important, there are millions of people in the US with neurological conditions, who want to be helped, for whom a neurologist is the best source of info and skills. Neurologists are needed, the opportunity is there to do good work.

 

[RADRULES]

HA HA HA!! I really get a kick out of all the Neurologists trying to get into imaging, because their specialty is dying a slow death. Sorry, but perhaps you should have studied a bit more in medical school so that you could have gotten into a COMPETITIVE specialty... you know, the kind that lots of people want to do.

In any event, as I am in the middle of my Neurorads fellowship at one of the top academic radiology departments in the country, I find it comical that any Neurologist thinks he/she can read a CT or MRI to the level of a Neurorad. If any of them would sit and readout with just ONE of my faculty ONE time they would understand their own ignorance and sit in awe of the knowledge and deep understanding of these guys.

I, for one, would happily put ANY of my reads up against ANY neurologist in the country and would not think twice. I would be happy to have a discussion of the principle of MRI as it applies to Neuroimaging. Don't forget there is a lot more to Neuroradiology than just the brain.... think spine, temporal bone, angio....

Please, for the love of God, know your place. It takes 6 to 7 years of post-graduate training to be a BC/CAQ Neuroradiologists.

Alas, we can both play this game... I am sure I could train a PA or to do neurological exams and self-refer to my own CT or MRI, which I could easily run and read. Plus, the "tough" cases I could always send to me local neurologist.... HA HA HA!

 

[Bonobo]

HA HA HA!! I really get a kick out of all the Neurologists trying to get into imaging, because their specialty is dying a slow death. Sorry, but perhaps you should have studied a bit more in medical school so that you could have gotten into a COMPETITIVE specialty... you know, the kind that lots of people want to do.

I for one know that I could have gotten into any specialty, including neurosurg and rads, and at top places. But I am choosing neurology because I believe that neurology will be where cardiology is today. I am sorry that radiologists are worried about losing their turf yet again, but the US lawmakers only care about the bottom line, and giving neurologists power to take care of stroke patients themselves and reduce disability across America just makes the most sense. As you guys hopefully realize now, about 1/3 of interventional neurology fellows are neurologists. And the growth will continue simply b/c radiologists don't want to forgo their 50 hr wk, $300,000 lifestyles to lead lifestyles like neurosurgeons. Most neurologists are not trying to become diagnostic neuroradiologists. We have you guys for that. We are simply trying to save our specialty because we care about patients, not to be in a *competitive* specialty to make a ton of money.

And just to flip around your argument of why neurologists shouldn't read films... radiologists should do what they are good at: reading films. Leave patient care to us.

B