Why would anyone go into cardiology today?

[Whisker Barrel Cortex]

Radiologists are just jealous and worried about other specialties, specifically Cardiology, taking over they're business. Slowly but surely, radiology will become a more narrowed field as other specialties expand their scope of practice and as technology advances. Cards will continue to do more and more imaging and "whole body" vascular intervention. Gastro/hepatology, vascular surg, neurology, pulm, etc, are all in the process of expanding their procedural services and image diagnostic capabilities. These fields are already reading their own imaging studies accurately. There's no sense a patient should be billed twice for a radiologist reading unless the primary doc refers it to rads. I read CXRs all the time and feel very comfortable with my accuracy. Why should a rads doc read it unless I have a question. This is the same for Cardiology and cardiac CT/MRI, for Vascular surgeons and arteriograms, etc, etc, etc.
Bottom line is that whoever primarily cares for the patients, are the ones that control the outcome of these turf battles. Radiology is just not in an optimal position to challenge these issues, unless they learn how to manage patients clinically over a potentially long period of time.

You THINK you read the study. Primarily interpreting is much different that looking at the study for the cardiomegaly or pulmonary edema. Once you miss that lung nodule on chest x-ray for your CHF patient and get sued, your lack of training in radiology will definitely be brought up. As a radiologist, I will be happy to testify against you as you are ill informed as to your limitations. The same is true for cardiac MRI/CT, which inludes much of the remainder of the chest and abdominal/pelvic CT / peripheral MRA which includes the remainder of the abdomen. You truly have no idea what it means to be the person who is responsible for everything on an imaging study and the quality of the imaging study. Sure you can look at a MIP of the vessels (even though you probably don't even have the faintest clue what a MIP really is) and make a judgment. The more difficult cases are the ones where your lack of knowledge of the technology will hurt you. The important ancillary findings in other organs are also a factor (in up to 10-15% of cases if you read my post above). Sure, that lymphoma isn't important to you cause it doesn't involve the heart, but it sure as hell is important to the patient.

I think the jealousy runs the other way. If you wanted to be a radiologist, you should have gone into radiology. You are not as adept or educated in the interpretation of imaging and its just a fact.

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[Bonobo]

This turf-war sounds like the grand-daddy of them all....

I want to throw out an idea that my friend, an MBA/economist mentioned while I was discussing this issue with him. He asked simply what patients would want if they were given an informed choice in a hypothetical economical society.

THE CARDIOLOGY CASE

A patient needs a cardiac CT/MRI to look at the coronary vessels for suspected CAD. They could get the imaging done quickly, at the same cardiology facility, and read by a cardiologist in the same group (or even the same cardiologist, let's say, if pure self-refferals were allowed). The interpretation would be done by an "expert" not only in hearts, but in their heart/vascular condition, and the decision will be made by the same cardiologists as what to do next. Imaging findings would be correlated with echo's, EKG's, etc, and would be used during interventional procedures. However, if there are any incidental findings in the lungs, etc, the cardiologist is not trained to detect them, and they might be missed. Assuming a pure libertarian, capitalist society, the patient would have to sign a waiver saying that the cardiologist could not be sued for missing that incidental lung nodule on the cardiac MRI. The patient still has the option, however, to take the scan later to be read by a radiologist, but this would of course cost extra for the read only (the cost of the MRI/CT itself was already paid for).


THE RADIOLOGY CASE

THe same patient would have to go to a radiology center and get the imaging (possible time delay). But then, the read would still be quick and the interpretation would come from a radiologist hopefully fellowship trained in cardiac MRI/CT. As a perk, the patient's chest would also be screened for any incidental findings. The read interpretation would then go to the cardiologist and result in a decision. The cardiologist might read the scan also herself, but rather quickly because of limited or no reimbursement in this case. A more thorough read by the cardiologist would require extra pay.


Now the question is simply this: which would you choose as a patient? Would most patients' agree to one scenario or the other? For cardiology, would the convenience and the complete, one-stop care be worth it despite not being screened for incidental findings (although for extra cost...)? For the radiology case, would the loss of time and convenience be worth it to be also screened for incidental findings?

I think this was an interesting scenario, so I thought I would post it. My sense is that patients would be split in their decision, and that a lot of it would depend on the accessibility of radiologists. A public-health based decision should probably focus on the economic savings from screening for incidental findings (is it less than $50,000 per QALY?) vs the extra savings from the convenience and speed of keeping the imaging in the same group (less errors, less likelihood for non-compliance, more accessibility for more patients). With tele-medicine, I think the radiologists are more likely to win this battle... but then they might be threatened to lose their turf to radiologists outside of the country as well in the future. One thing in favor of the cardiologists however is that they can more easily correlate the imaging with echo's, knowledge of the patient's hx and exam, and later when they perform angiography during interventional procedures.

B

 

[Al Pacino]

If you want to read the study (cardiac MR/CT, etc.), you have to read the WHOLE study and not just that one specific organ that you have expertise in. The problem with cardiology, neurology, and (insert specialty) is that they only want to read their own specific organ and forget about everything else.

Medicine is taking care of the WHOLE patient and not just one organ system. As others have stated, what good is it to be able to read the heart but completely miss the brewing lunc cancer.

As Whisker Barrel Cortex stated, the incidental organ findings in cardiac MR is 10-15% (do a search on Medline). THAT's a HUGE number, and not a trivial one. Americans are not going to sleep quietly at night knowing that some cardiologist has looked over their heart but missed the other 10-15% that is lurking outside of the heart.

Case in point: flexible sig vs. colonoscopy. It has been studied that a colonoscopy only picks out 2% more colon cancers than a flexible sig. This 2% increased cancer pick-up rate is balanced out by an increased risk for perforation. (Remember a flexible sig stops at the splenic flexure, while a colonoscopy goes beyond that to the ileum)

Yet, if you've rotated in primary care, most patients when presented between a flexible sig vs. a colonoscopy will go for the colonoscopy to pick up the extra 2% of colon cancers, despite the increased risk of colon perforation.

If Americans demand that extra 2%, what makes you think that they will let a cardiologist read only the heart and disregard the 10-15% of the so-called "incidental findings"?

 

[jdaasbo]

Here is a thought. We order/perform tests to answer a specific clinical questions (ie is there coronary artery disease or not?). We are all aware and agree that screening for "disease in general" with the "pan-CT" is neither cost-effective nor good medicine. Perhaps the answer lies in aquiring data only for the heart with the CT.

 

[Bonobo]

If you want to read the study (cardiac MR/CT, etc.), you have to read the WHOLE study and not just that one specific organ that you have expertise in. The problem with cardiology, neurology, and (insert specialty) is that they only want to read their own specific organ and forget about everything else.

Case in point: flexible sig vs. colonoscopy. It has been studied that a colonoscopy only picks out 2% more colon cancers than a flexible sig. This 2% increased cancer pick-up rate is balanced out by an increased risk for perforation. (Remember a flexible sig stops at the splenic flexure, while a colonoscopy goes beyond that to the ileum)

Yet, if you've rotated in primary care, most patients when presented between a flexible sig vs. a colonoscopy will go for the colonoscopy to pick up the extra 2% of colon cancers, despite the increased risk of colon perforation.

I am not too sure that your 2% idea is completely true. Colonoscopy by numerous studies has shown to be only marginally less cost-effective than flex sig (~$3000/life year saved), but is considerably less uncomfortable and embarrasing than flex sig. I've attached a sampling of abstracts below just to show that the jury is clearly out on which is better, but patients consistently choose colonoscopy--NOT b/c they catch 2% more cancers, but due to many other reasons as well (only have to do it every 10 years for example!!!).

Just noting that the situation presented by the poster above is a very simplified biased point of view. Please post your references showing that important clinical incidental findings are found 10-15% of the time on cardiac MR's. If this was true, then maybe we should consider using cardiac MR's as a screening tool....

B



RESULTS: Colonoscopy averted the greatest number of cases of colorectal cancer (35%), followed by flexible sigmoidoscopy (25%), and annual (24%) and biennial (14%) fecal occult blood testing. Colonoscopy averted the greatest number of deaths from colorectal cancer (31%), followed by annual fecal occult blood testing (29%), flexible sigmoidoscopy (21%) and biennial fecal occult blood testing (19%).

Among the 385 subjects with a normal distal colon, 14 (3.6%) had advanced lesions in the proximal colon that would be missed by FS alone.

CONCLUSIONS: Patients undergoing screening colonoscopy with conscious sedation are less likely to experience peri-procedural discomfort than those undergoing screening flexible sigmoidoscopy.

The subjects found the preparation for sigmoidoscopy easier, but the procedure more uncomfortable and embarrassing, as colonoscopy was performed under sedation. In this hospital-based study, colonoscopy was as acceptable to subjects, and only slightly more costly than sigmoidoscopy

 

[CCMD2005]

Cardiac CT has its limitations...it's not the holy grail some radiologists/ uneducated cardiologists are trying to make it out to be.
#1 Radiation exposure. A 64 slice chest CT has more radiation exposure than a simple diagnostic cath. (look this up on CDC website)
#2 Not 100% sensitive, Not 100% specific, but it has a HIGH negative predictive value. Which means it is a useful test for patients with atypical complaints and a low pre-test probability of CAD anyways (i.e. bogus chest pain admits), I am sure cardiologists would love to not be bothered by these patients. Anyone with ACS (UA/NSTEMI or STEMI) should be cathed - this is firmly established in trials. P
#3 Calcium in the coronaries makes the stenosis difficult to interpret, meaning seeing calcium in the coronaries will probably lead to a diagnostic cath to get a better idea of the lesion.
#4 CT does not give a functional assesment of ischemia, will still need to do SPECT imaging, maybe MRI in the future (10 years).
#5 The hype is ahead of the science, and this is being driven by GE and Philips, who make CT, and who are currently marketing these machines to radiologists and cardiologists (have you picked up JACC lately?).
#6 Anytime a new "screening" tool becomes available (which is what GE and Philips are attempting to do with this new technology), it only makes the incidence of the disease increase (i.e. prostate CA and the psa; Breast CA and mammograms), making cardiologists even busier.
-CC
UVA PGY-1 (July 2005)

 

[Whisker Barrel Cortex]

Here is a thought. We order/perform tests to answer a specific clinical questions (ie is there coronary artery disease or not?). We are all aware and agree that screening for "disease in general" with the "pan-CT" is neither cost-effective nor good medicine. Perhaps the answer lies in aquiring data only for the heart with the CT.

So the next time a clinician orders and abdominal / pelvic CT to "r/o abdominal pain" or "r/o pathology," I should ask them to tell me what exactly their looking for so we can image only that part of the body.

The patient will be exposed to the the same radiation dose no matter how much of the non cardiac stuff you include. These are high dose examinations (6-11mSv Effective dose, not that that means anything to you), with thin slices (0.625mm). Lymph nodes, by the way are located surrounding the heart. Can't exclude those. And that patient with chest pain, you wouldn't want to evaluate the aorta or the pulmonary arteries would you. Nothing there could cause chest pain. Its ludicrous that you want to expose the patient to the radiation (without knowledge of radiation biology) and obtain less information.

Just noting that the situation presented by the poster above is a very simplified biased point of view. Please post your references showing that important clinical incidental findings are found 10-15% of the time on cardiac MR's. If this was true, then maybe we should consider using cardiac MR's as a screening tool....

Here are a few. Please note that these fields are relatively new and this has not been a research focus, but here are a couple of studies that I can point out:

Cardiac MRI: Not published yet, but seems like a pretty well done study.
http://www.auntminnie.com/index.asp?Sec=sup&Sub=car&Pag=dis&ItemId=65107

Cardiac CTA: Not published yet (abstract only), but also appears valid.
http://www.auntminnie.com/index.asp?Sec=sup&Sub=cto&Pag=dis&ItemId=63642

Virtual colonscopy (can be extended to body CTA):
http://www.auntminnie.com/index.asp?Sec=sup&Sub=cto&Pag=dis&ItemId=63007
http://radiology.rsnajnls.org/cgi/content/abstract/215/2/353
http://www.auntminnie.com/index.asp?Sec=sup&Sub=vco&pag=dis&ItemId=55441

A current study on virtual colonoscopy at our center with over 1000 VCs done so far yields pretty similar numbers.

Don't cardiologists have enough to do without trying to do CT/MRI. It takes times to read these studies properly (and a lot of hands on time to do MRI). What is their motivation?

 

[ReMD]

You THINK you read the study. Primarily interpreting is much different that looking at the study for the cardiomegaly or pulmonary edema. Once you miss that lung nodule on chest x-ray for your CHF patient and get sued, your lack of training in radiology will definitely be brought up. As a radiologist, I will be happy to testify against you as you are ill informed as to your limitations. The same is true for cardiac MRI/CT, which inludes much of the remainder of the chest and abdominal/pelvic CT / peripheral MRA which includes the remainder of the abdomen. You truly have no idea what it means to be the person who is responsible for everything on an imaging study and the quality of the imaging study. Sure you can look at a MIP of the vessels (even though you probably don't even have the faintest clue what a MIP really is) and make a judgment. The more difficult cases are the ones where your lack of knowledge of the technology will hurt you. The important ancillary findings in other organs are also a factor (in up to 10-15% of cases if you read my post above). Sure, that lymphoma isn't important to you cause it doesn't involve the heart, but it sure as hell is important to the patient.

I think the jealousy runs the other way. If you wanted to be a radiologist, you should have gone into radiology. You are not as adept or educated in the interpretation of imaging and its just a fact.

As I said before, if I had a question when reading a CXR then I would consult a radiologist. Otherwise I will take the liability risks with my interpretation. Do you really think I wait for a radiologist to read studies before I make a decision. Besides one of the favorite things many radiologists do is find any way to "fudge" an interpretation. Quote, "cannot r/o ________, but would recommend f/u study in 3-6 months or if clinical suspicion is high then recommend repeat study." If clinical suspicion is so important then why don't radiologist come and evaluate the pt. They are doctors, aren't they. The point is that clinical correlation is very important and can play a huge deal when evaluating a study. I can't even count how many a-thals were misinterpreted by radiology at our VA. Pts going to CABG only to fing normal coronaries. Guess what, now cardiology is reading all the studies and can actually use their clinical assessment in the interpretation.
As I stated before, this will continue to be the trend. If I feel comfortable reading a study then I'm willing to take the liability. I'm sure other specialists will too, eventually. Just like an internist who reads an ECG; if there is a question then they will consult cards. Otherwise, why should a pt be billed twice.

 

[Whisker Barrel Cortex]

As I said before, if I had a question when reading a CXR then I would consult a radiologist. Otherwise I will take the liability risks with my interpretation. Do you really think I wait for a radiologist to read studies before I make a decision. Besides one of the favorite things many radiologists do is find any way to "fudge" an interpretation. Quote, "cannot r/o ________, but would recommend f/u study in 3-6 months or if clinical suspicion is high then recommend repeat study." If clinical suspicion is so important then why don't radiologist come and evaluate the pt. They are doctors, aren't they. The point is that clinical correlation is very important and can play a huge deal when evaluating a study. I can't even count how many a-thals were misinterpreted by radiology at our VA. Pts going to CABG only to fing normal coronaries. Guess what, now cardiology is reading all the studies and can actually use their clinical assessment in the interpretation.
As I stated before, this will continue to be the trend. If I feel comfortable reading a study then I'm willing to take the liability. I'm sure other specialists will too, eventually. Just like an internist who reads an ECG; if there is a question then they will consult cards. Otherwise, why should a pt be billed twice.

If you actually understood the limitations of imaging, you would realize that the reason we recommend f/u is due to those limitations. The clinical corrolation recommendationis used in two cases. One is if its a finding that can mean several things (thickened gallbladder wall in a cirrhotic with ascites on CT can be cholecystitis or due to his ascites/cirrhosis) and a brief history is all that is necessary. The other is if the finding can't be characterized on CT and the best way to figure out if it is something dangerous (malignant or benign) is to follow it up to see if it changes. Since you don't have the slightest idea how to interpret imaging, it doesn't surprise me that you don't understand this. Most internists I know (many of whom are my friends) couldn't tell the aorta from the pulmonary artery on CT.

Cardiology shares with nuc med in reading cardiac studies here and the inaccurate results are the same. Both sides can misinterpret things on these studies. Its just that when its a radiologist, you can point to them as the fall guy. See how easy it is.

As for the "why don't you come see the patient" crap, why don't you go operate on a patient. You went to medical school and had a surgery rotation, right. Its not what we do. We are busy enough reading studies all day. If we take the time to do that, the onc clinic / gi clinic / neuro clinic, etc will be calling wondering why we don't have reports.

Oh yeah, and at every hospital I worked at, a cardiologist does the official read on an EKG (usually a couple days afterwards) and gets paid, even though it has no impact on the care of the patient at that time.

Cardiologists want to do imaging b/c they are greedy and money hungry. So are many radiologists. Too bad the patient gets lost in the fray.

 

[jpro]

These nuc med studies are very specific in what they look for. Am I right? What else could you pick up on a nuc med study? BTW, I'm not talking about whole body FDG PET or anything. I'm talking about the perfusion studies. These cardiac studies are very specific for things only relating to the heart. I agree that the anatomical imaging modalities are best done by radiologist, but the functional imaging dealing with the heart does not require a radiologist. RADRULES already alluded to the fact that catheterization was "easy" so why does it become so difficult and specialized when radiologists and cardiologists fight over it. If you are imaging the body anatomically then you need a radiologist. If you are treating a patient or performing a functional imaging study on a patient I believe you should leave it up to the doctor who knows the patients physiology the best. That would be the cardiologist BTW.

Just wanted to throw that out there.

 

[buz]

Don't mean to be cynical but the popularity of any given specialty across the board is proportional to the amount of money made and inversely proportional to the amount of work needed to make that money. Cards is no exception. However if you want a chill lifestyle, do cards imaging and just analyze stress tests from 9-4 and then drive home in your aston-martin convertible. Stress tests in themselves are of dubious value especially when done as part of the pre-op eval.

My beef with cards is that I think cardiologists have no idea whatsoever what they are doing outside of treating STEMI. The past 30 years of studies of coronary disease has been based on cardiac cath being the "gold standard" and now there is the pink elephant in the room saying whether cardiac cath is of any value at all in "stable" CAD.

My 2 cents.

Abu- I had to respond to a glaring error in the above statement. Stress tests have been repeatedly shown to predict intraoperative cardiac risk, while cardiac cath has never been studied in terms of its predictive value for cardiac risk during surgery. While it seems intuitive that a patient with severe CAD on cath would represent a high risk for intraoperative MI, there has never been a study to prove this. Mounds of data exists on stress tests and pre-op risk, and if you send a pt. with an ischemic EKG to the you're digging a grave for you or the patient.

 

[jdaasbo]

Whiskey Barrel,

Let's be civil about this. Your comments come across as condescending and this does not help you make your point. Dazzling us with radiology technical terms also does help you make your point either. You do not need to convince me that you are a better radiologist than I am.

My initial argument was, that more data is not necassarily better. Frequently it is dangerous for the patient. Performing a test on a patient with a low pre-test probability for a disease will often yield false positives and lead to further diagnostic evaluation. This increases patients' expense and exposure to potential adverse events. This is not good medicine. This is the reason that clinicians do not recommend to their patients whole body CAT scans. This is the same reason that it is poor medicine to order a test to "rule out pathology." A good clinician should indicate for what exactly he/she is looking.

Clinicians (which radiologists by your own admission are not (no stigma here)) regularly choose medical tests and make medical decisions using the results from these tests. We are good at this. I must second that radiology reports which obfuscate the findings with nonspecific language and suggest additional radiologic studies are frequently not clinicaly helpful. I do realize that testing may be inconclusive and that the test ordered by the clinician is not always the appropriate one to answer the clinical question. At my institution it is not infrequent that the radiologist will call and suggest a different modality. When the radiologist's report is unclear, looking at the study myself with the radiologist (attending and or resident/fellow) is sometimes helpful.

Back to the point...

I argue that exposing the patient whom you have high pretest probability for coronary artery disease, but low probability for lymphoma, TB, primary lung cancer or whatever to the dose of radiation appropriate for cardiac CT but then processing only the data relevant to answering the clinical question is good medicine.

I also realize that this concept of "more is not better" may be antithetical to many peoples' beliefs.

Honestly I think this whole turf war is just that, a turf war. I don't know that there will be a clear winner. Perhaps the market will be split. On the other hand it is hard to deny the fact that it is the internist or cardiologist who will order the cardiac CT and never the radiologist. Perhaps clinicians will be more comfortable refering to other clinicians for the reasons outlined above?

We shall see.

 

[Whisker Barrel Cortex]

Whiskey Barrel,

Let's be civil about this. Your comments come across as condescending and this does not help you make your point. Dazzling us with radiology technical terms also does help you make your point either. You do not need to convince me that you are a better radiologist than I am.

My initial argument was, that more data is not necassarily better. Frequently it is dangerous for the patient. Performing a test on a patient with a low pre-test probability for a disease will often yield false positives and lead to further diagnostic evaluation. This increases patients' expense and exposure to potential adverse events. This is not good medicine. This is the reason that clinicians do not recommend to their patients whole body CAT scans. This is the same reason that it is poor medicine to order a test to "rule out pathology." A good clinician should indicate for what exactly he/she is looking.

Clinicians (which radiologists by your own admission are not (no stigma here)) regularly choose medical tests and make medical decisions using the results from these tests. We are good at this. I must second that radiology reports which obfuscate the findings with nonspecific language and suggest additional radiologic studies are frequently not clinicaly helpful. I do realize that testing may be inconclusive and that the test ordered by the clinician is not always the appropriate one to answer the clinical question. At my institution it is not infrequent that the radiologist will call and suggest a different modality. When the radiologist's report is unclear, looking at the study myself with the radiologist (attending and or resident/fellow) is sometimes helpful.

Back to the point...

I argue that exposing the patient whom you have high pretest probability for coronary artery disease, but low probability for lymphoma, TB, primary lung cancer or whatever to the dose of radiation appropriate for cardiac CT but then processing only the data relevant to answering the clinical question is good medicine.

I also realize that this concept of "more is not better" may be antithetical to many peoples' beliefs.

Honestly I think this whole turf war is just that, a turf war. I don't know that there will be a clear winner. Perhaps the market will be split. On the other hand it is hard to deny the fact that it is the internist or cardiologist who will order the cardiac CT and never the radiologist. Perhaps clinicians will be more comfortable refering to other clinicians for the reasons outlined above?

We shall see.

I may seem a little condescending, but its b/c people who have never intepreted a CT or MRI are saying that think they can do it just as well as a radiologist (maybe not you specifically). Its just not true and I find that insulting. I train for radiology for 4 years (after internship) followed by a 1-2 year fellowship (about 75% of residents will be fellowship trained) to master a difficult topic. A cardiologist will take a weekend course on cardiac CT and consider him/herself qualified, when he/she is nothing of the sort. I have the utmost respect for internal medicine docs in their area of expertise (most of my good friends are medicine residents soon to be fellows). However, I expect the same in return.

When clinicians refuse to listen to my advice on an imaging study of choice, it insults me. Even when the study of choice is performed, there are limitations to what imaging can ascertain. Just as you see that patient in follow-up for their undiagnosed chronic pain, not fully controlled hypertension, etc, the radiologists option for unclear situations is to recommend follow-up.

Basically, we have three options when we see a finding.
1. Definitely (or 99% chance) benign, which is actually the most common finding. You just don't hear about it b/c we don't include it in the impression.
2. Definitely malignant (sometimes we can come down hard on certain diagnosis, sometimes biopsy is necessary) or something bad such as abcess or infarct.
3. Can't tell. You can't tell if a 3mm lung nodule or an irregular renal cyst are benign. If we think it has more malignant features, we may recommend biopsy right off the bat. If it is much more likely benign, we will recommend f/u or alternate modality to confirm that finding.

Now extend these three to thousands of possible diagnoses involving every internal organ, bone, muscle, brain, neck, etc inluding 99 y/o patients and 1 day old babies and you have radiology in a (very large and complicated) nutshell.

I feel that people just need to understand the practice of radiology. I feel I understand the practice of other specialists even if I don't know enough to pracitce them myself. Unfortunately, only the really good clinicians truly understand the role and benefit of a good radiologist.

 

[RADRULES]

The truth is simple: Cardiologist want to make more money, so they want cardiac CT and MRI.

Cardiac nucs was given up my the nucs people, mainly because they were "scared" of dealing with chest pain during the stress portion of the examination. A LOT of those nucs doctor who gave up this are partially were NOT radiologists.

Cardiac CT/MRI is far more advanced a modality and technically challenging than nucs. Also, it requires an understand of imaging physics and the ability to tailor the study for the question at hand.

There is a great deal of information on these studies which would easily be missed by ANYONE other than a board certified radiologist.

As for only imagin the heart.... unfortunately, this is something that some of the vendors are trying to do. They want to limit the FOV to the heart and sell these machine to the cardiologists.

This, in my opinion, is unethical. The amount of radiation exposure in a cardiac CT tailored to the heart is the EXACTLY the same as if you were to image the whole chest. Not imaging the chest is just plain WRONG! You could pick up early lung cancers and other findings and save the patient's life!

The fact that someone would even entertain this option is sad.

The key is that MRI can do much more than just perfusion.... it can assess myocardiac viability... the holy grail... .what is dead and what is just chronically ischemic.

As for CT... I suspect radiology will hold on to this for the long haul. When the patient comes to the ED with chest pain... they will receive a "triple rule out" CT to rule out dissection, pulmonary embolism and acute MI... I doubt that cardiologist will be reading these.

 

[punjabiMD]

As for CT... I suspect radiology will hold on to this for the long haul. When the patient comes to the ED with chest pain... they will receive a "triple rule out" CT to rule out dissection, pulmonary embolism and acute MI... I doubt that cardiologist will be reading these.

what a waste of cash to do a CT on every patient with chest pain. I don't see this being done on any chest pain patient unless indicated by the history given by the patient... althought most CP patients I've seen will at least get an CXR done. Doing it on every single person who presents with CP is simply ridiculous. We might as well stop getting histories on them as well.

 

[CCMD2005]

The radiologists will probably hold on to interpreting the images in the hospital, but that is not where the money is to be made.
Outpatient imaging will be done by cardiologists if new rules are not put into place that prohibit "self-referral for this procedure" because all the cardiologist will have to do is buy a CT scanner with a "limited window" and start radiating people.
We'll see, I have a feeling both groups will end up interpreting the imaging modality, not to mention a bunch of the big name cardiology fellowship programs (Duke, Texas Heart, Mayo, Cleveland, etc.) are incorportating CT/MRI into the fellowships and I read that more cardiologists are in cardiac CT/MRI specific "fellowships" than radiologists.
I just say we wait until we have better data to show that it actually affects outcomes before we get too carried away.
This "self-referral" arguement is weak (because it wouldn't allow urologists to do urodynamic studies nor cystos, nor GI men/women to do colonoscopies, nor cardiologists to do caths, etc.)...a better arguement is that people should meet competencies before they can be reimbursed for imaging (be they radiologists or cardiologists). That would bring about the highest quality image interpretations.
-CC

 

[usmlestep12]

I may seem a little condescending, but its b/c people who have never intepreted a CT or MRI are saying that think they can do it just as well as a radiologist (maybe not you specifically). Its just not true and I find that insulting. I train for radiology for 4 years (after internship) followed by a 1-2 year fellowship (about 75% of residents will be fellowship trained) to master a difficult topic. A cardiologist will take a weekend course on cardiac CT and consider him/herself qualified, when he/she is nothing of the sort. I have the utmost respect for internal medicine docs in their area of expertise (most of my good friends are medicine residents soon to be fellows). However, I expect the same in return

That's the source of this BIG issue...apparently generated by Radiologists...
A Cardiologist trains for 8 years (against your luxury filled 4 years of sitting on ass)...3 (Int med)+3(Fellowship)+2(Interventional or EP)= 8 full years of hard work...and by hard work I mean real hard work...and you know that well...
And now you claim that you accomplished those things in your 4 years of (sitting on ass) that Cardiologists still couldn't master after 8 looooong years of hard work....

 

[usmlestep12]

This "self-referral" arguement is weak (because it wouldn't allow urologists to do urodynamic studies nor cystos, nor GI men/women to do colonoscopies, nor cardiologists to do caths, etc.)...a better arguement is that people should meet competencies before they can be reimbursed for imaging (be they radiologists or cardiologists). That would bring about the highest quality image interpretations.
-CC

But that wouldn't solve the main turf war...which is "Where should the bucks end up...? Cards or Rads..?? "

 

[CCMD2005]

But that wouldn't solve the main turf war...which is "Where should the bucks end up...? Cards or Rads..?? "

It would solve the "turf" battle because it would allow both radiologists and cardiologists to interpret the study if mutually agreed upon professional competencies of this imaging modality specific for cardiac imaging were established. Hence, ending the "turf" war because the bucks would end up in both camps.
The simple fact of the matter is that patient care is best served with a collaborative (sp?) approach. Although, it may sound like a lofty goal, you need to have high goals to acheive them.
-CC

 

[ReMD]

I do respect Radiologists a tremendous amount. Just as I do a Psychiatrist or any other medical field. Maybe, I don't know as much about reading images but the same goes for some types of skin biopsies or pain injections that I do. Yeah, a Derm guy may be better at doing a skin biopsy but I still do them all the time. Same for injections. Basically, with an M.D. you can practice both medicine and surgery. It's all about the comfort level of the physician.
If Cards want to read studies, and they feel comfortable doing it, then they will do it. Same goes for any other field. If a Radiologist feels comfortable managing medical problems, then they can do it.
It's unfortunate to some extent for rads but as technology advances, many clinicians will begin using it to their advantage. Let's be realistic, money is a huge factor. But whiose going to stop them. They essentially control the patients and can send them wherever they want.
I personally would much rather have a Radiologist reading my abd CT or the like, but I would feel very comfortable having a Cards read an perfusion study or cardiac imaging. The general public usually won't know the difference b/w either. All that matters is who/where they're referred to.

 

[Whisker Barrel Cortex]

That's the source of this BIG issue...apparently generated by Radiologists...
A Cardiologist trains for 8 years (against your luxury filled 4 years of sitting on ass)...3 (Int med)+3(Fellowship)+2(Interventional or EP)= 8 full years of hard work...and by hard work I mean real hard work...and you know that well...
And now you claim that you accomplished those things in your 4 years of (sitting on ass) that Cardiologists still couldn't master after 8 looooong years of hard work....

"Luxury filled 4 years of sitting on ass." You obviously have some incorrect ideas of what radiology entails. The number of calls I take is similar to what a medicine resident in my year of training takes. While on call, I am busier than any of the medicine residents or interns are and make more decisions that affect patient care than they do. And I have two more years to go while the medicine folks are about to start fellowship next year. So please get off of your high horse and get a clue.

The point is that those "8 loooong years of hard work" include minimal image intpretation of CT/MRI. Even if they do more training in imaging (I would think at least a year would be required focusing only on imaging), it will not cover other pathology that is inluded on these studies. I had a 2nd year cardiology fellow ask if the vertebral body was the aorta on a cardiac MRI. Yeah, thats what his 6 looong year of training taught him. Most of the cards fellows have no idea what MRI sequences are, what they show, how they're done, etc. Its just not in their training. If you asked me to manage an acute MI patient or manage a arythmia, I wouldn't be able to do it. Why is the inverse situation so incomprehensible to you?

Thank you for the insulting post. Now I have absolutely no respect for you personally and will not take any of your posts seriously. And its not really 8 years to become a general cardiologist, its 6. Good job artifcially extending the length of training to make it seem longer for your argument. I can do the same. Almost all radiologists do a fellowship and do internship so maybe I should say the training is 1 year internship + 4 years radiolgoy + 1 year chest fellowship. Or I can do as you do to try to make it seem longer and add on a neuroradiology fellowship (2 years) and neurointerventional fellwoship (2 years) so that it extends to 9 years total. Ohhh, see radiology is longer than cardiology . Maybe they should start doing cardiac caths again.

 

[Whisker Barrel Cortex]

Basically, with an M.D. you can practice both medicine and surgery. It's all about the comfort level of the physician.
If Cards want to read studies, and they feel comfortable doing it, then they will do it. Same goes for any other field. If a Radiologist feels comfortable managing medical problems, then they can do it.

Its not just a matter of being "comfortable" with something. Its a matter of doing it well and being trained in all aspects of what you are doing.

 

[usmlestep12]

Its not just a matter of being "comfortable" with something. Its a matter of doing it well and being trained in all aspects of what you are doing.

Alright agreed that you work as hard as the Cards fellows...
However there is something more to the coronaries than just reading the scans and X-rays ..so much so that it takes 8 years to master that art..(yes absolutely ..please update your knowledge on this since most of the EP and Interventional are going to be 2 more years after Cards felowship)..

And during those 5 long years ( after those 3 years of internal medicine) they are so busy studying just the heart and coronaries that they hardly have time left to even peep into anything else...
In other words I want to say that it is not just Cath -angios or CT-MRIs that are enough for investigating a coronary problem...A full time Cardioloigst is in fact indespensible for the diagnosis of a coronary problem...

 

[RADRULES]

A cardiac CT is nothing more than a high resolution contrast enahnced CHEST CT. This means that the entire CHEST is imaged, not just the heart.

There is an entire sunspecialty of CHEST radiology, and cardiologists who want to read cardiac CT should be prepared to read the whole study.

It is very simple, if you are scared to read the whole study, then you have no business reading a Cardiac CT. This "small FOV" stuff is just plain unethical.

But, it just proves the greed of cardiologist. We will see what happens, a LOT of cancers will be missed by cardiologists and I will be the first one to nail them to the wall.

Just the other day I overread a cardiac MRI read by a cardiologists where he missed several lesion in the spine. It is not good patient care and poor form on their part.

By the way, Cardiac cath was invented and pioneered by radiologists. I have done several myself and they are not that hard to do or interpret. If you have good angio skills, they are easy.

 

[CCMD2005]

How long do you think it would take to learn chest CT or cardiac MRI?
- 6 months, 1 year, 2 years? Current fellowships are 1 year after completing cardiology training.
-CC

 

[ReMD]

I think the radiologists on this forum really want to be Cardiologists. It's not too late if that's true. Then they'll never have to worry about losing their procedures/imaging realm again.

It's just a matter of time before other specialties do the same as Cardiology.
tActually, they've already started. Once the new generation of clinicians graduate, the Radiologist will have a much more limited role when it comes to certain procedures/imaging.

Whoever controls the patients, will win the turf wars.

The Radiologist will never even know when some of these procedures are done or the images are interpreted by the clinicians.

If you went into Radiology to do procedures or interpret the imaging studies mentioned on this forum, then you'll be very disappointed in the near future.

 

[Whisker Barrel Cortex]

I think the radiologists on this forum really want to be Cardiologists. It's not too late if that's true. Then they'll never have to worry about losing their procedures/imaging realm again.

It's just a matter of time before other specialties do the same as Cardiology.
tActually, they've already started. Once the new generation of clinicians graduate, the Radiologist will have a much more limited role when it comes to certain procedures/imaging.

Whoever controls the patients, will win the turf wars.

The Radiologist will never even know when some of these procedures are done or the images are interpreted by the clinicians.

If you went into Radiology to do procedures or interpret the imaging studies mentioned on this forum, then you'll be very disappointed in the near future.

I think that you want to be a radiologist. I understand you couldn't get into radiology, but thats no reason to be a hater (this sort of asinine post on your behalf deserves this kind of response). Too bad patient care is now secondary to your ego and pocketbook.

 

[Whisker Barrel Cortex]

How long do you think it would take to learn chest CT or cardiac MRI?
- 6 months, 1 year, 2 years? Current fellowships are 1 year after completing cardiology training.
-CC

The problem is that the lungs, spine, mediastinum, vertebral bodies, esophagus, etc all have pathologic and benign conditions that can be seen on these studies. The training you receive in an imaging cardiac imaging fellowship will not prepare you to deal with these findings. Its a shame that monetary issues are clouding the cardiologists desire for adequate patient care. The people that lose the "turf war" are the patients.

 

[Al Pacino]

But, it just proves the greed of cardiologist. We will see what happens, a LOT of cancers will be missed by cardiologists and I will be the first one to nail them to the wall.

Count me in. I will be starting my radiology residency in a year, and reading this thread is motivating me to do my best in residency so that I can provide the best patient care and also nail these imposters who think they can provide radiological readings as good as those who undergo 5-6 years of a radiology residency.

 

[RADRULES]

"new generation of clinician."

HA HA HA HA!!!!

This is the funniest thing I hav heard in a long time!

If you mean ZERO ability to do a physical exam and total dependence on imaing... then we agree and I am not very worried.

Once in residency we made the dx of zoster on a pt with chest pain by CT... we could tell on CT that his shirt had not been removed and his chest was never examined.

 

[Santiago]

For the last few posts by ReMD and Usmlestep12, I can only say ignorance( about Rads) is bliss.
Leave radiologists, all other specialities are pissed with cardiologists.
I believe, if and when there is a turf war, cardiologists will def win against us unless the patients themselves decide and the various regulatory machanisms come into play. If things moves as it is, based solely on economics, we stand a slim chance.
What I am pissed off is why do we as radiologists teach radiological/interventional skills to non radiologists which then comes back and bites us in the ass in the not too distant future?
I interviewed for fellowship spots in VIR and in some places the rads people were training vascular surgeons and cards. Part of the blame lies with us. Look at how many VIR spots were left unfilled last year.

 

[usmlestep12]

The problem is that the lungs, spine, mediastinum, vertebral bodies, esophagus, etc all have pathologic and benign conditions that can be seen on these studies. The training you receive in an imaging cardiac imaging fellowship will not prepare you to deal with these findings. Its a shame that monetary issues are clouding the cardiologists desire for adequate patient care. The people that lose the "turf war" are the patients.

Once again you don't understand the real issue here...
When a Cards doc orders the Cardiac CT or MRI...he is not looking for chest tumours or vertebral lesions...nor is he suspecting any of them ...his interest is coronaries...and I bet you that nobody can interpret coronaries better than him...
and also to mention few more things here... a lot of Cardiac pathologies are linked to lungs too...like you have pulmonary edema in cardiac failure...or you have cardica failure in cor-pulmonale...and many more...
And a Cardiologist is better aware of these facts...better than anyone else in this world...since he has seen the patient clinically...followed him up for years...treated him...and much more...
so the bottomline is that when a patient is referred for Cardiac CT or MRI in perspective of a coronay lesion...a Cardiologist should be the first person to read and interpret it...and if there is anything left then it can be reffered to Rads...
However directly sending the Cardiac CT or MRI to the Radiologist to screen the tumours or vertebral lesions (which may not be important in a case of emergency) in a patient having classical symptoms of coronary disease and awaiting stenting or Bypass surgery depending on the outcome of his Cardiac CT or MRI doesn't make any sense to me...

 

[Santiago]

No, you don't understand.
Cardiac CT and Cardiac MR's are not like EKG's/Stress imaging where only the heart is involved. They are investigations which are expensive and involve a good dose of radiation(fot Ct atleast). Also, if a cardiologist and rads both read & bill the image, the costs would be catastrophic. Thats the main prob in self referral.
Also, I beg to differ that a card would read coronaries better than a fellowship trained rads. We have seen too many examples.
Its all about the economics. You want to get into it for the money, maybe you will be forced to leave it also for the money.
Every speciality thinks they can read images better than radiologists in their own organ area. This is a misconception. We ourselves go through organ and modality based fellowships to reach that level of expertise. Neuroradiology fellowships are a prime case in point. There might be a few neurologists and surgeons who may read it as well as neuroradiologists but for the majority, its not the case.

 

[GoPistons]

I don't think there is any doubt that Cardiologist's will start interpreting their own scans. Their overwhelming arrogance to think that they are good enough interpreters to not miss things will come back to bite them in the ass. I eagerly await the first of many legal cases in which spinal lesions, lymphoma, and lung cancer are missed. It is almost laughable.

I learned to interpret EKGs in the 2nd year of medical school, during my medical rotations, and during my intern year, and you know what?? I can't interpret them very well. I am not arrogant enough to think that my paultry training in it makes me good enough to identify very subtle findings. In the same way, Cardiologists now think they can glance over the spine, ribs, lung, and LNs, and honestly say they know what they are doing? Give me a break? Radiologist's train for years and see millions of images to pick out subtle and suspicious lung nodules. Furthermore, most cards don't have a clue about the various MRI sequences, etc. involved in imaging... and they shouldn't.

This is about money and only money. If EKG interpretations paid $500 / study, would other clinicians convince themselves they were good enough to interpret them?? Of course they would. In reality, that will just hurt patients and make many lawyers very rich.

For you Cards out there. Go ahead and interpret your cardiac images. When you are destroyed on the witness stand, you can then use your arrogance to figure out how you are going to finance your rising insurance premiums.

 

[Al Pacino]

Back to the point...
I argue that exposing the patient whom you have high pretest probability for coronary artery disease, but low probability for lymphoma, TB, primary lung cancer or whatever to the dose of radiation appropriate for cardiac CT but then processing only the data relevant to answering the clinical question is good medicine.

So, let me see if I understand you correctly. You believe it's appropriate to order a chest CT and only read the heart, but ignore other findings that may pop up in systems outside of the heart. So let's say the patient has a cancer outside of the heart, will you ignore it because you're only interested in the coronary arteries?

Is that "good medicine" when you have a pt who will die of a missed cancer because you will "process only the data relevant to answering the clinical question"?

 

[Eidolon6]

So the few cardiologists I know now interpreting cardiac MRI did 1 year of training to interpret the tests in the academic medical center. Cardiologists also interpret echos and nuc med studies often in the context of other noncardiac diseases. I'm not really sure the radiology crowd's arguments are up to snuff here. These predictions are cardiologists not being qualified to interpret radiographic tests seem to be reactions of those whose egos are bruised because they don't have some braintrust over their little corner of medicine. My experience has been with multiple specialties that using diagnostic tools involves understanding of the techniques/procedures involved, having a significant volume of experience and integrating clinical context into interpretation. The best radiology guys I've dealt with (most of them private practice guys and not sh*tty rads residents who'd rather refuse tests and pretend they know how to practice clinical medicine because they did a transitional year at Jarvis Christian Hosptial for Wayward Yutes) have been the type to call me on occasion and ask me to paint the clinical picture for them rather than accept the one-line diagnosis that fits on the imaging requisition and spit out the usual "cannot rule out this, that and this" BS. They are they guys I like to call physicians...unlike a fearfully growing number of folks (a fair number of residents in the current radiology rush of the past few years) that think being a radiologist is the best specialty because...you don't have to see/touch the patient and their money gets wired to you electronically.


The other issue here is reimbursement. I don't know any starving radiologists....not one. Now I do know a down-and-out radiologist/alcoholic as one of my VA patients, but thankfully he is no longer practicing...but his downward spiral has more to do with his wife than cardiologists. Frankly, radiological reimbursement is actually one of the current thorns in the health care economic reform (much like pathology of the 80s)...its frankly expensive, whether justifiable or not. Radiologists currently, hour for hour are still some the best paid medical specialists....which is fascinating for a specialty that has such a limited direct patient care role. Cardiologists, surgeons and other subspecialists are not likely to take the significant bite out of the typical radiolo-gits reimbursement, it will be the fed, the insurance companies, HMOs and PPOs....as with all ends of medicine.

 

[Santiago]

Yes, Cards can read and interpret Cardiac MR's and CT's. We are not challenging their right. But you must undergo a minimum period of training, get some sort of certification and then go ahead. It should not be like everyone with a card fellowship can go and do a three week course and start reporting. Cardiac MR/CT is not rocket science, but its not a three week thing too. By all means, do 1- 2 year fellowship in cardiovascular imaging and do it. We radilogists may not like it, but atleast the patients would suffer less.

 

[Whisker Barrel Cortex]

The best radiology guys I've dealt with (most of them private practice guys and not sh*tty rads residents who'd rather refuse tests and pretend they know how to practice clinical medicine because they did a transitional year at Jarvis Christian Hosptial for Wayward Yutes) have been the type to call me on occasion and ask me to paint the clinical picture for them rather than accept the one-line diagnosis that fits on the imaging requisition and spit out the usual "cannot rule out this, that and this" BS. They are they guys I like to call physicians...unlike a fearfully growing number of folks (a fair number of residents in the current radiology rush of the past few years) that think being a radiologist is the best specialty because...you don't have to see/touch the patient and their money gets wired to you electronically.

It goes both ways. First, you have no idea what rads call is like. I have had many instances where people have outright lied to me to get a study done after hours. I will always try to find out what the history is so I can get the study done correctly and perform the right kind of study. Sometimes the history is pretty damn flimsy. Those bright clinical residents response will often be "the attending wanted it." They often don't know much about the patient at all. So please get off you high horse.

The best internal medicine docs I know not only take a good clinical history, they have a general idea of what they are looking for, will listen to your advice on what the best study is, and will review complicated cases with you personally. These are the guys I like to call physicians, unlike the current crop of medicine residents that take a crappy history and physical and just order an imaging study to try to get a diagnosis (isn't it great how the insults can go both ways).

After a 1-2 year fellowship, cards can be good at interpreting cardiac MRI or cardiac CT. We have a cardiologist who interprets MRI along with the rads. He is very good at reading the heart. Most of the time he works with the MRI fellow (a radiologist) so non-cardiac things are not missed. There have been several cases of missed lesions (metastatic spine mass, lung nodule) with him as staff. I'm sure rads have missed things as well, just not as often since we are trained in primary image intepretation.

 

[presidiomd]

Attended a talk by the Cards fellowship director here a few days ago; he said they receive about 400 applications for 4 slots every year (!) He was saying the quality of applicants goes up every year, and that even if they set the USMLE cut off level at 250, there would still be dozens of applicants left.

So, I think they are PLENTY of people that want to go into cards today, and personally, I don't think it's all about the money (though it doesn't hurt). Cardiologists to me seem like intellectuals who are practical and hands on.

Interesting that with all this demand, why don't they increase the number of fellows?

Because they would make less money. It really is that simple.

 

[presidiomd]

But that wouldn't solve the main turf war...which is "Where should the bucks end up...? Cards or Rads..?? "

I know what will solve the turf war. Its called socialized medicine. That's when both of these specialties won't earn ass compared to what they currently make.
The day is coming, and I can't wait. We are all overpayed. Face it. At the end of the day, i'd rather have the radiologist read any film/study, because thats all they do, and who am i to assume that i could do better. Arguing over the internet is like competing in the Special Olympics: even if you win, you're still fu..ing ******ed! I'll admit it. I'm a ****** for participating. And You?

 

[Corazon]

I know what will solve the turf war. Its called socialized medicine. That's when both of these specialties won't earn ass compared to what they currently make.
The day is coming, and I can't wait. We are all overpayed. Face it. At the end of the day, i'd rather have the radiologist read any film/study, because thats all they do, and who am i to assume that i could do better. Arguing over the internet is like competing in the Special Olympics: even if you win, you're still fu..ing ******ed! I'll admit it. I'm a ****** for participating. And You?

Just a thought in regards to socalized medicine.... If and when it happens, the government better be prepared for a MASS EXODUS of physicians, b/c I have spoken to numerous docs in PP that would retire as soon as they could once medicine is socialized. It is not something the government can simply put in place and think that physicinas will simply be the puppets of a socialized framwork within an otherwise capitalistic system. It seems like a good idea (in the liberal mind) but would not work nearly as well as many would think.

In regards to Cardiac CT/MRI... a logical and fair solution I have heard from both cardiologist and radiologist is to split the professional fee 50/50. Therefore the scan is read by both, the patient experiences maximal benefit, and everyone gets their piece of the pie. The real thing at stake is who gets to keep the technical fee which is where the $$$ is at. I imagine WBC and RadRules will attest to this that Radiologist that make big bank make most of their $$ from the technical fees not from the $$ they get from reading the films. This is the sole reason why self-refferal is such a threat to radiology.

 

[Whisker Barrel Cortex]

Ok,

I am done with this discussion. I will hold on to my belief that cardiologists will be doing a disservice to their patients by being the primary intepreters of cardiac CT. Its obvious that I cannot convince those who disagree. The monetary issues are too convining for cards for them to ignore this rising field. With the amount of work cardiologists have to do these days, it surprises me that they are trying to find more work to do. Actually, the same goes for radiologists, who are already very busy. We will see how regulatory and market forces play out in the next 10 years. It does make me sad that cardiologists, who often insulting refer to the lack of direct patient care provided by radiologists, are willing to sacrifice the best care for their patients for the sake of the almighty buck.

 

[Corazon]

Ok,

I am done with this discussion. I will hold on to my belief that cardiologists will be doing a disservice to their patients by being the primary intepreters of cardiac CT. Its obvious that I cannot convince those who disagree. The monetary issues are too convining for cards for them to ignore this rising field. With the amount of work cardiologists have to do these days, it surprises me that they are trying to find more work to do. Actually, the same goes for radiologists, who are already very busy. We will see how regulatory and market forces play out in the next 10 years. It does make me sad that cardiologists, who often insulting refer to the lack of direct patient care provided by radiologists, are willing to sacrifice the best care for their patients for the sake of the almighty buck.

Refer to above post. What problem do you have with a 50/50 split of the reading fee? It seems fair to me. Let the patient decide whether he/she would rather have the study done 1) At the Cardiologist's office, where he/she is already present, being that the cardiologist is the physician actually taking care of the patient. Let Cardiologist convey any secondary findings of study(Pulmonary/spine/esophageal/etc..) to patient after receiving radiologist interpretation of non-cardiac aspects of study. Or, 2) Leave Cardiologist's office , go to radiologists office, get study done, and then return to Cardiologists office to f/u results of "cardiac" aspect of study since radiologists does not ever talk to the patient and makes no clinical decisions for them.

Funny thing is I don't think that radiologists actually care that much about what is best for the patient (in this partiucular case). What they care about is fighting self-referral b/c they do not want to lose hold of the "business" aspects of radiology. Rather, they feel that money made from the techinical aspects of radiological studies should be theirs, and only theirs. This is not an issue with only cardiologists. It is also happening with Ortho/ENT/Neurosurg/Neurorads. I view the move by other specialties to implement imaging into their offices as a wise entrepreneurial venture. If you guys really just want to help patients then just read the study.

I know you guys will quote literature that "proves" self-referral is driving up imaging costs. Thats fine. I'm not going to dispute that, but let the Ins Companies and Medicare decide that. I have not read the studies specifically, but would like to read them if someone could post them.

You guys should have no beef with reading the non-cardiac portion of the Cardiac Ct/MRI for a portion of the "professional" reading fee: IF what you really care about is the best interest of the patient. You may say that NO ONE can provide the quality of images that imaging centers, owned by radiologists, can provide, and therefore radiologists shopuld be the only ones to actually obtain the images. I'll put forth that with a little effort (and capital) that non-radiologists can provide the same quality study that you guys can. Once this becomes the norm, radiologists will be left with what is REFERRED to them b/c you guys assume no primary responsibilty for the patient and therefore no control over where the patient goes to obtain medical care of any form. Bottom line, with everything else equal, it is more conveient for a patient to get everything done in one place. This is the future of medical care in our convenience driven society.

 

[Whisker Barrel Cortex]

I know you guys will quote literature that "proves" self-referral is driving up imaging costs. Thats fine. I'm not going to dispute that, but let the Ins Companies and Medicare decide that. I have not read the studies specifically, but would like to read them if someone could post them.

Here are the studies. The most robust studies showed 2-8 X increased imaging. Some included CT/MRI/US, some only plain film. No current studies are yet available for cardiac CT or MRI. I cannot access the articles themselves from where I'm at. So you'll have to find them yourself.

Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice—a comparison of self-referring and radiologist-referring physicians. N Engl J Med. 1990;323:1604-1608

Referrals to physician-owned imaging facilities warrant HCFA’s scrutiny : report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives. Washington, DC: U.S. General Accounting Office

Levin DC, Parker L, Intenzo CM, Sunshine JH. Recent rapid increase in utilization of radionuclide myocardial perfusion imaging and related procedures: 1996–1998 practice patterns. Radiology. 2002;222:144-148

Childs AW, Hunter ED. Non-medical factors influencing use of diagnostic x-ray by physicians. Med Care. 1972;

Hemenway D, Killen A, Cashman SB, Parks CL, Bicknell WJ. Physicians’ response to financial incentives. Evidence from a for-profit ambulatory care center. N Engl J Med. 1990;322:1059-1063

Radecki SE, Steele JP. Effect of on-site facilities on use of diagnostic radiology by non-radiologists. Invest Radiol. 1990;25:190-193

Strasser RP, Bass MJ, Brennan M. The effect of an on-site radiology facility on radiologic utilization in family practice. J Fam Practice. 1987;24:619-623

 

[Eidolon6]

So please get off you high horse.

No, thanks. I like it up here. I've got really long legs.

 

[Corazon]

Here are the studies. The most robust studies showed 2-8 X increased imaging. Some included CT/MRI/US, some only plain film. No current studies are yet available for cardiac CT or MRI. I cannot access the articles themselves from where I'm at. So you'll have to find them yourself.

Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice—a comparison of self-referring and radiologist-referring physicians. N Engl J Med. 1990;323:1604-1608

Referrals to physician-owned imaging facilities warrant HCFA’s scrutiny : report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives. Washington, DC: U.S. General Accounting Office

Levin DC, Parker L, Intenzo CM, Sunshine JH. Recent rapid increase in utilization of radionuclide myocardial perfusion imaging and related procedures: 1996–1998 practice patterns. Radiology. 2002;222:144-148

Childs AW, Hunter ED. Non-medical factors influencing use of diagnostic x-ray by physicians. Med Care. 1972;

Hemenway D, Killen A, Cashman SB, Parks CL, Bicknell WJ. Physicians’ response to financial incentives. Evidence from a for-profit ambulatory care center. N Engl J Med. 1990;322:1059-1063

Radecki SE, Steele JP. Effect of on-site facilities on use of diagnostic radiology by non-radiologists. Invest Radiol. 1990;25:190-193

Strasser RP, Bass MJ, Brennan M. The effect of an on-site radiology facility on radiologic utilization in family practice. J Fam Practice. 1987;24:619-623

I appreciate you posting the references. I look forward to reading them. I still am interested in your opinion of a 50/50 split of the reading in regards to Cardiac CT/MRI?

 

[Docxter]

I appreciate you posting the references. I look forward to reading them. I still am interested in your opinion of a 50/50 split of the reading in regards to Cardiac CT/MRI?

This should be OK as long as both parties have adequate training, and no self-referral abuse is involved.

 

[Docxter]

No, thanks. I like it up here. I've got really long legs.

I guess that's the best answer when you have nothing logical to say. Maturity just radiates out from you, doesn't it?

 

[RADRULES]

CORAZON,

What you fail to understand is that imaging equipment in a radiology department is STATE OF THE ART. Imaging equipment in physician offices is CRAP.

This may change, but currently Orthopods keep 0.2 Tesla magnets in office with **** extremity coils. The images off of these things are pure crap. I would never read something off of one of these things unless I had to.

The MR scanners in a imaging center or rad department will be 1.5 T at minimum.

Plus, we are imaging experts, we can tailor studies to answer the clinical question and take full responsibility for the exam. With in office imaging you don't even know/trust the technologist.... you have no input on how the study is done.

As for what you said about Technical fees.... that is not really true. Most private practice radiology groups do NOT own the equipment... the hospital which contracts with the radiology group owns the equipment. That is how non-radiologist were able to move in on the fluoroscopy suites (vascular surgery) and Gamma cameras (cardiology). Most of the income which the group derives is from the professional fee. Some radiology groups do own imaging centers and the like. However, there is a lot involved in owning and maintaining state of the art imaging equipment, especially with CT and the radiation issues. MRI is still very expensive... you can expect $2 million for the 1.5 T machine and from $200k a year in keeping in up.

Thus, only large clincian groups would get involved in this, and there would be TREMENDOUS temptation to self-refer when given the expenses involved.

 

[Whisker Barrel Cortex]

I appreciate you posting the references. I look forward to reading them. I still am interested in your opinion of a 50/50 split of the reading in regards to Cardiac CT/MRI?

I agree with Docxter that this is an acceptable alternative as long as the cardiologist interpreting the study has had fellowship training in cardiovascular imaging.

I also think that self-referral to your own imaging center is ripe with opportunities for abuse. Even if subconsiously, clinicians tend to order more studies when it is their own imaging facility, as the above studies show. When you are dealing with the cost and radiation dose of cardiac CT, this becomes a significant concern. I know of several examples of clinicians who decided to get into imaging, bought their own scanners, and found that the income from that imaging didn't quite cover the expenses. Some of these physicians got rid of the leased machine. I suspect some of the others just SOMEHOW needed more imaging on more patients. There are also studies that show that non-radiologist owned facilities are also more lax in radiation safety and protection.

I would also ask that all cardiologists who own their own CT scanner should be required to have the same education radiation physics and radiation biology that radiologists do.

I think there is much to come on the regulatory front to stem the overutilization of imaging, and self-referral is part of that. I foresee that:
1. Certification will be required to own, operate, and lease imaging equipment.
2. Certification and specific training will be required to interpret imaging.

Other possible changes will include:
3. More requirements in terms of adequate indications for studies.
4. Decrease in reimbursement for all studies. This especially applies to follow-up imaging. This is the real threat to radiologists incomes, not the competition.

A little background: Back in the early 80s, mammography was performed in many general physicians and surgeons offices. The quality of these studies was horrendous and varied wildly from facility to facility. The government intervened and enacted the Mammography Quality Standards Act. Once these requirements were put into place, the non-radiologists almost completely ceased performing and interpreting these studies. Some radiologists decry these requirements as overly onerous, but it is not disputed that this has immeasurably improved imaging. I foresee similar, but hopefully less onerous requirements for other imaging in the future.

In case you can't tell, this is one of my pet issues and I have given presetations on this topic.


As for this:

No, thanks. I like it up here. I've got really long legs.

It really speaks volumes as to the poster by itself. No other response is necessary.