Why would anyone go into cardiology today?

[Corazon]

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.

My statements about the technical fees were based upon what a lot of PP radiologists have told me, but I imagine that it is different everywhere. I'm glad to see that there is some common ground as far as the 50/50 split for the reading fee goes. Unfortunately, as much as Physicians bicker between each other regarding the numerous turf wars, the patients are the ines that ultimately lose out. My feeling is that all of this will work itself out, and if non-radiologists want to own and operate imaging equipment then they should be held to the same standards that radiologists are. ( I would hope they already are, but it seems that it is not so being that an orthopod can use a magnet 7-8 times weaker to do MSk imaging, I am assuming that telsa are linearly proportional to magnet power). At any rate, if everyone compromises and shares the fruits that new technologies bare, then hopefully the patients will not get lost in the shuffle and everyone can contribute to patient care.

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[Docxter]

A few months ago, there was a cardiologist who was posting on auntminnie.com, a radiology website. I can't seem to find the exact post but here's the gist of it: His group owned an MRI machine to which they would refer. He said that his business manager expected x number of MRI studies per month from the cardiologists in the group (regardless of medical necessity). If they were going low on the numbers towards the end of the month, he actually had the audacity to say something like "I would then order MRIs for everyone coming through my office, and there's nothing you loser radiologists can do". He also mentioned how the new self-referal rules have enabled him to milk medicare and the system via this route. I have to look more to find the exact post, but I guess you get the picture.

 

[usmlestep12]

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.

It goes both ways again...
I would also like to see the Radiologists who want to interpret the Cardiac CT or MRI or coronaries to undergo same training(I am not quoting the number of years it takes ..you can judge that yourself) that Cardiologists undergo...of seeing the patients...taking histories...managing clinical problems..interpreting the accompanying EKGs (if you have missed that in your med-school cuz you never wanted to be a cardiologist)...in order to correlate everything...
this is because Coronoary findings on X-ray ,CT or MRI are just not representative most of the times of what is going on inside the patient's body...
It's a big picture that you need to take clinical decisions or to interpret those images...

 

[Whisker Barrel Cortex]

It goes both ways again...
I would also like to see the Radiologists who want to interpret the Cardiac CT or MRI or coronaries to undergo same training(I am not quoting the number of years it takes ..you can judge that yourself) that Cardiologists undergo...of seeing the patients...taking histories...managing clinical problems..interpreting the accompanying EKGs (if you have missed that in your med-school cuz you never wanted to be a cardiologist)...in order to correlate everything...
this is because Coronoary findings on X-ray ,CT or MRI are just not representative most of the times of what is going on inside the patient's body...
It's a big picture that you need to take clinical decisions or to interpret those images...

Do you even know what a radiologist does? We intepret images in conjunction with clinical history and often with discussion with the clinician in order to reach an appropriate diagnosis. We tailor studies to obtain the best possible study, we understand imaging and the clinical basis for imaging very well. We do this every day in every part of the body.

And please stop with all your references to your years of study. Its totally irrelevent in that it provides minimal to no education in CT/MRI

Uhh. I thought I was gonna be done with this post. I just can't leave responses like this alone.

 

[Voxel]

Come-on. You're wasting your breath. We know what it's all about.

 

[hans19]

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.

When the government stepped in, the reimbursement also dropped... Is it a coincidence that non-radiologists suddenly wanted nothing to do with them anymore?

 

[Bonobo]

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.

Actually, there is a major study looking at preop coronary revascularization prior to vascular surgery. The results have suggested that cardiac cath as a pre-op tool is not very useful, especially if it delays a semi-urgent surgical procedure. Of course, this is only one study.

B



B

 

[Bonobo]

I think this is a fantastic debate showing how complicated the medical system is in the US. Please hold the insults and heated comments and realize how much interesting opinion and information is being presented. It would be interesting to hear a similar debate between top cardiologists and radiologists, as well as economists, political scientists, business people, and patients added to the mix.

I wanted to make a few comments to hear what you guys think. The 50/50 idea is actually not that great. What physicians would be willing to take on the same time effort and liability for half the price? Rather, in a situation where cardiologists and radiologists are both allowed to read cardiac CT and MRIs, some cardiologists will choose to read them, while others will refer them to radiologists to save time and liability.

Liability, of course, is the way to solve this. Why are general physicians rarely doing surgeries? Liability. If cardiologists are willing to read cardiac CT and MRIs, then they should go ahead with the understanding that they are liable for poor interpretations. Of course, if they find a small lung mass, they might then refer the scan to a radiologist for a better read, but they would have to be able to find the lung mass in the first place.

Cardiologists could lower their liability by simply spending a full year in training how to read these scans. This would not only increase their ability to read the cardiac CT and MRIs, but also give them a defense when being sued for missing a finding that most similarly trained radiologists and cardiologists would miss anyway.

It is because of this that cardiologists will probably win the turf war. Because they can convince the public and politicians that real extra training (i.e. 1 year, not 3 weeks) will level the playing field. Since the "Coalition for Patient-Centered Imaging" represents many more doctors than radiologists and since the former doctors are in control of patients, the self-referral argument is the only thing that radiology really has left. That is why they are pushing it so strongly. However, there is a clear fallacy in this argument (specialists self-refer their patients all the time for things like surgical procedures, interventional pain procedures, EMGs, EKGs, colonoscopies, bhroncoscopies, skin biopsies, etc.)

I personally think this is the right outcome, if and only if any doctor reading cardiac CTs/MRIs is required to have the proper training (a minimum of 1 year on top of typical fellowship training) and the willingness to take on the liability. I should note that neuroradiologists, neurologists, and neurosurgeons were able to collectively reach the decision that if any of these doctors were sufficiently trained, they should be allowed to practice endovascular neurosurgery. Wouldn't it be nice if radiologists and cardiologists got together to do the same rather than start another turf war? Now of course, the neuro-docs were somewhat suspicious in their leaving out of vasc surgeons and cardiologists.....

B

 

[rtk]

There is a good deal of information about this debate available on www.theheart.org . Of course, it likely is slanted to favor cardiology. I'm attaching an interesting exerpt from this source below:

Underpinning the whole debate is the widely held sense among radiologists that they keep "losing" cardiac imaging modalities to cardiologists. In the past year, the Society of Chairmen in Academic Radiology Departments (SCARD) has backed a program dubbed the "Manhattan Project," the aim of which is to provide focused training, particularly to radiologists, in cardiac and vascular imaging. The project's name, borrowed from the WWII effort led by physicist J Robert Oppenheimer to develop the first atomic weapons in the US, was chosen "to highlight time pressure, its level of importance, and the need for a concentrated effort to deliver results," a SCARD website explains.
As Levin puts it: "The cardiologists took over coronary angiography, they took over echocardiography, and in many places they are trying and in a lot of places successfully to take over cardiac nuclear scanning. So the radiologists have kind of lost out to some extent in cardiac imaging," Levin explains. "And now the Manhattan Project is an effort to speed up and improve the quality of the training of radiologists, particularly in heart CT and MRI."

But Budoff believes the aim is to ensure that cardiac CT remains in the radiology realm. "The radiologists are trying very hard right now to come out with guidelines for utilization that call for a radiology residency to be a part of it so that only radiologists can read the CT scans and interpret the images. It's kind of a national war."

In Maryland, for example, a recent Attorney General Official Opinion clarifying the 1993 Maryland Self-Referral Law bars all nonradiology practices from referring patients for CT or MRI tests that are owned by the practice, a law that effectively keeps cardiologists from owning and operating their own scanners. The federal physician self-referral law (the "Stark" Law), other state self-referral laws, state certificate of need (CON) laws, and federal and state antikickback laws may also make it difficult or impossible for cardiologists to purchase CT scanners to be used within their own practices.

Radiologist Dr Dieter Enzmann (UCLA), coordinator and founder of the Manhattan Project, is adamant that his motives were not "political."
"The Manhattan Project seems to have gained some notoriety, but it's nothing more than an attempt on radiology's part to identify sites around the country that could train other radiologists and in fact other cardiologists in cardiac imaging: MRI and CT. It's not exclusive to radiologists, and it's not meant to be political. It's meant to be a self-help training program primarily for radiologists, but also for anyone else."

Enzmann continues, "Whenever something like this comes along, where technologies intersect different specialties, the immediate flag goes up about turf wars and to some extent that discussion is inevitable, but that's not the goal of the Manhattan Project. There's no way that the Manhattan Project could fence out other subspecialties, and that wasn't the goal." Indeed, the 12 hospitals participating in the Manhattan Project by offering hands-on fellowships in CT and MR imaging are open to cardiologists as well as radiologists, and according to Enzmann more cardiologists than radiologists are signing up for the programs.

 

[rtk]

Here's one more exerpt from an article about this debate. It's the summary paragraph of an editorial written by Dr. Anthony N. DeMaria, (Editor-in-Chief, Journal of the American College of Cardiology) titled The morphing of cardiovascular specialists published in the Journal of the American College of Cardiology, 15 March 2005, Volume 45, Issue 6 Pages 960-961:

It is clear from the foregoing that the nature of cardiovascular specialization is poised to undergo another major transformation in response to technological advances. There are, of course, a number of ways in which such change could evolve. It appears that the most powerful and first instinct is that of self preservation, and some are already staking out turf. However, while a tug of war may continue, the winner will always be the group with the greatest knowledge and expertise. Therefore, the turf will always belong to those who have acquired multidisciplinary skills. As various individuals do this, I see a blurring of the boundaries between disciplines, and perhaps the emergence of new types of cardiologists. Coupling ultrasound and radioisotope procedures with the new CMR and CT techniques could form the basis for the cardiovascular imaging specialist. The training of such individuals would consist of both cardiologic and radiologic experiences, and time directed to patient care would be reduced in favor of interpretation of studies. Likewise, the borders of interventional cardiology may blur with that of interventional radiology and peripheral vascular surgery. The pool of individuals for this new specialty could be drawn from all disciplines, and they would focus upon percutaneous treatment of vascular disease. Although it is unlikely that surgeons would cross-train in interventional cardiology, it may be that some physicians in each group will focus so strongly on the percutaneous implantation of mechanical cardiac devices that it may occupy the vast majority of their time. The effect that such changes may have on cardiology are hard to predict. Although these specialists would be further distanced from their colleagues in general cardiology or other subspecialties, such as electrophysiology, they may serve to calm the tensions between major disciplines such as cardiology and radiology. This in itself would be of enormous benefit. In any event, this evolution would be consistent with the trend toward specialization occurring in all phases of contemporary life. The morphing of cardiovascular specialists will be consistent with the apparently widely held current concept that it is better to know everything about something than something about everything.

Seems to me that Dr. DeMaria has a good perspective on this topic...

 

[ReMD]

I agree that Cardiologists or any other clinician should have the training to read imaging studies prior to doing so, as long as they also are willing to accept the liability. That way they can identify a problem and refer it to radiology for a more expanded differential. Similar to the way pts are triaged by clinicians.

This will NOT, however, take an additional year after fellowship. Instead many Cardiology programs, as well as other fellowships, are integrating this training into their curriculums. Some are suggesting using the trainee's 3rd year of Internal Medicine to focus on their specialty of choice if they want. That way a generalist or specialist can use that extra year in their training to:

1) Start their clinical fellowship, then in their last year of fellowship focus on interpreting imaging studies. Or..

2) Use their 3rd year of Internal Med to focus on interpreting the imaging studies.

We have similar programs now, but they are more focused on research for those that want academic careers.

It's just a matter of time before this intergration begins.

Radiologists will still have plenty of business. It is just that many clinicians are seeking ways to increase their income given all the prospected cuts in reimburesment to come.

It's sad but true. We all know the potential serious problems with reimburesments in the future. Ie., a proposed 25% cut in medicare payments in the next 10 years, despite ever increasing inflation and overhead.

 

[jpro]

The original question was, “Why would anyone go into cardiology today?"

If cardiology broke off into its own residency, there is no doubt in my mind that it would be one of the most competitive. Cardiologists do some really neat stuff, and the field is becoming more technology driven. It's a really cool specialty. They make good money, but the hours and call suck. Hey, do what you like. The fact is that people who don't care much about lifestyle are drawn to this field while others only care about lifestyle+money. Some are money hungry, but one could argue that about rads, derm, gas, ENT, neurosurgery, ortho, ect…. heck even FP

I think many of us would choose cardiology because we enjoy the physiology of the heart and all of its plumming. The way medicine is practiced changes rapidly. If you are in a particular field for the wrong reasons then you run the risk of being very disappointed one day.

 

[mellow yellow]

Does anyone know of any decent online or text resources that discuss the different cardiac imaging modalities, indications v. limitations, etc? I looking for something that is concise, not bogged down with technical details, and more geared toward internal medicine/cardiology rather than a rads-slanted view.

 

[jdaasbo]

The latest edition of Hurst's "The Heart" has a chapter on each.

 

[Eidolon6]

Kudos RTK...puts the debate in a more civilized perspective. Thanks.

 

[novacek88]

How would the lifestyle of a non-interventional cardiologist vary from an interventionalist? Why would one want to only practice general cardiology since procedures seems so much more fun and the pay is significantly more as well?

 

[VIR]

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 read your own chest x rays? With all due respect, your confidence in your abilities and that of your clinical colleagues to arrive at a diagnosis is heavily reliant on your interpretation of the clinical scenario. You don't understand the nature of the imaging findings. You don't understand the variations in presentation. Radiology generates a list of potential causes of a specific finding, and tailors it based on the clinical scenario if you deign to include it on your requisition. Yes, you have an advantage of knowing the patient. But what are you looking for on the film? Your differential will include pneumonia, failure, atelectasis and perhaps COPD. It's a small list. Now if you are looking for a white patch on a black lung to confirm your suspicion, you've confirmed it without understanding how that image is formed, and your diagnosis may or may not be right. Perhaps it will be right most of the time. I would venture to say that most of the time is not good enough. I can also prescribe antibiotics and be right most of the time. Eventually, you will be wrong, and will learn an expensive lesson.
Incidentally, of all studies you could have chosen to read on your own, the chest xray is the hardest. It is much easier to read a CT. There are so many potential pitfalls hiding in a chest xray, honestly, you're asking for real trouble.
From a small pneumothorax, or atypical presentation of pneumothorax in a supine patient, to lung nodules that I guarantee you won't pick up. I have seen a young man with a medastinal germ cell tumor, missed by the primary care physician on his office xray unit, present with widespread mets. He was very angry. The original film had an obvious mediastinal mass.
As for peripheral interventions, well cardiologists have long had the philosophy that if it's narrow, stent it. This was controversial in the heart. In the peripheral system it is actually harmful. A good friend of mine left his practice after the cardiologists started doing carotid stents after a weekend course. He offered them 500 dollars for every case they didn't do. He took a different job at a better practice.
In a nutshell, there is no shortage of second rate care. You can do anything you want to do and bill for it. No one can stop you. Eventually you will have a bad experience, worse of course for the victim of your arrogance, and will reconsider.
Good luck with those chest films. I'm sure they're all negative.

 

[VIR]

Numerous posters in the medical specialities have said that radiology will decline as clinicians adopt imaging techniques in their practices.
I am touched by your concern, and to that end I would like to reassure you that with every year, our numbers go up. With every increase in our diagnostic capability, which you think you will co-opt as part of your practice, our numbers go up. Would you like to know why?
It is because there are more in medicine who are substandard physicians than there are intellectuals like yourself. At a certain point, people begin to get into a rhythm, they have a set way they do things. An aggressive guy coming out of fellowship will try to co-opt emerging moneymakers in radiology. But most clinicians do not keep up. It requires too much effort to be a master of all trades. Money is not everything, how many things can you buy? Where will you put them?
I'm not saying you are stupid.
Just my observation that the growing power to diagnose has not resulted in a drop in the number of studies due to the number of studies the cardiologist may or may not read. There are, after all, just so many specialists. The generalists continue to order the tests. The specialists continue to order the tests.
Your predictions are nice, but our RVU's are going up.
What might happen is that medicare might drop reimbursement from 400 to 40 on a CT scan, like thwey dropped the reimbursement for cataracts on the ophthalmologists, devastating the specialty. Then the turf war will be over, because who wants to lose money on every study. But we are always the innovators. And to tell you the truth, I would do the same job for 150k. You just gotta like what you do.

 

[v-tach]

How would the lifestyle of a non-interventional cardiologist vary from an interventionalist? Why would one want to only practice general cardiology since procedures seems so much more fun and the pay is significantly more as well?

One possible reason is that general cardiology allows more continuity of care--they tend to be the ones following up with the patients rather than concentrating mainly on procedures. Some people prefer the longer-term patient relationships. Plus, there's more opportunity to counsel patients about healthy lifestyle choices etc. to try and prevent further problems. I, personally, think there needs to be more emphasis on preventive care so people won't need as many invasive procedures. Of course, in fairness, a lot of the problem is that some patients are unwilling to make the lifestyle changes that would help them stay healthier.

 

[DrKram20]

I don't mean to step in the middle of this pissing match here, and I hope I haven't gotten any on me. I was hoping someone could point me in right direction for finding information on cardiac EP, as well as info on some of the top programs etc. Seems like a very fascinating area of medicine.Thanks for the assistance, you may resume the contest.

 

[sbc220]

hi...i am a 3rd year med student at SUNY downstate...i was wondering if someone can address the lifestyle issue in interventional cardiology...most websites i see hover around a call schedule of 1:5...is that reasonable?? how many hours a week does someone work in interventional? thanks...