Expertise and judgment ensure turf war success

Rinckside 2002; 13,4: 13-15.

ecently, I asked a Spanish radiologist how he thought radiology would look in another ten or twenty years. His reply was completely different from what I had expected.

“I am afraid that radiology will disappear as an independent medical discipline. This will not concern me any more, since I will be retired by that time; but I see it coming,” he said.

“Radiology is an artificial medical discipline. It is not like surgery, internal medicine, or their subdisciplines. Radiology is a service. I believe it requires a higher level of medical knowledge than laboratory medicine, perhaps less than pathology, the two other main medical service disciplines. Yet, it remains a service; a radiologist is a doctor’s doctor. Surgeons and other physicians can perform without radiologists; radiologists cannot perform their trade without referring physicians.”

I was rather baffled hearing such statements from a well-established and well-known radiologist. I would rather have expected him to fight for radiology and told him so.

“Sure, I will fight for radiology. It is our field and it is our personal survival,” he said. “This is what we have learned and this is what feeds our families. However, fighting for it does not mean that we will win the fight. Perhaps we will not lose the war, we will win some battles. But we will also lose some battles.”

He pointed out that surgeons, internists, and neurologists helped create our discipline.

“Don’t forget that radiology is one of the youngest medical specialties. X-ray examinations are slightly more than one hundred years old. These days computed radiology will celebrate its thirtieth birthday. Since when do you find departments of radiology in major hospitals? Perhaps sixty years? And in minor hospitals? Perhaps forty years?”

He speculated where there is one huge radiology department today, there could be seven or eight units all over the hospital: “Here today, gone tomorrow. The future of radiology is diagnostic imaging which might exclude radiologists. The other doctors will carve it up.”

These were strong words. The technology revolution has also opened imaging to other medical specialists who have imaging equipment in their practices. Many obstetricians, gynecologists, oncologists, and urologists have acquired their own ultrasound equipment. The ultrasound imaging business outside radiology practices accounts for 70% of the volume of ultrasound in the United States of America [1]. In Germany, the overall figure for imaging without the involvement of radiologists is of a similar magnitude.

"Are other physicians picking cherries out of radiology's cake?"

Thus, one easily understands the resigned comments of a German radiologist:

“Radiologists will be killed by physicians of other disciplines taking over imaging. Orthopedists, neurologists, cardiologists, you name them. They pick the cherries out of the radiological cake and leave us the bones.”

A cherry-bone cake, bon appétit.

   On the other hand, surgeons often complain that radiologists take their patients. One surgeon compared the development of radiology with throwing a boomerang. This strange comparison seems apt.

“The idea was getting our hands free for real surgical work by releasing image production to other doctors – throwing the boomerang. However, today the boomerang doesn’t hit its goal but returns and hits us. The radiologists have started doing our jobs,” he said.

Internal medicine practitioners also argue that radiologists are stealing their patients:

“We have lost endoscopic retrograde cholangiopancreatography (ERCP) because radiologists perform magnetic resonance cholangio-pancreatography (MRCP).”

Cardiologists, of all doctors, complain that they could lose coronary angiography because of MR angiography. At the same time the orthopedists complain that the traumatologists will replace them. No discipline seems to be stable any more. There is an all-fronts “turf war” going on.

Cardiologists, vascular surgeons, and neurosurgeons are beginning to acquire and control larger imaging devices such as CT and MRI, either in their own hospital departments or in ambulatory centers. They try to interpret images and bill directly for these studies.

Training in minimally invasive interventional radiology has been introduced for surgeons who try to reclaim their territory. Private radiological practices that rely on patient referral from vascular surgeons suddenly find that these referrals run out if surgeons perform their own image-guided procedures.

As radiologists, of course, we want to fight them. However, even if we could beat them (we can’t), I suggest we join them instead. They need our expertise. They also need somebody to do the job. Economical, collaborative solutions can be arranged according to local laws and medical ethics.

An average cardiologist who starts performing MR imaging examinations of the heart, faces a number of different possible outcomes: remain an average cardiologist and below-average MR specialist, become a good cardiologist who can read some MR images, become a bad cardiologist who finally will become a radiologist, or turn into a workaholic who is a bad doctor.

Exceptions are possible. The same holds for radiologists.

A way out?

In the future, radiologists might have to re-organize their daily work lives and professional activities. However, hasn’t this been the case anyway over the last thirty, twenty, definitely ten years?

I can understand that you don’t want to deal with further changes, but if you want something stable, you may be in the wrong business. Changes in imaging technology influence our daily lives permanently, for good or bad.

Lack of either leadership or cooperation is a problem in radiology as a medical discipline. There is no united front of radiologists, but rather different groups with diverse goals. Money is often the main goal – not the survival of radiology as such. Management of both professional and technical resources has risen in significance. Radiology has turned into a business, even at the small hospital level radiology.

Image reading skills and medical knowledge remain important for radiologists, however. The contribution imaging makes to medical care has grown impressively over the past few years and offers even more promise for the near future. In spite of this, it is difficult for radiologists, referring colleagues, and the public at large to recognize that technological progress does not necessarily ensure a better outcome for patients or financial success for radiologists.

Everybody complains, but only those who act will stay in the race. Radiology is a specialty undergoing rapid transition. According to a recently published study, a total of 73% of the procedures performed by radiologists in 1995 relied on technologies that did not exist in 1970 [2]. Soon you will have to deal with molecular, cellular, genetic, and functional imaging applications. However, radiologists will have to devote more time to managerial, entrepreneurial, and bureaucratic activities, leaving less time to interpret images.

Many radiologists, including department heads – from provincial hospitals to the biggest university hospitals – are unable to find their way through the complexity of their discipline and their departments. New techniques, turf wars, complex administration and reimbursement rules, staff problems, and fights with bureaucrats have made it less attractive over the years.

Radiologists in Europe and the United States are retiring from practice at younger ages for a variety of reasons including, if they are lucky, successful management of retirement funds and the desire to pursue other interests while still healthy. Additionally, many countries also face a growing shortage of radiologists because there is no fresh blood coming in. The reasons are manifold and include the lack of attractive professional prospects, recognition, and financial security.

Some young radiologists in the United States, but also in Europe, lack relevant training. Teaching should be recognized as an essential component of radiology residency training. This is a multi-layered and complex problem.

   In his Annual Oration in Diagnostic Radiology at the RSNA meeting in 2000, Dr. Gary J. Becker pointed out, that “a problem long recognized by interventional radiologists is the lack of clinical training emphasis in radiology residency programs. Because we faculty have been training and creating young interventional radiologists in our own image, they tend to lack clinical skills and their practices lack the infrastructure to compete with other disciplines [2]."

"There will always be a market for a radiologist who delivers good services."

This is where the circle closes. Training of radiologists has to be clinically relevant. If radiologists are doctors’ doctors, they have to understand their medical partners’ needs. In other words: If you deliver good services, there will always be a market for a radiologist.

Surgeons, cardiologists, orthopedists, and internists cannot handle medical imaging without a major loss of quality. In an ever more complex imaging environment, they will need people to produce and interpret images. Even if the medical specialty of radiology doesn’t look like it, never forget that medicine, radiology included, is not an exact science but an art. If handled like a craft, a mixture between art and technology, radiology is difficult and time-consuming to learn and to perform.

   You can teach monkeys to push the bottoms of a CT. However, it takes years to learn how to reject an x-ray examination because it is not necessary.

Relax: The skies are not always gray.

References

1. Margulis AR, Sunshine JH. Radiology at the turn of the millenium. Radiology 2000; 214: 15-23.
2. Becker GJ. The future of interventional radiology. Radiology 2001; 220: 281-292.

Citation: Rinck PA. Expertise and judgment ensure turf war success. Rinckside 2002; 13,4: 13-15.

A digest version of this column was published as:
Expertise and judgment ensure turf war success.
Diagnostic Imaging Europe. 2002; 18,12: 13-14.