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Editorials |
1 From the Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107 (D.C.L., V.M.R.); the Department of Radiology, University of Michigan Medical Center, Ann Arbor (R.L.B.); and the Department of Radiology, Western Pennsylvania Hospital, Pittsburgh (H.L.N.). From the 1997 RSNA scientific assembly. Received July 30, 1998; revision requested September 24; revision received October 26; accepted November 4. Address reprint requests to D.C.L.
Index terms: Editorials • Radiology and radiologists • Radiology and radiologists, socioeconomic issues
In a previous editorial (1) dealing with strategies that radiologists can use when confronted with turf battles, we pointed out that such issues had to be pursued on two levels—local and global. We focused on strategies at the local level and recommended positions or actions radiologists can take in their own hospital or practice environment. Herein, we recommend steps that organized radiology should take collectively.
1. Support mandatory accreditation of imaging facilities. It is no longer legal to operate a mammography facility in the United States without receiving certification from the U.S. Food and Drug Administration (FDA). This requirement was implemented in October 1994 after passage of the Mammography Quality Standards Act (MQSA) of 1992. The MQSA grew out of (a) the realization among women's advocates, radiologists, and policymakers that mammography quality was variable (2) and (b) the existence of the mammography accreditation program of the American College of Radiology (ACR) (3). The ACR and, in some cases, state agencies have been designated as accrediting bodies. To receive FDA certification, a mammography facility must be accredited by an approved accrediting body, such as the ACR, and pass an annual inspection by the FDA. The requirements for physicians interpreting the mammograms are rigorous. In addition to state licensure, the physician must be certified in diagnostic radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, or the Royal College of Physicians and Surgeons of Canada or have at least 2 months of documented full-time training in mammographic interpretation. In addition, he or she must meet specific requirements for both recent practice experience and continuing medical education in mammography. There are also rigorous training and experience requirements for both the technologists and the medical physicist who staff the facility. The facility itself must meet a host of standards covering equipment performance, quality control or quality assurance procedures, radiation safety, films and reports, outcomes analysis, and record-keeping.
The MQSA has increased the bureaucratic hassles with which radiologists must deal (4). From a purely medical standpoint, however, it has clearly had a beneficial effect by forcing substandard providers out of the field. Women undergoing mammography can now be assured that their examinations will be performed properly and interpreted by experienced physicians.
Interestingly, mammography is neither the first nor the only example of federal government regulation of facilities providing medical services. In response to quality concerns in the operation of clinical laboratories, Congress adopted the Clinical Laboratory Improvement Amendments (CLIA) of 1988 (5), which were subsequently implemented in 1993. The CLIA require clinical laboratories that perform moderate- or high-complexity testing to meet minimum standards for quality control, quality assurance, personnel training, patient test management, and proficiency testing (6,7). Monitoring is conducted by either the Health Care Financing Administration or an accrediting organization approved by the U.S. Department of Health and Human Services.
The ACR is now in the process of implementing or developing accreditation programs in ultrasonography (US), stereotactic mammographic and US-guided breast biopsies, magnetic resonance (MR) imaging, chest and general radiography, nuclear medicine, computed tomography (CT), and interventional radiology. Other organizations, such as the American Institute of Ultrasound in Medicine (AIUM) and the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), are doing likewise. In some instances involving radiologic examinations, major payors have begun requiring compliance with either accreditation program standards or their own credentialing standards in order for providers to qualify for reimbursement (Zinninger M, oral communication, 1998). For example, as will be discussed later, Blue Cross/Blue Shield of Massachusetts recently began requiring physicians performing US to participate in a quality-assurance program that has standards consistent with those of the ACR and AIUM accreditation programs (8). Several other third-party insurance carriers in eastern states have adopted similar requirements. In a large preferred provider organization in Michigan, nonradiologists performing US are required to be accredited by a national accrediting body (eg, ACR, AIUM, or ICAVL). Pennsylvania Blue Shield is considering implementing its own MR imaging accreditation program (9) after publication of a study showing major variations in the quality of these examinations (10).
It thus seems that accreditation programs represent a trend that is accelerating. We believe that organized radiology should support this trend. One of the strongest arguments radiologists can make in most turf battles over imaging examinations is that they are the only physicians with the necessary training and experience to conduct and interpret these examinations correctly. This position and, more important, good patient care will be fostered if all providers of imaging examinations and imaging-guided interventions must meet standards mandated by formal accreditation programs. At the same time, we do not imply that the subspecialties of radiology can only be practiced by the type of highly subspecialized radiologists who are typically found in the larger academic centers. Well-trained "generalist" radiologists should be capable of fulfilling the requirements of many or even all of the accreditation programs being developed. Mammography is a good example of this—most accredited breast imaging facilities around the country are located in community hospitals or free-standing outpatient centers.
2. Support physician training standards for diagnostic imaging and imaging-guided interventions. Training standards for physicians are closely related to accreditation programs and clinical practice standards or guidelines (such as those of the ACR). They can be part of an accreditation program, be part of clinical practice guidelines, or stand alone. Cardiologists have been quite active in developing training standards, and some of their models can be instructive. For example, in 1988 a joint task force of the American College of Cardiology (ACC) and the American Heart Association (AHA) published guidelines for percutaneous transluminal coronary angioplasty (PTCA) (11). These guidelines described indications and contraindications for PTCA, expected results, risks, lesion classification, postprocedural management, required imaging facilities, and the requirements for physician training and credentialing. The latter subject was subsequently addressed in more detail in a separate publication by a task force of the American College of Physicians (ACP), the ACC, and the AHA (12); and by the Cardiac Catheterization Committee of the ACC (13). The minimum training requirements called for (a) at least 4 months of full-time experience in a cardiac catheterization laboratory, (b) performance of at least 300 diagnostic coronary angiographic examinations, (c) an additional year of fellowship training or comparable practice experience devoted to PTCA, and (d) performance during the training period of at least 125 PTCA procedures under supervision. It was further recommended that a caseload of 50–75 procedures per year was needed for maintenance of continued competence. Note the inclusion of specific numbers of procedures during a training period.
In the area of diagnostic cardiac imaging, the joint ACP/ACC/AHA task force defined training standards for performance of adult echocardiography (14). For physicians wishing to independently perform these examinations, a long list of cognitive and technical skills must be mastered, and at least 240 two-dimensional or M-mode echocardiograms, including 180 Doppler examinations, must be performed and interpreted in a training setting. The same joint task force has developed training standards that include specific numbers of cases for electrocardiography (15), insertion of temporary transvenous pacemakers (16), and a number of other procedures. As a result of the publication of these standards, it is now difficult for anyone to obtain clinical privileges to practice these procedures in hospitals without documentation of the requisite training. Although they do not have the force of law like the MQSA or CLIA, hospital credentialing committees are well aware of them and use them in making decisions.
For training standards to have impact, they should ideally be rigorous, sponsored by multidisciplinary organizations, and published in widely read journals. In radiology, relatively few such standards have been developed. One standard occurred in 1992, when the Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, and Clinical Cardiology of the AHA developed training standards for peripheral percutaneous transluminal angioplasty (PTA) (17). In addition to calling for acquisition of a body of knowledge pertaining to peripheral vascular disease and certification (or eligibility) by an appropriate board in radiology, internal medicine, or surgery, they required performance of at least 100 diagnostic peripheral angiographic examinations and 50 peripheral or renal PTA examinations in a training setting, as well as experience with at least 10 cases of peripheral intraarterial thrombolytic therapy. Another multidisciplinary organization, the AIUM, has developed training standards for physicians who evaluate and interpret diagnostic US examinations. They call for acquisition of a detailed body of knowledge and completion of an approved postgraduate training program (or an equivalent clinical experience) that includes at least 3 months of US training under supervision. During this time, the trainee must be involved in interpreting at least 300 diagnostic US examinations (500 if the physician plans to use US for multiple subspecialty applications or anatomic areas). These training standards have been incorporated into the US accreditation programs sponsored by both the ACR and the AIUM.
We recommend that radiology organizations become more active in developing training standards for physicians. It is preferable that the organization be composed not only of radiologists but of physicians from other disciplines as well—the AHA and the AIUM are good examples. Once such standards are developed and adopted, they should be published in the official journal of that organization or some other appropriate publication. The standards themselves should specify minimum numbers of examinations and months of training required. The rationale for such standards is that patients are entitled to have their imaging examinations or imaging-guided interventions performed only by physicians who are properly trained to perform them. This rationale was nicely articulated in a proposal by the ACC for training standards for coronary interventional procedures: "Although hospitals may be encouraged to grant privileges to inadequately trained physicians to protect the hospital's referral lines, this pressure must be vigorously resisted. Standard of care issues mandate that interventional operators be adequately trained and that they maintain their skills by performing procedures on a regular basis and by participating in formal continuing medical education" (13). This principle obviously applies to the practice of all interventional procedures, not just those involving the coronary arteries. Another principle that applies equally well to all types of imaging was promulgated by the ACP/ACC/AHA task force in their training standards for echocardiography: "The completion of a short course or workshop that offers a limited cognitive or technical background in echocardiography will not by itself result in competence" (14). Thus, the familiar weekend courses that are advertised for training in various imaging procedures or interventions will not suffice.
3. Establish a formal radiology curriculum. It is clear that certification by the American Board of Radiology does not confer upon radiologists the exclusive rights to imaging. Organized radiology should make it a mission to ensure that imaging is performed only by well-trained physicians. Establishment of accreditation programs or training standards for diagnostic imaging and imaging-guided interventions, as described earlier, are ways to achieve this goal. Another way is to establish formal curricula for radiology residency and fellowship programs.
The program requirements for residency training in diagnostic radiology, as detailed in the Graduate Medical Education Directory ("the green book") published by the Accreditation Council for Graduate Medical Education (ACGME), are very broad (18). They state that residency training should be divided into "periods of experience" in chest radiology (including mammography), musculoskeletal radiology, gastrointestinal radiology, genitourinary radiology, neuroradiology, pediatric radiology, and cardiovascular and interventional radiology. This statement is followed by a brief enumeration of procedures in which the resident should become experienced, as well as a list of the different imaging modalities with which he or she should become familiar. Within these broad outlines, there is little uniformity among radiology training programs with respect to core clinical rotations, length of time residents spend on any clinical rotation, or the body of knowledge they are responsible to learn on that rotation.
Conversely, the ACGME-approved program requirements for certain other medical specialties are much more specific. For example, in anesthesiology the requirements for residency education include providing anesthetics for a minimum of 40 vaginal deliveries, 20 cesarean sections, 100 pediatric surgeries, 20 cardiopulmonary bypasses, 20 other major vascular cases, 20 intrathoracic noncardiac cases, 20 craniotomies, and 50 epidural cases (19). They also specify management of 100 patients undergoing ambulatory surgery and a host of other procedural minimums. The program requirements in cardiovascular disease (a subspecialty of internal medicine) are also quite specific, calling for at least 4 months in the cardiac catheterization laboratory and minimum time intervals in a number of other aspects of the field (including 4 months of nuclear cardiology). Minimum numbers of procedures are specified, such as 100 coronary angiographic examinations, 50 exercise stress tests, and 150 echocardiographic examinations (20).
We recommend that a more formal curriculum be developed for radiology residency training—one that is much more explicit about required core clinical rotations and includes the length of time residents should spend on each rotation, the numbers of procedures or imaging examinations to be performed, and the body of knowledge for which the resident must become responsible. If organized radiology could be persuaded to follow this path, the various subspecialty societies could serve as educational resources. These societies could be asked to develop as complete a curriculum as possible in their areas and update them as frequently as necessary. Several of the subspecialty societies (eg, the Society of Thoracic Radiology, Society of Pediatric Radiology, and Society of Cardiovascular and Interventional Radiology) have already initiated the process and are developing mission statements along with recommended training requirements for the residents. A curriculum of this sort, if developed by the subspecialty societies and then endorsed by the Association of Program Directors in Radiology (APDR), could be published in widely read radiology journals and become the standard for training in our field. Eventually, the curriculum could be incorporated into the Graduate Medical Education Directory of the ACGME, although it would first have to be endorsed by the radiology Residency Review Committee and go through the ACGME endorsement process. By providing clear definitions of core rotations, the length of training required in each one, the numbers of procedures or imaging examinations to be performed, and the body of knowledge to be learned, the curriculum would undoubtedly enhance the quality of resident education. An added benefit, however, is that it would in all probability become the standard against which any physician wishing to engage in the practice of radiology would be judged.
It is of interest to note that the concept of a formal curriculum was endorsed by the vast majority of APDR members in a survey conducted by Rao (21). A consensus of the program directors was that the radiology residency curriculum should include a minimum of 3 months in each of the following areas: chest radiology, gastrointestinal radiology, musculoskeletal radiology, pediatric radiology, cardiovascular and interventional radiology, US, and body CT. They recommended a minimum of 4 months in neuroradiology, inclusive of neuroangiography, CT, and MR imaging of the central nervous system. At least 2 months of training were recommended for uroradiology, mammography, body MR imaging, and emergency radiology.
4. Regional radiology organizations should encourage payors to develop their own quality assessment or performance standards that providers of imaging services must meet to qualify for reimbursement. A recent article (8) described a technical and professional privileging program developed by Blue Cross/Blue Shield of Massachusetts and administered by a private company, Radiology Management Sciences. The goal was to ensure that outpatient diagnostic imaging facilities met appropriate standards of care and were staffed by physicians who were adequately trained. Technical privileging required an application and response to a detailed questionnaire about technologist qualifications, equipment specifications and performance, quality control procedures, and other aspects. Professional privileging required verification of physician specialty training and board status. Nonradiologist specialists were only allowed privileges for certain diagnostic imaging codes that were an accepted part of that specialty's practice and for which training was available to its residents. On this basis, emergency medicine physicians and certain other specialists received no imaging privileges whatsoever. Physicians requesting privileges in US had to meet certification standards of the AIUM, ACR, ICAVL, or the American Urological Association. Of the first 1,223 facilities to participate, 219 (18%) withdrew because they were unable or unwilling to submit to the process; they were denied all further reimbursement for imaging by Blue Cross/Blue Shield. Of the 1,004 facilities inspected, 197 (20%) failed for relatively minor deficiencies and were given the opportunity to remedy them. Another 106 (10%) failed because of "fundamental and serious" deficiencies; they were suspended from reimbursement for 18 months. Pass rates were higher than 95% for facilities operated by radiologists or cardiologists and for mobile imaging units; 75%–83% for facilities operated by primary care physicians, obstetrician/gynecologists, orthopedic surgeons, and other surgical specialists; and 62% or less for internal medicine physicians, chiropractors, and podiatrists. The authors reported that the program saved 2% in imaging expenditures for the insurance carrier, which was 10 times the cost of the program.
We are aware of other states, such as Michigan, Pennsylvania, and New Jersey, where Blue Cross and Blue Shield have recently instituted similar programs for private office radiography. Although not identical, their questionnaires are equally detailed. Future reimbursement depends on satisfactory compliance with the standards.
A somewhat different type of quality assessment program was instituted in 1989 by U.S. Healthcare for obstetric US (22–24). This program used a questionnaire about equipment and the qualifications of the physicians and technologists performing the studies. It also required review of at least three obstetric US examinations and the written reports by a panel of two radiologists and one obstetrician-perinatologist. A Wall Street Journal report in 1995 publicized this program and indicated that among the physician practices applying for accreditation between 1992 and 1994, 75% of radiologists passed, whereas only 36% of obstetricians did so (25).
We recommend that state radiology societies and other organizations contact their local payors to encourage them to develop programs of this sort. Providers of low-quality services can thereby be forced out of the field by denial of reimbursement. In addition to improving the quality of patient care, this will have the added benefit to the payors of saving them money.
5. Radiology organizations should publicly challenge attempts by nonradiologists to insinuate themselves into the practice of diagnostic imaging. An example of this was the response in the spring of 1997 by the Society of Chairmen of Academic Radiology Departments (SCARD) and the APDR to the attempt by emergency medicine physicians to develop a curriculum for emergency medicine residency training in emergency US and to begin performing these procedures in emergency departments (26–28). These efforts appeared to be coordinated by two major organizations within emergency medicine, the American College of Emergency Physicians and the Society for Academic Emergency Medicine (26). A position statement was prepared by SCARD and was unanimously adopted by both SCARD and APDR at their annual spring meetings (29). The statement rejected the move by emergency medicine physicians by pointing out a number of flaws in their approach. Perhaps the most important of these was that program requirements for residency education in emergency medicine, as detailed in the Graduate Medical Education Directory of the ACGME, did not then and still do not call for any training in diagnostic imaging during the course of the residency (30). If the "bible" of residency training fails to even mention such a requirement, it is highly unlikely that imaging would receive any serious emphasis during emergency medicine residencies. This also means there is no need for radiologists in teaching institutions to provide training to emergency medicine residents.
Other points made in the SCARD-APDR statement were that (a) high-quality US is already being provided in most emergency departments by radiologists and cardiologists, (b) emergency medicine physicians have been shown to perform poorly when they attempt to interpret imaging studies, (c) hospitals put themselves at risk of liability if they permit the performance of sophisticated diagnostic tests by physicians who are not thoroughly trained in those techniques, and (d) the curriculum proposed by the emergency medicine physicians for training their residents in US is inadequate compared with the standards set by the ACR and the AIUM.
It is not yet clear how much effect the SCARD-APDR statement has had because it is a recent development. We believe, however, that it is important for radiology organizations to draft position statements when turf battles arise that affect their members. These statements should represent the collective viewpoint and ideas of the organization and, once adopted, be distributed to the membership. That way, if and when confrontations occurred at members' hospitals, they will be armed with some ammunition for the debate. Moreover, a public record of its position will thereby have been created by the sponsoring organizations.
6. Improve and enlarge the scope of radiology research. Academic radiology departments, national organizations, and the major radiology journals must work together to improve the quality of research in the field. One way of doing this is the formation of multiinstitutional consortia to conduct large-scale clinical trials of the interventional procedures and diagnostic imaging studies that radiologists perform. Cardiologists have been very productive in this regard. The TIMI, TAMI, GUSTO, BARI, ACIP, and RITA trials are just a few examples of the multiinstitutional trials of coronary interventions that have been carried out (31–36); there are literally dozens of others. These trials have been funded by the National Institutes of Health, various national and international medical associations, pharmaceutical and device manufacturers, the Robert Wood Johnson Foundation, and others. In some instances, they have been self-funded. One important way of preserving the practice of radiology by radiologists is to demonstrate to the rest of the medical world that we are the leaders in establishing the efficacy, effectiveness, outcomes, and cost-effectiveness of imaging examinations and imaging-guided interventions. Multiinstitutional clinical trials are a very good way of accomplishing this. The Radiology Diagnostic Oncology Group studies (37–39) and the STAR registry of the Society of Cardiovascular and Interventional Radiology (40,41) are good examples of such trials, but more are needed.
As part of this effort, academic radiology departments must improve their training of residents in the basics of research and study design. Subjects like biostatistics, epidemiology, outcomes assessment, and cost-effectiveness analysis should be taught and perhaps even included in the written examination of the American Board of Radiology. Some departments have created a special research track within their residency program. This would appear to be a worthwhile endeavor, assuming the department has the resources to support it (eg, laboratory facilities, computers, and an information system).
A good way to enlarge the scope of radiology research is for academic radiology departments to encourage faculty to submit their research for presentation at national meetings of other specialties and for publication in nonradiology journals. Physicians in other fields generally do not attend radiology meetings or read radiology journals. Thus, their perception may be that little or no research is occurring in imaging as it pertains to their field. Instead, they may perceive a vacuum and rush in to fill it. An example of this is research in cardiac MR imaging, most of which is carried out by cardiologists and published in nonradiology journals. Once nonradiologist physicians become active in imaging research, it is only a matter of time until they attempt to control clinical practice in that area as well. Frequent publication of research by radiologists in the nonradiology literature would help alleviate this problem.
All of this constitutes a formidable agenda for the national radiology community. Much of it has to do with the careful definition of standards—through mechanisms like the accreditation of imaging facilities, training standards for physicians, curricula for residency and fellowships, and the enforcement of quality assurance requirements. In addition, there is the need for radiology organizations to become more proactive in formulating, adopting, and circulating to their membership position statements that spell out the issues when turf controversies erupt. Research continues to be an important element, and, as pointed out earlier (1), we again emphasize that by generously supporting research, community hospital and private practice radiologists not only help advance the science of radiology but also help protect themselves against encroachment by other physicians.
We believe that, despite the fact that turf battles often hinge on local economic and political issues, with concerted action by major national radiology organizations there is much that can be accomplished at the national level. The ACR and other groups have been active and effective, though their efforts sometimes arouse controversy among their own members. We hope the recommendations contained herein will further stimulate the radiology community and its many national organizations to take steps to ensure the integrity of our specialty and to guarantee to our patients that it is practiced only by physicians who are properly trained to do so.
References
This article has been cited by other articles:
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  D.A. Brown and A.N. Hasso Toward a Uniform Policy for Handling Incidental Findings in Neuroimaging Research AJNR Am. J. Neuroradiol., September 1, 2008; 29(8): 1425 - 1427. [Abstract] [Full Text] [PDF]
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