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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received April 15, 2004; accepted April 16. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
The concept of starting a column in Radiology dealing primarily with the social, economic, and political problems that affect the practice of medicine was conceived over a cup of coffee with Stanley S. Siegelman, MD, the former editor of Radiology, at the Radiological Society of North America in 1992. This will be my last article as editor of Perspectives, and I thought it would be interesting to revisit some of the previous articles published over the past 11 years.
Potential Clinical Problems Associated with PACS
The first column was published in 1993 and concerned the possible problems that might arise as picture archiving and communication systems (PACS) evolved around the country (1). Although the benefits were obvious, I was concerned about the possible side effects. My major concerns were the following: (a) When the image was immediately sent to the referring physician, would the physician act on the image without waiting for or reviewing the report, which might lead to poor patient treatment? (b) Would clinicians in different specialties demand the right to read and bill for the examinations? Hospitals tend to respond to the demands of referring physicians over the concerns of the radiologist. (c) Would large radiology groups expand their practice and provide 24-hour remote reading stations, forcing local groups out of their hospitals? (d) With the availability of images, would there be a decrease in clinical consultations in the department?
As I reflect today on the changes that have occurred with PACS, these changes have been more moderate than I feared. The technology has advanced so rapidly that reports and images are available instantly to the physician. In most areas, there has not been any major attempt by clinicians to capture procedures or to bill for examinations. Ultrasonography (US) had crossed over into many clinical areas prior to PACS. It seems that most of the competition is in special procedures (neuroradiology and vascular radiology), where there have been major increases in the number of examinations and the percentage of outpatient procedures performed while a sizable reimbursement is retained. The other area, where I do believe there has been change, is in clinical consultation in the radiology department. I believe that with the external availability of images and reports, many clinicians have fewer direct consultations with the radiologist, which to some degree may affect patient care.
Middleman in Medicine
In 1994 (2), I discussed the dangers of the "middleman" in medicine, and the radiologist is, of course, such an intermediary. The patient is referred to the radiologist by the clinician, and the radiologist reports back to the clinician. Although the radiologist provides an important service, he or she can be bypassed since the radiologist does not have control over nor direct access to patients. Basic outpatient radiology is still dominated by nonradiologists. Sunshine et al (3) in 1993, using Medicare statistics, calculated that nonradiologists outside of the hospital performed over 80% of hip, knee, wrist, ankle, foot, and hand radiographic examinations and over 60% of chest and lumbar spine imaging and 17% of gastrointestinal studies. An article published at that time in the Annals of Emergency Medicine (4) extolled the abilities of the emergency room physician to interpret images in hospital emergency rooms, stating that in 95% of cases the interpretation of the emergency room physician was the same as that of the radiologist.
I was concerned over who was going to control radiology as managed health care progressed. In the Perspectives I stated
We do not know in any detail what is going to happen in medicine in the next 5 years except that it will become more structured. Solo providers will be brought into groups. Ambulatory care will continue to expand and hospital care to contract. Managed care providers will want more control over utilization. Capitation will shift risks from payers to providers. In radiology, the regulations on self-referral will help, but they will not interfere with the individual physician or group performing their own studies. If the fee-for-service system is abandoned, then there will be little competition for what we do. It is curious that we, together with the rest of medicine, are trying to stem the flow of HMOs [health maintenance organizations] and capitated medicine, although the demise of the fee-for-service system will protect radiology as a specialty (2).
Lower fees have certainly occurred, but my prediction of a decreased number of examinations and my fears as to our possible loss of control of radiologic studies in hospitals turned out to be entirely wrong, thus far. Specialized studies such as computed tomography (CT), magnetic resonance imaging, and US have all continued to increase, offsetting any decrease in conventional radiology. Despite radiologists’ position as intermediaries, radiology as a specialty remains strong and desirable, attracting the brightest medical students.
Algorithms: The New Math in Medicine
Later, in 1994, I (5) discussed algorithms and guidelines in medicine. The purpose of the guidelines was to decrease the cost of medical care and attempt to increase the quality of care by deciding when to initiate and when to avoid medical intervention. The underlying truth is that guidelines are useless unless they lead to better outcomes. The Perspectives stated that "algorithms will be developed that state what ‘insurance’ will pay for in the work-up of each individual problem" and also that "Much of the medical community will resist the imposition of algorithms that must be followed to secure payment" (5).
Most physicians believe that each patient must be individualized—one size does not fit all. People react differently to similar situations or diseases, and each person must be evaluated before treatment is selected. We all use guidelines, but we want to reserve the right to vary from these guidelines when we believe it is necessary for the patient’s benefit. My fear that guidelines would be imposed on physicians has not yet materialized. Perhaps this has been delayed because of the realization that not only is each individual somewhat different, but the way each disease affects each individual is frequently different. Guidelines may be utilized as concepts but are very difficult to be forced upon us as rules.
Recertification
In 1995 (6), I reviewed the concepts of recertification, which was originally suggested in 1940 by the Committee on Graduate Medicine and was then presented at the annual meeting of the American Board of Medical Specialties in 1963 (7). The problem was that passing an examination after residency did not ensure lifelong competence. The American Board of Family Practice, formed in 1969, started with time-limited certificates. The American Board of Internal Medicine attempted voluntary recertification in 1987, but less than 5% of their membership responded (8). I have always believed that for most radiologists (including myself), external pressure in the form of grades, examinations, et cetera stimulates us to acquire greater knowledge. Among residents, approximately 10% will achieve the desired knowledge if given a syllabus and access to a library; another 10% will always underachieve, regardless of the efforts of the instructors; and the remaining 80% will learn more and become better physicians if they are stimulated by examinations and quizzes.
My suggestions in the Perspectives in 1995 were perhaps a little too ambitious. Since a medical license allows a physician to practice in any area of medicine, I believed the recertification examination should be a multistage examination that includes a cognitive examination in the generalist area, a cognitive examination in the physician’s subspecialty, followed by a retrospective analysis of his or her charts or reports, and finally interviews with co-workers and supervisors to assess ethical and moral behavior. On reflection, the cost, time, and personal invasiveness of this proposed multistage process are unreasonable. After all, the object is not to penalize but to reeducate. The examination should exclude that small percentage of physicians who cannot demonstrate reasonable competence. In the end, society will decide what level of excellence will be required, and if the public does not agree that the recertification process is ensuring competence, the specter of relicensure may emerge. Recertification with a failure rate of near zero will not impress the public that competence is actually ensured. Failure in recertification does not prohibit a physician from practicing; he or she simply loses the certification. The physician may request reexamination at any time.
Qualifying Examination: Is It a Measure of Competence?
Another interesting topic, which I discussed in 1995 (9), was the problem of measuring competence, a problem that affects all admission committees and departmental chairs. When students apply to universities, their grades, board scores, honors, extracurricular activities, letters of reference, and personal interviews are utilized. This may not be a perfect method, but it is the best we have. Letters of reference are uniformly flattering, and interviews, although useful, have many variables and are subjective.
Future attending physicians (residents) are selected in a similar manner. The residents are evaluated over time as to competence, which includes their knowledge and performance. Knowledge can be tested with an examination, but performance can only be evaluated with a long-term observation. The resident is observed as to his or her work habits, empathy, morality, and relations with patients and peers—areas that are not tested at an examination. By the end of the first 12–18 months, it usually becomes apparent who has and who does not have the ability to become a "good" physician in that specialty. This would be an appropriate time to weed out those who are well below average, but in practice this weeding is rarely performed.
Kenneth Krabbenhoft, MD, the former executive director of the American Board of Radiology, estimated that fewer than one candidate per 1,000 is not recommended as a suitable candidate for board examination (9). Attending physicians may huddle in the hallway and agree that a particular resident does not perform satisfactorily, but they do not remove the resident from the program, partially because it will unbalance the program and affect service. The bottom line is that there is no ideal way to evaluate residents and establish competence. Assessment of minimal requirements for knowledge is possible with an examination, but assessment for performance is far more difficult.
In 2010, Who Will Practice Radiology?
Our discipline is called radiology, a term coined by Beclere in 1896 (10). From the very onset, turf battles arose between radiology and other specialties, and they will persist despite the ongoing revolutions in health care. They are present throughout medicine—internal medicine and cardiology, pediatrics and family medicine, orthopedics and neurosurgery, and radiology and multiple specialties. We radiologists do not admit patients, which means we do not control patients; therefore, we cannot expect, because we are radiologists, that ipso facto, we should control imaging. The radiologist has never totally dominated ambulatory imaging, but in the hospital the administration, for economic and practical reasons, tended to centralize imaging in one department. We must not assume that this must continue in the future. Imaging will be performed by the individuals who are most capable and most cost-effective and who will provide the best outcome for the patient. For radiologists to control imaging, they must develop a gatekeeper mentality, using their judgment as to the best modality for each case. Radiologists must become part of the clinical teams, institutes, and centers and actively participate in those areas. Radiologists must work directly with the clinicians in their specialties in the areas where patients are treated. Radiologists are intermediaries in patient care and must adapt to survive.
Malpractice
I commented on the problems of malpractice in 1995 and revisited the area in 2003 (11,12). Although the limitation on pain and suffering to $250,000, which started in California and has spread to other states, has helped, it is not the solution to the malpractice problem. I believe that the solution to the problem of malpractice requires knowledgeable people to make decisions based on the merits of the case. Compensation for injuries following medical or surgical treatments cannot be determined by a jury influenced more by the end result than by the causative factors.
What we need is a system that lowers costs and provides recompense for both negligent and nonnegligent errors, which should include medical expenses, loss of wages, and in cases of negligence, which seriously affected the patient’s quality of life, additional compensation. I believe that all adverse medical events should be compensated. This would markedly reduce malpractice actions. In addition, I believe that both patients and physicians will be better served if malpractice cases are subject to compulsory arbitration, rather than to our present tort system. Under this scheme, instead of 40–45 cents of each dollar going to the patient, more than 80 cents would go to the injured party. Decisions could be made more rapidly by knowledgeable individuals. The emotional bias of the jury would be removed. Everyone with an adverse event would be compensated. Overall costs would be substantially reduced. This is what I believe should happen, but I am afraid this will not happen in the predictable future. The influence on Congress by the insurance companies and trial lawyers is too great to allow this to come to realization.
Future Physician Requirements
In 1996, I reviewed the available literature relating to future physician requirements—shortages or surpluses (13,14). From 1970 to 1995, the number of generalists had increased by 34% per 100,000 people and of specialists by 90% per 100,000 people. In 1996, it was estimated that there were 195 physicians per 100,000 people: 127 specialists and 68 generalists. At that time, the needs were estimated to be 90 specialists and 59 generalists per 100,000 people (15). Therefore, there was general agreement that there was a surplus of specialists and perhaps a need for more generalists. HMO executives and state and federal governments were urging more emphasis on generalists, even suggesting residency quotas to encourage generalists. Cooler heads pointed out that future needs are difficult to project, and that issues relating to supply and demand are constantly changing. Committees and organizations that have made predictions in the past were often wrong. Market pressures usually make the necessary adjustments, and government agencies would be best advised to avoid overacting.
In 1995, there were approximately 25,000 practicing radiologists in the United States, about 9.5 per 100,000 people. Approximately 1,000 radiologists enter active practice each year and about 600 retire or die. This increment of 1.6% yearly, if continued, would provide about 29,000 radiologists by 2010 (16,17). My personal belief at that time was that the job market for radiologists would be difficult for the next few years, with a probable decline in residency applications. I believed that in all probability, the situation would correct itself after 2000. Radiologists’ incomes might decline and stabilize at a lower level. In reality, radiologists were in short supply, and after a brief decline, income started increasing again. Today our residents have little problem in finding suitable positions at incomes well above those of 1995.
Affirmative Action
Affirmative action was a recurring theme throughout the 1990s. When I started researching this subject, I had mixed emotions, trying to balance the positive and negative aspects of affirmative action. The dictionary defined a minority as a group that differs from the others in some characteristic (race, religion, or ethnic background) and is often subjected to differential treatment. Affirmative action implies support, not just because one is a minority, but because one is economically and/or socially deprived. It is estimated that (non-Hispanic) whites by 2050 will be the minority, less than 50% of the population, but will probably not be eligible as a group for affirmative action. In 1996, approximately one-third of medical students belonged to minority groups, the great bulk being of Asian descent. The need for minority physicians, particularly blacks and Hispanics, is twofold: (a) The need to provide physicians to improve access to health care for minorities in underserved minority areas (more black and Hispanic physicians settle in minority areas). (b) Minority physicians tend to become leaders of their communities. In my Perspectives article (18), I stated that I do not support affirmative action in medicine when it is based on past injustices. I do support some degree of affirmative action to increase health care resources in underserved areas. I do not believe in accepting unqualified candidates, nor do I believe in a quota system. However, the difference between grade point averages of 3.6 and 3.8 is probably meaningless in most cases. Minority persons who appear to be good candidates should definitely be given the opportunity.
Tenure
The concept of tenure in the university system was intended to protect faculty from outside pressures (19). As time passed, its main purpose became security of employment. In 1997, there were about 75,000 faculty members in medical schools, about three-fourths of them on clinical tracks (20). In 1993, 72% of the basic science and 47% of the clinical faculty had tenure (21).
Tenure has different meanings in different schools. Back in 1976, in 17% of schools tenure had no financial guarantees but was limited to the guarantee of a continuing appointment; in another 7%, the total basic science salary was guaranteed but there was little or no guarantee for clinical faculty (21). The majority of schools had a financial guarantee, which varied from school to school. Most guaranteed some form of base salary, not to include clinical income. Tenure, once obtained, is for the duration of the individual’s working life. No other profession receives a lifetime guarantee of employment. It certainly is not necessary today to have tenure to enjoy academic freedom. There are well-developed grievance mechanisms and court proceedings to provide protection. Tenure, after all, is a contract. Most individuals who receive tenure at age 35 or 40 have another 25 or 30 years of academic employment ahead. The majority have developed work habits and needs for ego gratification that will provide the impetus for future accomplishments. But what of the individual who, 10 years after achieving tenure, is totally unproductive and remains so for the next 20 years? Tenure should not be a system that supports the retention of unproductive faculty. This individual may not receive raises, but it is difficult if not impossible in most schools to discharge him or her.
I believed that tenure should be a 10-year renewable contract. The tenure contract should state what is expected of the individual in terms of productive research, grants, teaching, and the like. When the tenure contract becomes renewable, there should be a tenure review that should be conducted by a faculty committee, which may include a member of the administration. The committee should determine if the terms of the contract have been met. If so, the contract is renewed, if not, it is terminated. The individual may still remain on faculty but without tenure. Financial pressure on many schools may soon pressure administrations to discontinue tenure appointments in the future. This would be a mistake. Allowing schools to rectify inappropriate tenured appointments would encourage them to keep the concept of tenure alive in 10-year contracts.
The Underinsured: A Problem That Must Be Solved
A situation that is of concern to our entire country is the problem of the uninsured and underinsured and their inadequate access to health care (22). Politicians seem to avoid this problem, which just gets worse each year. The underinsured in our country are victims of a totally confused health policy. In 1998, the Census Bureau estimated that 44.3 million people in the United States had no health care coverage. The figure keeps growing, and it is estimated that 60 million Americans may be without health insurance by 2007 (23). Light (24) estimated that 25% of our population, consisting of the uninsured and underinsured, face loss of all their resources if they become seriously ill. Many depend on employer-provided insurance, but since the downturn in 2001, many employers have downgraded their insurance coverage.
The last major debate on national health insurance was in 1993, when President Clinton proposed a plan to be controlled by private insurance and large corporations. Too much was thrust on the public too suddenly, and intense political opposition doomed the plan. The compromise that followed was managed care. More recently, major plans have been introduced to modify Medicare, but our politicians have avoided the concept of national health insurance. I noted in the original Perspectives that we spend 22% more on recreation, restaurants, and foreign travel than on health care (21). Our only hope for some framework supporting total population coverage is if we accept the concept that health care is a national investment. Whatever is done has to be accomplished within a framework of cost control—the public would not look kindly on inefficiency and waste in the spending of tax dollars.
I believe that our public would not support a socialized system similar to that in many European countries. The most logical approach was to consider a "layered" approach, more consistent with American concepts. The basic insurance would be similar to Medicaid and would cover everyone. The niceties of health care, such as free choice of physicians, no gatekeeper, and expanded pharmaceutical coverage, would be covered in extra "layers," which would be paid for by individuals or employers. This would add to our budgetary problems, but health care ranks right under defense as a national need. I personally cannot accept the concept that health care is a commodity to be sold like candy on the open market. I believe that basic health care should be a guaranteed right provided to every individual. In my original Perspectives (22) I stated, "any action leading to universal health insurance would require the symbiosis of a crisis in health care (which we are approaching), strong leadership (not currently available), and a public consensus (not present)." I believe that the public is embarrassed by our 44 million uninsured and would support a well-planned program. Medicare, which was founded in 1966, is a form of national health insurance with a copayment and has been very positively accepted by our nation. We are a nation of optimists. The American way has been to attack our problems and solve them. This is a major problem—it is time to work out a solution.
Health Care Rationing
This article (25) was stimulated by a decision by the U.S. Supreme Court concerning Pegram v Herdrich, a case where a woman with abdominal pain had to wait 8 days before receiving appropriate diagnostic tests (26). In the interim, her appendix ruptured—she sued, claiming her HMO improperly restricted her access to diagnostic procedures. The Supreme Court decided in favor of the HMO, stating that health care rationing is part of the mission of an HMO, which enables it to become cost-effective and achieve a profitable status.
With health care costs increasing, rationing will increase. We have always had some form of rationing, which is practiced world wide. The question is, who should make the decision on how or what to ration, and how will it be regulated? Managed care rations with delay, denial, and dilution (selection of which patients should receive specialized treatments). In the past, there has been little control over how managed care rations. The entire concept of rationing by for-profit corporations raises major questions in the area of social justice. Should they be allowed to ration according to age or the social or economic value of an individual? The possibilities are endless, and it becomes obvious that rationing cannot be arbitrarily decided by corporate executives and therefore must be controlled and regulated.
Certain types of procedures lend themselves to rationing because they can be statistically evaluated, and cost effectiveness can be determined. This is particularly true in the area of screening. For example, it has been estimated that screening Papanicolaou tests for cervical carcinoma cost $1 million per life saved, while occult blood testing for colon carcinoma costs $26 million per life saved (27). Therefore, the latter is not cost-effective and has been replaced by colonoscopy. The bottom line is that rationing is necessary or health care costs will explode. We would like rationing to be ethical, fair, and efficient—goals that are rarely achieved. If every managed care organization sets up its own system, we will have many definitions of ethical and fair, some of which will border on the immoral. Currently, the check on rationing is through the court systems; this is confusing and unreliable. I believe we should try to regulate rationing on a national basis—one code for all systems. Principles might include such items as age, quality of life, curability, and productivity. This would provide standards for our court systems to enforce. Will this be uniform and fair? Of course not. Individuals with unlimited finances can always purchase the care they need, and the system will certainly be manipulated by many. However, with all its faults and difficulties, it would at least start to provide a level field for all.
Managed Health Care
With the drastic changes occurring in the practice of medicine in the 1990s, it is not surprising that I devoted over a dozen articles to the subject of managed care (28–32). The most popular type of managed care that arose in the early 1990s was the HMO, which had an enrollment of 13 million in 1980 and then rapidly increased to over 56 million in 1995 (33,34). The federal government removed itself from the health care scene in the early days, allowing companies to form and operate with few restrictions. Politicians do not like to propose or become involved in plans that reduce or restrict benefits that might produce a voter backlash. They much prefer to wait and later be able to criticize the results that they indirectly fostered.
It soon became apparent that the satisfied customers in the HMOs were the healthy individuals who received more preventive medical care and paid less for overall health care. Ill patients became disillusioned. Managed care, utilizing a gatekeeper philosophy, attempted to limit diagnostic studies, expensive therapy, and access to specialists. In many instances, managed care encouraged primary physicians to perform tests for which they were not fully qualified. From the patient’s viewpoint, managed care directed more of its efforts toward reducing costs than toward quality care.
Many of the Perspectives were highly critical of managed care, but I tried to emphasize that we were undergoing major changes in health care: an evolution that would continue for years and is still continuing. Patient dissatisfaction forced states and the federal government to start regulating managed care. As time passed, HMOs became less popular, and preferred provider organizations, or PPOs, have evolved. Managed care, in essence, was approaching a level of "layered" care, as I previously discussed. Patients acquired more control over their health care and easier access to diagnostic tests, therapies, and specialists. Costs, of course, increased. Managed care was created to cure double-digit inflation in health care; double-digit inflation is now back under managed care.
I do not know what will evolve in our health care system in the next 15 years. I mentioned previously that Americans would not accept the European style of socialized medicine; the one-payer system would appear to our public as a giant federal monopoly. I believe the public would accept a "layered" system, where everyone is covered by a basic plan (eg, MediCal) and then can purchase options, increasing their access to physicians, drugs, and the like. Under such a plan, we at least will not have 45 million individuals without any health insurance. I believe the costs can be held within reason and perhaps may not be much more than we are paying today. We are in a time of rapid and unpredictable change. Managed care is the direction of medicine today, but it is not necessarily the final solution.
I have enjoyed the past 11 years preparing Perspectives and adding to my education and knowledge. It is time for me to pass the baton, and it is being taken up by a very accomplished individual, James H. Thrall, MD. My thanks to those who have written or e-mailed their positive or negative comments to me. In this article I am saying au revoir, but not necessarily goodbye. I hope to be able to contribute to Perspectives in the future.
REFERENCES
This article has been cited by other articles:
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  N. A. Koontz and R. B. Gunderman Gestalt Theory: Implications for Radiology Education Am. J. Roentgenol., May 1, 2008; 190(5): 1156 - 1160. [Abstract] [Full Text] [PDF]
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 A. V. Proto Radiology 2004: Richard M. Friedenberg Completes His Service as Perspectives Editor Radiology, August 1, 2004; 232(2): 315 - 316. [Full Text] [PDF]
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