Subspecialization and Teleradiology: An Uneasy Alliance

Why would orthopedic surgeons bypass a nearby hospital or imaging center when referring patients? If they happened to be in the Midwest, they might prefer the subspecialized interpretations offered by Linda L. Dew, MD, FRCPC. After more than two decades as a practicing radiologist, Dew has developed expertise in imaging of the feet, ankles, hands, and wrists. Choosy surgeons have come to rely on her, and they have no qualms about asking patients to go slightly out of their way for an interpretation that they can trust. Dew, who works for a teleradiology company (headquartered in Southern California) that has a strong presence in Illinois, says, “Orthopedic surgeons and podiatrists do not tolerate mistakes, and they know, soon after surgery begins, whether what you said is correct or not.” Consistently excellent interpretations are important for radiologists, wherever they happen to practice, but Dew believes that the extra focus on subspecialization is particularly prominent within teleradiology companies. With patient outcomes and valuable pieces of the referral pie at stake, subspecialization is increasingly perceived as a necessity in a profession that has always embraced the latest in medical technology. Barry D. Pressman, MD, FACR, agrees that subspecialization benefits patients and referring physicians, but he is unwilling to concede that ground to teleradiology. This past president of the ACR® believes strongly that local radiologists can embrace subspecialization—and that they must, if they hope to remain relevant. As chair of the S. Mark Taper Foundation Imaging Center and Department at Cedars-Sinai Medical Center (Los Angeles, California), Pressman has populated his staff with radiologists who have undergone additional training (primarily as fellows) and are experts in multiple subspecialties. The full subspecialization of the radiology department at Cedars-Sinai Medical Center essentially means that thoracic radiologists are reading chest CT exams and chest radiographs; neuroradiologists are reading spine CT and MRI exams, as well as spine radiographs. Pressman, who began practicing in 1975, says, “I don’t care what the modality is; it’s the body area that matters. There are some places that come at it via modality, but through that route, they become specialists in body imaging. Fully subspecialized means having people who cover the entire imaging spectrum of the human being, with subspecialty areas.” Everyone in such a practice should be doing work in his or her field of subspecialization, and no part of the body should fall into the category of “We’ll just have someone read that,” he says. In the past, that philosophy has been reserved for general radiology, a term that Pressman rejects in favor of broad-based, nonsubspecialized radiology. Far from disparaging the nonsubspecialized practitioner, Pressman views broad-based radiologists as well-trained specialists experienced in gastrointestinal and chest radiography. Many generalists have branched into other areas, such as body CT and neurological CT, without fellowship training. “People who are doing multiple things, but have not done any subspecialty training, I call multidisciplinary radi-ologists,” Pressman says. “To me, there is no such thing as true general radiology anymore. Radiology has gotten subspecialized to the point that I do not know what a general radiologist is.” Pressman’s message has not received unanimous acceptance within the profession, as evidenced by the reaction to a presentation1 that he made a few years ago. “I gave a presidential speech at the ACR on this subject, and many people in the audience were pleased and agreed with me—and some wanted to kill me,” he says (with a chuckle). “They were people who considered themselves general radiologists, and they felt I was deprecating what they do. I was saying, ‘Here is what you need to do to survive, going forward.’ Subspecialization is a crucial thing for the survival of radiology as a specialty. The alternative is to be subsumed by clinicians who do their own imaging and interpretation.” Prescription for Disaster Pressman and his staff take care of all the night coverage at Cedars-Sinai Medical Center, in an arrangement that staff physicians strongly prefer. “They want to know the radiologist well and would never accept a teleradiology arrangement,” Pressman says. “The other reason we do not use teleradiology is that I have always felt it was a prescription for disaster. Once a hospital gets the feeling that they can do without you at night, they can certainly think of ways to cover the day.” Pressman understands that small practices must often rely on teleradiology, but he views even these arrangements as inherently risky. “If you can do it, use consortia of groups at different hospitals, so that you are not using some third party who knows nothing about your hospital,” Pressman says. “It’s better to have people in the area who come by once in a while; introduce them to the staff. They may work in the hospital next door or in the next city. You can put a name with the face, and they are not stealing your practice from you.” Adding in-house subspecialization is incredibly important precisely because the additional expertise has clinical value, and with it comes the crucial relevance that the profession has earned. Radiologists must work with highly specialized physicians, and Pressman believes that this is simply impossible if radiologists are not equally devoted to a narrow specialty. It comes down to clinician trust, and referrers will go wherever they must (and to teleradiology companies, if necessary) to get the expertise that they seek. “We, as radiologists, must become conversant with the language, thinking, conditions, and treatments that clinicians deal with; otherwise, they can read the images better than we can,” Pressman says. “If you don’t understand the medicine, and you don’t know the surgical approaches and the equipment they are using, then you don’t know what their problems are—and then, you become superfluous.” In areas such as cardiology, Pressman acknowledges, radiologists are beginning to lose the turf battle. “We must show them what they don’t know about imaging, and do that in the context of their specialty,” Pressman says. “Ultimately, is it fair to the patient if the physician reading the imaging and advising the clinician is really not an expert in that imaging? Would anybody go to a neurosurgeon to have a baby delivered? Why would you go to a radiologist who primarily does obstetric ultrasound to have your head examined? If you do that, you should have your head examined.” Subspecialization is a growing trend, both in radiology practices/departments and at teleradiology companies, but Dew points out that she is not confined to foot/ankle and hand/wrist work. She maintains her expertise in knee and shoulder imaging, and capably covers these areas, when necessary. “I keep up those skills, but a lot of podiatrists and foot/ankle surgeons will send their patients past six MRI centers to go to one of the centers I read for,” Dew says. Referring physicians appreciate expert subspecialty interpretations, but they also call to discuss the results. Dew and her staff members offer this level of service, while rejecting the notion that teleradiology companies are in some way less customer focused than local groups. Dew keeps the cellphone numbers of all orthopedic surgeons, podiatrists, and hand surgeons with whom she works, so she can call them directly. “They also have my number, if they have a question about what kind of scan to perform or when they should perform it,” Dew says. “If an orthopedist is seeing a patient at 7 am and the patient was scanned at 6 pm the previous day, we make sure that patient’s interpretation is done.” She continues, “We have workstations in our homes, as well as in the MRI centers we are covering. All of us tend to work during the day, take a break, and then work in the evenings a bit also, to make sure everything is done—or we might get up very early the next morning to make sure those cases are read.” In many ways, Dew says, her company can provide greater speed thanks to better technology. “It’s a fallacy to think that teleradiology groups are not doing as good a job,” Dew says. “Instead of dictating something and having it typed by the transcriptionist hours later, when I finish looking at the case, I am done dictating it. I check the voice dictation right away, so I am doing the editing. I can sign off on the final report and send it out immediately. In the hospital, it can take a long time for things to get transcribed. The quality here is high, and I’m proud to be part of the group.” Us and Them Steven C. Garner, MD, CHE, believes that teleradiology can be an excellent way to supplement the skills of a department that might lack some key subspecialties. He reasons that a critical mass of radiologists must remain on-site for teaching, consultations, needle localizations, biopsies, and special procedures, so any us-versus-them attitude is wasted energy. The degree of subspecialization needed ultimately depends on the facility. Garner, chair of the radiology department at New York Methodist Hospital in Brooklyn, says, “At a tertiary/university center, you’ll have a different demand for subspecialty work than you would have at a community hospital. The superspecialist complex procedures are not done in enough numbers to support a physician at a community hospital. Patients are best served at a hospital where radiologists are doing a large number of cases, and somebody is experienced at doing them.” Even if a facility is lucky enough to have a neurointerventional radiologist on board, Garner says, it only makes sense if the community knows about it. “It takes proper marketing of the department to let people know about the services because many referring physicians are not aware that a service is available, or what it would be used for,” Garner says. “We rely heavily on teaching, educational courses, and rounds to introduce physicians to new services and new modalities.” When it comes to relatively new endeavors such as neurointerventional radiology, spreading the word is crucial. “We can actually provide therapy to reverse strokes, if physicians and patients are aware of the importance of getting to the emergency department as soon as possible,” Garner says. He continues, “It is often possible for the neurointerventional radiologist to remove a clot or put a catheter in the right part of the brain to dissolve a clot. This is amazing treatment, but it doesn’t do us any good if referring physicians are not aware of it and don’t send patients to the hospital at the first sign. This even involves teaching ambulance drivers so they can bring patients safely to our hospital.” Economic factors fuel the need for education throughout the health-care continuum because underused high-tech equipment does not bring in the reimbursement that it should. “If you’re not doing the specialized procedures, you may not be using equipment in an efficient way,” Garner says. “You want to do the procedures that your new piece of equipment allows you to do, not just the bread-and-butter procedures.” He adds, “We just bought a new and expensive interventional suite. We would not want to use it exclusively for everyday procedures such as femoral angiograms. We do want to use it to treat fibroids with embolization, to stop bleeding in a patient after multiple trauma, or to reverse a stroke.” Key Dialogue Choosing a teleradiology partner to help read subspecialty images should be a deliberate process because many referring physicians are accustomed to reports from hospital-based physicians. “When they get reports from an outside source, they’re not as familiar with the person reading it and may not like the style,” Garner explains. “Bring the teleradiology group on in a deliberate fashion, and foster a dialogue between referring physicians and the outsourced group. Most important are close oversight and management by the chair, as if he or she had one team.” For solo radiologists at critical-access hospitals, teleradiology can be an invaluable resource for primary interpretations and consultations. At other times, using teleradiology can simply mean a chance to get some rest. Kinchen Ballentine, MD, the only radiologist at Abbeville Area Medical Center in South Carolina, says, “Occasionally, I send out interpretations so I can sleep all night.” Ballentine uses a large teleradiology group (primarily for CT and MRI exams) and relies on it for subspecialty consultations, when necessary. “I consider myself a general radiologist,” Ballentine says. “I need to be able to interpret most of the imaging modalities in a hospital of this size. Basically, you must be able to recognize every malady, and you need to do basic interventional radiology.” As a veteran of more than 30 years in radiology, Ballentine sees the trend toward subspecialization as beneficial and inevitable. “It’s a good thing because it’s good for patients,” he says. “Subspecialists can usually come up with the answer more quickly, and when they need to, they can share images and form a more firm opinion. Crosstalk among the different subspecialties can only benefit patients.” Additional Reading - Inevitable EvolutionGreg Thompson is a contributing writer for Radiology Business Journal.