NEJM feature: Radiologists should adopt consultant model
Bruce J. Hillman, MD. Image source: American College of Radiology
“It’s time for radiologists to exit the darkroom and act like true consultants,” said Bruce J. Hillman, MD, department of radiology and public health sciences at University of Virginia (Charlottesville) and author of an editorial about the uncritical use of high-tech imaging in the June 24 issue of the New England Journal of Medicine. Radiologists need to converse with their physician colleagues to educate them about the downsides of inappropriate use of high-tech studies, Hillman said in an interview.

If radiology can’t--or won’t--deploy the consultant model, the profession risks stifling imaging research and development that promises to make possible personalized medicine. The problem stems from inappropriate use of CT, MRI, PET and other advanced imaging technologies, according to Hillman and co-author Jeff C. Goldsmith, PhD, also of University of Virginia.

Anecdotal estimates designate up to one-third of imaging exams as unnecessary. CT, for example, has become high-cost triage in many emergency departments, with physicians ordering the study before evaluating the patient. Defensive medicine exacerbates the problem. A recent survey of Massachusetts physicians showed that 18 to 28 percent of diagnostic imaging referrals represent defensive practices, adding $1.4 billion to state healthcare costs.

Although the dissemination of advanced imaging technologies into routine clinical practice has made diagnosis more accurate and less invasive, costs have skyrocketed, putting imaging in the increasingly uncomfortable policy spotlight. Until recently, imaging costs were the fastest-growing physician-directed expenditures in Medicare, wrote the authors. Plus, overuse increases radiation dose and exposes patients to additional tests for common but unimportant findings.

One ‘solution’ to containing inappropriate use is a dual threat: Draconian cuts in technical reimbursement and increased regulatory oversight. This could reduce the number of physicians interested in imaging and could curb both appropriate and inappropriate diagnostic imaging use. The upstream impact on research and development could be quite negative.

“Companies could curtail investments in incredible works-in-progress that could have a real impact on patients,” warned Hillman.

The overuse foursome
Hillman identified four factors that contribute to imaging overuse:
  • Patient demand for imaging studies is strong, partially due to direct-to-consumer advertising and the proliferation of consumer health websites;
  • Increased imaging aligns with physicians’ financial interest because of the Medicare loophole that allows physicians to self-refer for in-office studies;
  • Physicians practice defensive diagnostic imaging to reduce liability; and
  • Clinical education promotes a ‘shotgun’ approach that promotes testing and encourages an impossible and costly quest for diagnostic certainty.

The environment isn’t really moving in the right direction when it comes to self-referral and defensive medicine, claimed Hillman. He did, however, point to two factors that may prompt reductions in appropriate use—the threat of Draconian cuts in technical reimbursement and professional and consumer concerns about radiation dose.

Tightening the belt
A high-tech imaging diet is in order. Hillman and Goldsmith recommended a three-pronged approach. First, the medical profession needs to lobby for real tort reform that cuts down on frivolous suits without disenfranchising legitimate claims, and second, society must say ‘enough is enough’ and end the in-office exception that allows self-referral. Finally, clinical education and practice has to adapt to a new imaging culture. The radiologist must act more as the diagnostic imaging consultant rather than simply accepting ‘orders.’

“Society would benefit if radiologists were more assertive as consultants,” wrote Hillman. Radiology orders are requests for consultation, and radiologists need to join the diagnostic conversation and question ill-advised imaging. Physicians want diagnostic certainty, but too often it is an expensive, unattainable goal. Failure to change the current model is ultimately self-defeating for the specialty, continued Hillman.

Changing the high-tech imaging culture will not be easy, Hillman acknowledged. However, appropriate use of high-tech imaging is the foundation that supports imaging innovation. Overuse threatens the foundation, courting policies that restrict imaging. Continued policies would reduce the imaging market and discourage future investment. The innovations that promise to usher in the era of personalized medicine could evaporate before they materialize. The radiology profession can direct its future and better assure continued innovation with a new and improved practice model that reflects fiscal reality and clinical responsibility.

The NEJM perspective is based on Hillman and Goldsmith’s upcoming book slated for fall publication: The Sorcerer's Apprentice - How Medical Imaging is Changing Health Care.