As radiologists contemplate new roles as clinical consultants and imaging gatekeepers, they may want to fasten their seatbelts and prep for bumpy ride. An editorial published July 4 in New England Journal of Medicine detailed the pending transition and obstacles blocking the path.

Saurabh Jha, MBBS, of the department of radiology at Hospital of the University of Pennsylvania, Philadelphia, noted the seismic shifts occurring in U.S. healthcare, including increasing scrutiny of imaging utilization and evolving payment models.

Jha also contrasted the dominant U.S. radiology practice model—service provider—with the approach in Britain where he trained in surgery.

“Since imaging was a scarce commodity in the National Health Service (NHS), radiologists acted as gatekeepers. To get through the gate, clinicians had to be at the top of their game. To triage effectively, radiologists had to think like the referring physicians. Both sides pushed each other, and the net clinical acumen improved,” Jha wrote.

In the U.S., the radiologist is a service provider who green-lights nearly all imaging requests. Performance has been measured on the basis of volume and turn-around time. However, the focus on value demands a new approach.

“Gatekeeper is the ultimate destination in the spectrum of clinical engagement of the radiologist that starts with being a consultant,” Jha wrote in an email to Health Imaging. He warned that the change will not come without pain.

For starters, the current reimbursement system provides no rewards for denying exams. In fact, gatekeepers lose a reimbursable exam and time that could be spent reviewing reimbursable studies. More problematic are the practice implications for radiologists who earn a reputation as gatekeepers. Service providers turned gatekeepers justifiably fear that referring physicians will take their business to radiologists who will rubber stamp their requests.

Jha recommended that radiologists move to the center of the clinical decision-making process by developing clinical-imaging conferences, acting as imaging consultants and conducting imaging rounds.

“Practice leaders can give radiologists who volunteer to take up such roles time off the schedule. The more clinically engaged radiologist would question select imaging studies (e.g. in-patient advanced imaging studies, or patients with multiplicity of studies), conduct imaging rounds, go over negative cases, not just or not even positive ones,” he wrote.

The engaged approach runs counter to the current tech-centric practice model. In fact, with their affinity for software and technical solutions, some radiologists put their eggs in the clinical decision support basket, hoping that software can fill the gatekeeper role. “It’s ironic: the profession has great angst about its propensity to be commodified and outsourced, yet it may relinquish its last bastion of clinical involvement to software,” wrote Jha.

Jha’s final challenge echoed that of other leaders in imaging: Stand by as passive observers or strategically manage a rational decline by embracing the gatekeeping role.