We Are Radiologists

Murray L. Janower, M.D.
(Preston Hickey Lecture)

Medicine and the practice of radiology are going through major, rapid, even jarring change. The practice of radiology is supposedly the most threatened of specialties with challenges coming from the managed care industry, attempts by some to substitute nonspecialists in place of properly trained radiologists, the rise and potential abuse of teleradiology, so-called sweatshops that attempt to eviscerate the role of the on-site radiologist, technological changes, and social reality first to name a few. This lecture in Dr Hickey's honor is to restore our memories and point out some things that we can and must do to maintain the core of our existence as radiologists.

Now, one might think that these challenges are something new, but one only has to review the practice of radiology in the early decades of this century and to read many of Dr. Hickey's writings to appreciate that ours is not the only generation to face difficult challenges. Our continuing existence and success as radiologists over more than 100 years manifest our ability to overcome the doubters and naysayers of times past and our ability to create value for patients, for other doctors, and for providers while maintaining the vitality of our profession. I suggest that we have the ability today, just as we did then to regenerate and reinvent ourselves, to develop new technologies, to provide value to publicize that value, and to overcome all of the new obstacles we face just as we have in the past. Today, I want to propose to you some of the things that each of us individually and all of us together can and must do to maintain radiology as the vital, useful, and creative field it has become in the provision of medical services.

First, an assertion. I assert that, for all of our problems, radiology has been and remains at the very center of medical practice. No patient can receive adequate medical care without the input of the radiologist, both in diagnosis and treatment.

Second, we must stand firm in the belief that the patient receives optimum radiological care because their examinations and procedures are managed, performed, and interpreted by the best-trained, qualified, and credentialed physician-namely, the radiologist. We must stress that we are skilled specialists with skills honed by a minimum of a 5-year training program beyond medical school. We devote full time to imaging and radiology, and we are the best-qualified physicians to diagnose and sometimes treat a patient's problems.

Third, we must educate out patients, other clinicians, and third-party payers about our contributions. We must show better results than we have in our limited outcome analysis studies. We must prove that we really do make a contribution, that our diagnoses are more accurate than [those of] our nonimaging specialist colleagues, that utilization is better managed by us, and that patients are much better off when we deliver their radiological services. However, we must document these statements with facts. Unfortunately, there really is only a small body of literature in these areas, so we must encourage further studies conducted by us. How many of us have compared and documented the superiority of our readings over [that of] the emergency room physicians at our local hospitals. How many of use have documented that the accuracy of our interpretation of ultrasonic examinations - be it of the abdomen, pelvis, or other regions - is far superior to [that of] other practitioners? We must provide objective evidence to confirm the expertise of the radiologist and then we must get the information out to targeted publics. We must make public information an essential element of our specialty - this is crucial.

Fourth, our departments have to be user-friendly, both to the patients and to our referring physicians. We must ensure that every procedure will fit into an overall diagnostic and treatment plan. Every part of the medical team must be aware that there is one physician who is concerned about the entire diagnostic and treatment process, and this doctor is called the radiologist. Our referring physicians should not have to have any concern that their requested examination will be performed promptly. Out of the sight of patients, we must screen all requests to determine that a proper examination has been requested. We must educate our colleagues about the merits of procedures that are available and which examinations are most cost-effective for a particular patient's problems. We must be concerned about sequencing of examinations, about avoiding duplications, and, always, about promptness. We must improve our productivity not only personally but also of our departments and offices. We must function at the lowest cost possible. We must emphasize service, speed, efficiency, and accuracy. And if we do this, our patients will be our most vocal advocates.

We can fulfill our mission to deliver superb radiological services in a number of ways depending on our setting. In the hospital, the job is relatively simple. The patient is best served if radiological services are immediately available and that means 24 hr a day, 7 days a week. The availability of our services should not stop at 5:00 P.M. on weekdays and at noon on Saturdays and Sundays. Patients must know that the proper examination has been chosen and that these examinations have been performed with properly functioning equipment monitored regularly with a lowest radiation dose to minimize any potential risk. The patient has to know that the technologist is properly trained and credentialed and that a qualified radiologist is in control of the entire process. Patients also need to know that their examinations are interpreted immediately so there is no delay in utilizing the findings to their overall diagnosis and treatment. Do the patient or our physicians ever consider the above? I think it is very rare.

And, to carry this discussion further, we should ask ourselves still a fifth question: What do we know about how our colleagues practice and how they make use of the information that we give to them? How do we know that we are offering the right product at the right time and for the right price? We have asked other physicians to accept the criteria we develop for our services, but should we ask them to help us in this developmental process? As we consider our clinicians' needs, there are many questions, to ask ourselves. Are we using teleradiology appropriately to make our interpretations and images available to our colleagues promptly at all times? Are the images, regardless of how they are documented, available to the clinicians at locations convenient to them? Are we meeting our colleagues' needs? Have we ever asked?

So, let's summarize our activities in the direct care of each patient. We have picked the equipment, supplies, and techniques used in performing the examination. We have trained and continually supervised the technologist to ensure that the lowest radiation dose and the highest quality examination have been obtained. We have interpreted these images, have reviewed all possible diagnostic alternatives, and have arrived at the most likely diagnosis. We have carefully reviewed all aspects of the case with the clinician, offered a myriad of diagnostic possibilities, suggested further radiological examinations if needed, and helped establish the correct diagnosis. We are sure that the radiology department is well organized so that both the patient and [the] clinician receive prompt service and results. In some cases, we have gone further and, in selected cases, performed minimally invasive diagnostic and therapeutic procedures with significant savings in patient comfort and financial cost. After all this, we go home each night with a satisfied feeling knowing that we have helped so many people, hopefully saved a life or two on the way, and demonstrated that the on-site radiologist cannot be replaced.

At the same time, we must be certain that our role in patient care is allied with all medical interests to ensure that optimal-neither minimal nor excessive-radiological services are provided to patients. It has been well shown that the volume and cost of radiological examinations increases dramatically when the clinicians perform their own imaging studies; third-party payers must be continually reminded of this fact. Managed care must realize that it is in their financial interest to stop all practices of self-referral. We must emphasize that criteria exist to establish the credentials of those physicians performing imaging, which examinations should be performed and in which sequence, and that there are well-defined quality standards for these examinations established by the American College of Radiology.

How about science? What is the radiologist's role here? Who develops the new imaging techniques? Where did image intensification, ultrasound, computed tomography, and MRI come from? If you don't know, they came from us! We are the scientists who develop and implement the new techniques in imaging. Look at how the practice of radiology has changed in the last 25 years. Can you imagine practicing without all of the above-mentioned techniques? The patients are so much better off because of the availability of these new tests-yet neither the patients nor the clinicians truly appreciate the fact that the radiologist is participating in the development of new techniques through his or her daily activities. Look at open MRI, new thrombolytic techniques, monoclonal antibodies, and new interventional techniques just to mention a few. Look at how mammography has impacted on the health care of women. Do the women really appreciate the contribution of the radiologist? Have we made enough effort to tell all concerned individuals about how new technologies got started, where they came from, or that we-the radiologists-have developed and integrated them into clinical practice?

While on the subject of new types of examinations, when will the next breakthrough come? I am not talking about advances in any of the above entities or any technique that we are currently using, I'm talking about new technology.

Will images be made with microwaves, different uses of magnetization, or the use of plain light, to name a few? I don't have the answer, but every decade something totally new and previously unknown is introduced, and I am sure that this will happen in the new millennium. I'm also sure that I don't have to repeat for you where these developments will come from if we are indeed fulfilling our mission.

Now, how about our role as teachers? Professionals share their knowledge, and so we must share with other radiologists and teach residents and medical students. We must teach what we do to other physicians and colleagues; they must understand what to request, when to ask for help, and how to judge our contributions. We must expand our roles as educators and continue to attract the best and brightest students into our specialty.

So, who are we and what do we do? We are complete physicians who act as consultants in the delivery of patient care. We are also quality control experts, new instrument developers, information managers, efficiency experts, and educators, among many other things, and we must see to it that patients understand our role. Think of it this way: If each radiologist spoke to at least five patients a day-stating "I am Dr. __________, your radiologist, and here is what I do to help you and your physician"- we would speak to over 30 million patients a year who would tell their neighbors and colleagues what we have done for them. Americans would know that radiologists put their skills and professionalism first in caring for patients, that radiologists are a critical part of their health care team providing for their individual health needs, and that the radiologist is at the center of the delivery of quality patient care. Never forget that we are physicians first and that patients are our primary concern. We rely on and use imaging technologies to guide us through a vast array of diagnostic and therapeutic pathways. We are called radiologists and we are dedicated practitioners. And if we tell the world our story, despite new challenges to us, our profession will continue to be a vital, robust, and vibrant field.