What a thrill to be in medicine during this age of ever-evolving technological ascent, and radiology proves to be a field advancing by leaps and bounds with super fast equipment and increasingly precise detections. High tech CT, PET and MR equipment lead the way, and with the implementation of electronic medical records, radiologists are able to receive data quicker, detect abnormalities sooner that can dramatically improve a patient's treatment, and consult with one another more efficiently. But all this remarkable equipment does not come cheap. Medical imaging costs are reaching $100 billion a year as imaging utilization increases at unprecedented rates. With such astounding innovations as the 64-slice CT scanner and recent applications of combined PET/CT, the radiology specialty has become a desirous practice, and imaging has become an equally desirous commodity.
The 64-slice CT scanner takes 64 pictures of the heart in less than a second. The new scanner is used in routine angiography where multiple thin images can detect blockages in the arteries that can lead to a heart attack. Accompanying the equipment is software which enables the creation of three dimensional reconstructions.
"Basically we're trying to replace all diagnostic angiography with CT scans for angiographic concepts," says Dr. Julia R. Fielding, associate professor of radiology program at the University of North Carolina Hospital, Chapel Hill. "In particular, I think we will see a new type of angiography emerging that does not involve any needles or catheters in the groin area or any work done in the interventional suite."
CT imaging of the heart is currently limited by the speed at which images are obtained. The 64-slice CT scanners image chest volume quickly enough to obtain stop-action pictures of a heart beating 80, 90, or 100 beats per minute. Ultimately the scanner will be used in coronary artery CT where it can then be determined if an abnormality is cardiac or something else.
While faster scanning is more convenient for the patient, radiologists must vigilantly be aware of radiation doses. At the UNC, Chapel Hill, both the 16 and 64 slice CT's are equipped with automatic dose modulation, where with every slice, the machine calculates the sickness of the patient and delivers the minimum dose of radiation required to obtain a picture, a protocol which is still relatively novel.
"It's always a balancing act between obtaining the correct information and not doing a test in a wasteful manner," Fielding explains, "but still avoiding radiation as much as possible."
And the fast moving machines have equally improved testing in pediatrics where diagnostic imaging is necessary beyond ultrasound. Wiggly children no longer have to be sedated thanks to the speedy machines, which both parents and physicians appreciate.
Where high speed CT scanners have become integral in cardiac diagnostics, positron emission topography (PET) scanning has become an invaluable tool in detecting tumors. Routine in oncology practices, PET imaging has also become an effective follow up tool for staging patients' disease and treatment, which can supplant the need for a follow up biopsy. With multiple data provided by CT and PET scans, a natural evolution for many physicians has been to combine their uses for greatest effectiveness in localizing anatomy and abnormalities precisely. Although the fusing of equipment is on the horizon, the expense is enough to convince some healthcare facilities to take the wait and see method.
Ultrasound is on the cutting edge as well with tissue equalization and the use of three dimensional imaging. Fielding also stresses the evolving use of MR, which is being looked at for testing tumor function and to fuse with other diagnostic tools, such as breast MR. "I think we're going to be seeing a lot of functional type work going on with MR imaging just as we're seeing with PET imaging," she adds. "We're trying to combine the technology to get the most information and the most bang for the buck."
Some facilities are already virtually film free facilities and include comprehensive 3-D imaging workstations. For Fielding, a gynecology and neurology specialist, electronic input and outflow is essential among an ever increasing staff open 24 seven.
"We have to provide the same level of care around the clock and that's a critical issue," Fielding says about the need for continuous coverage by physicians, nurses and technologists to ensure the daunting amount of information is processed and transmitted quickly. "It's very interesting because I started my career with films, then about half way through it started to switch over and now it's completely the opposite."
Physicians can decipher images with greater accuracy in shorter amounts of time, which will eventually mean fewer office visits for patients.
"It's the greatest time to be alive as a physician," Fielding beams. "If you look at each patient individually, I think that medicine has evolved much more as a science and an art. We're helping to keep people alive longer and also alive better. We can detect fast, we can tell you what's going on quickly, we can monitor your treatment and I think we serve as a very good consultants to patients and other physicians. So I love coming to work everyday."
All of these advancements are enticing medical students to the radiology specialty. In fact, the demand for radiology residencies is on the rise across the nation. Dr. Paul Molina, professor of the Radiology Residency Training program at the University of North Carolina, Chapel Hill and president of the North Carolina Radiology Association attributes the field's allure to the "wow" factor.
"Medical students are seeing radiology as an exciting field," he says. "It's so attractive, the cutting edge technology and the ability to push the frontiers of diagnosis. Students that are adept with computer graphics and digital techniques, radiology is a good fit."
In the past few years a significant spike has hit radiology programs, helping supply what is a shortage of services in some areas. In UNC's highly competitive residency program, 700 students apply annually, even though there are only six open slots.
"This is a good thing as an academic radiologist training the next generation," says Molina. "The key point is to increase the quality, not just the number, because there is a finite number of residency slots, so we are more discriminating. We have the best and the brightest going into the field."
Molina says a hot area to watch is the maturation of computer aided detection (CAD) as an adjunct to radiologists, helping them become more efficient and increase the volumes of studies they can do.
"Burgeoning research will come to fruition and make us more accurate."
Teleradiology is another important tool that is rapidly advancing many practices. This technology allows access to timely, quality images for hospital ER's and other healthcare facilities that don't have access to a radiologist's simultaneous interpretation. While it has led to improved quality of care in the United States, the potential for use abroad is raising significant challenges to high-quality care. For that reason, the American College of Radiology assembled the ACR Task Force on International Teleradiology in 2003, to study legal and quality control issues facing this emerging practice. The Task Force basically ensures that any foreign physician who wishes to consult or view images go through the same licensing and credentialing procedures as U.S. physicians to practice in the states, in order to protect patients from inferior diagnoses.
"The problem comes when you are sending things to non group members or when corporations are outsourcing services," says Dr. Arl Van Moore, Chair of the ACR Task Force on International Teleradiology. "What we want to do is set down certain, specific guidelines and material which will be acceptable practices in all telemedicine, especially in the international settings."
Van Moore says the teleradiology practice will evolve more and more to include robotic surgery performed from distant locations and other visual areas like pathology.
"It's clear the future is going to be impacted by this in many ways," he maintains.
While groundbreaking equipment and cutting edge technology have unarguably progressed the quality of medicine, diagnostic imaging is extremely expensive and an increasing portion of the healthcare bill. Over utilization of imaging from improper use has become a significant thorn in medicine's side, and while many physicians, insurers and Medicare agree there is a problem, there is debate over the source of it.
According to the Medicare Payment Advisory Commission (MedPAC), diagnostic imaging is the fastest growing type of physician service expenditure in the United States, with an annual growth rate that is more than twice that of other physician services. The commission is concerned about this continual rise and is examining various strategies that can be used to alter the growth increase they deem unacceptable. The utilization of imaging is no doubt related to its increasing availability. However, insurance companies Medicare leaders and some physicians contend the problem of over-utilization is fueled by the self-referral system and a lack of quality standards. In fact, when comparing radiologists to non radiologists, Medicare data show that imaging utilization among non radiologists is up to more than twice that of radiologists, who have received years of unique, post-medical training in radiation safety, radiological procedures and interpretation of medical images.
A study published by the Journal of the American Medical Association also asserts that non radiologists who perform their own imaging procedures are up to seven times more likely to order tests than physicians with no financial interest in the radiology practice to which they are referring patients. With all the financial pressures facing physicians, many practices are looking to increase revenue, and diagnostic imaging has become a common way to do so. Insurers, Medicare leaders, hospitals and some doctors are particularly concerned about machines popping up in physicians' offices, possibly causing a source of unnecessary tests and lower-quality images.
The American College of Radiology agrees with MedPAC's stance of enacting quality control standards on all imaging to prevent entrepreneurial motivation and inappropriate testing regardless of reason, from financial gain, ignorance, patient demand or even defensive medicine. Creating appropriateness criteria for testing modalities, the ACR asserts, could ultimately protect physicians from medical liability and avert practices from getting into the imaging business as a financial venture.
Dr. James Borgstede, Chair of the ACR Board of Chancellors has been on the forefront as ACR establishes a cohesive relationship with MedPAC and CMMS in order to stemming the tide from over utilization of unnecessary diagnostic imaging.
"I've had the chance to meet with a number of the chief medical officers of Blue Cross Blue Shield in the last year," he explains. "They're seeing increases in imaging utilization in some places upwards of 40 to 50 percent per year and they've made it clear that that just can't continue. The federal government has the same concerns to control costs in the Medicare program and made it very clear that there's got to be a solution to the cost problem."
MedPAC and private payers are interested in using a credentialing program to increase quality and drive down the utilization costs. Borgstede says Blue Cross Blue Shield of Pennsylvania has implemented a program requiring diagnostic centers to have pre-certification for MR, CT and PET. While the ACR endorses MedPAC's stance of issuing quality standards, that doesn't mean they are against outpatient diagnostic centers or non radiologists providing tests, so long as they meet quality standards and appropriateness criteria.
"Other physicians will say this is just a turf battle, that all the radiologists want all the imaging to come to them," says Borgstede. "If this were a turf battle, what I would be doing instead of searching for a solution is say, 'Don't do away with the imaging, just make it come to me.' But I'm not saying that. I'm saying that some of the imaging is inappropriate, it should not be done, and it won't be done by radiologists."
What the ACR proposes is that their appropriateness criteria be used to identify the appropriate imaging examination for common specific clinical conditions. The ACR is improving these appropriateness criteria to make them more facile for physicians requesting examinations. In essence this would ensure quality control through a system of checks and balances for imaging services, one on which radiologists could professionally agree and anyone providing imaging would have to adhere.
"The College has developed appropriateness criteria in conjunction with other specialties, not in a vacuum, and we say, look, if you want to perform an imaging examination, you have to have good reason, and we list all the radiology modalities that can be used for a specific clinical condition and rank them on their appropriateness," explains Borgstede. "I can't imagine anybody in the private sector who would run a $100 billion a year industry without a quality control program."
Eventually, Borgstede hopes, as electronic medical records fully integrate medicine, the appropriateness criteria would be installed with such software. The ACR also advocates use of its accreditation programs to insure radiation safety and high quality examinations.
As advanced equipment improves diagnosis, treatment and follow-up recovery, the role of radiologists proves a vital resource in every stage of healthcare. The age of innovation and expense is underway and radiology is a field with great promise and great responsibility.
