When you want a surgical consult, you send your patient to the surgeon of your choice with a presenting complaint. When you want a radiology consult, you order a radiology test. These are very different. When you send a patient to a surgeon with fever, RUQ pain, leukocytosis, and a concern the patient may have cholecystitis, you don’t get mad with the surgeon if he determines the patient has cholangitis instead, and needs to be treated medically and possibly with endoscopy, but not with surgery. It would never cross your mind to send a patient to a surgeon with a note telling him not only what surgery to perform but whether he should use sutures or stapling, laparoscopic or open approaches. But it is routine for clinicians to make the initial decision of CT vs US vs MRI, and to determine whether the CT is done with oral or IV contrast, both, or neither.
In most specialities, you consult a physician about a patient. You send the patient to Dr. X and you expect he’ll be seen by Dr. X, not his partner. In radiology you don’t want the patient evaluated by Dr. X, you want a specific study interpreted by “a radiologist” who in many ways is indistinguishable from other radiologists (which is one reason radiologists can afford to take more vacation than other specialists; they can afford to be away longer because their partners are viewed as perfect substitutes.) And yet these distinctions are recognized neither by medical ethics nor the law. The radiologist, no more than the surgeon, cannot say he was doing what he did because that’s what the referrer requested.
Fact of the matter is, radiologists change orders all the time. A routine Chest CT is converted to a High-Resolution Chest CT. An abdomen CT with contrast is converted to one without and with. A CT ordered with routine oral contrast is converted to one that uses a neutral oral contrast agent (like water). Gas insufflation of the rectum might be done, even if not requested, to help distinguish sigmoid diverticulitis from cancer. A routine abdomen CT might be changed to a biphasic study. Few clinicians wish to be informed of these changes ahead of time, or bothered to be asked for permission. They just want their question answered, understandably so.
How is this ethically different from changing a SBFT to a CT enterography? Both study the small bowel; both use ionizing radiation. Granted, one places the patient at risk of a reaction to iodinated contrast, but a radiologist changing a non-contrast CT to a contrast-enhanced CT poses exactly the same additional risk to the patient yet is viewed very differently.
To their credit, surgeons, on being sent a consult, actually take their own history and do their own physical, not a feature of the radiology consult. But can this explain the difference? Would one really have no problem with a radiologist sent a patient for a chest CT due to “rales in the left base” who responded, “CT canceled; no rales on my examination of the patient.”?
One rationale for the way things are is historical: back in the day, there were fewer imaging study options available, and clinicians could keep up with them as well as radiologists. The clinician thus knew the patient and knew what he wanted to learn about the patient AND knew the entire gamut of imaging studies available, so he had a comparative advantage over the radiologist in choosing the study. But those days are long gone.
Another rationale for the way things are is regulatory: when everyone is concerned with increased health care costs, some would argue it is simply prudent to prevent those who receive payment for the studies from determining which studies are done. And it must be admitted it is rarely the case radiologists are calling up clinicians to suggest a SBFT when a CT enterography was ordered. The recommendations DO tend to be toward the more exotic and expensive imaging studies.
But this explains too much. No one is upset about cost when the gastroenterologist so frequently ends up recommending people be scoped. Surgeons benefit more from recommending surgery than watchful waiting, but no one suggests the referring physician rather than the consulting surgeon be the one to make the call.
So why the double standard for radiologists? Why the casual acceptance of certain changes (typically intramodality changes [single to double contrast UGI; enhanced to unenhanced CT; renogram with Tc99m-MAG3 rather than Tc99m-DTPA]) simultaneous with the belief intermodality changes cannot be made without the permission of the ordering physician?
Some thoughts:
- Intramodality changes are accepted because being called on all such changes would be disruptive. They simply happen too many times during the day.
- Intramodality changes are accepted because many times the referrer simply doesn’t focus on that level of detail. He reads the report of the double contrast UGI and wants only to know if there was an ulcer or gastritis, not really focusing on the nature of the technique that obtained the answer.
- Intermodality changes raise questions that take time to answer: the doctor KNOWS he ordered a CT. Why is he reading a report about an MRI? Did the front desk order the wrong study? Did the radiologist’s team make a mistake?
- Intermodality changes are an affront: The doctor KNOWS he ordered a CT. Why wasn’t he called if his patient were getting an MRI instead?! This is associated with:
- Intermodality changes may raise questions in the mind of the patient: The doctor knows he explained to the patient why she needed a CT. If it turns out he was wrong, and the patient needed an MRI, the patient may begin to doubt the ordering physician’s judgment. Does the radiologist know/care enough to take the time to explain matters to the patient when such orders are changed?
- Local knowledge: There may well be some doubt that, despite their superior knowledge of imaging, radiologists really are in a position to know the appropriate clinical details. Did they check for allergies to iodinated contrast when they gave contrast after you ordered it without? Are they aware of the patient’s renal history placing him at increased risk for NSF?
And no doubt there are other considerations escaping me at the moment.
Please recognize, radiologists are not typically clamouring for this level of parity in consulting power. We would spend much more time and get no further reimbursement if we were frequently changing orders intermodality-wise. It is quick and easy and we have established processes for intramodality changes. But from an ethical and legal perspective, it is an unusual distinction, potentially unique in medicine.
Consider also that this mechanism--You obtain a radiology consult by ordering a test, not requesting a specific radiologist actually consult--is to a degree an artifact of how hospital regulations have set up the specialty of radiology. JACHO regulations require that all ordered imaging studies be officially read, and so hospitals contract with radiology groups to read all imaging studies. Yet when they take on so much, it would be impossible to do H&Ps like other consultants.
It need not be this way. Consider an alternative mechanism: Each group of clinicians--of pulmonologists, of general surgeons, of orthopods, of GPs, of perinatologists, etc.--hire one or more radiologists as part of their group. The immediate benefit is subspecialized readings. The orthopods will fight to associate with the best MSK imagers, the neurosurgeons with the best neuroradiologists, the general surgeons with the best body imagers, etc. Fewer general radiologists (who read many things well but few things exceedingly well) are needed, and more radiologists can subspecialize and improve their output quality.
A second immediate benefit is one can develop sophisticated protocols without having to get a buy-in from every other radiologist in the group. One need only convince one’s own clinical colleagues that, for example, CT enterography is typically better than SBFT for Crohn work ups.
Of course, a specialized radiologist may need to be a “part-time” member of more than one group (say, one radiologist partnering with two gastroenterology groups and 1 general surgical group) to get enough business. But it’s really just a different way of divvying up the current workload among the current radiologists, so we know it is able to be done.
Radiologists would no longer be looked at as interchangeable. While today clinicians of course detect quality differences among radiologists, there is little they can do about it. The quality of the worst is seldom so bad as to justify a complaint with teeth. Instead, clinicians ask radiologists they trust for second opinions, which has the ironic effect of slowing the productivity of the most respected members of the group. Wouldn’t it be easier to just ask the more respected members to be part of YOUR group?
If imaging were reorganized in this fashion, the idea of switching from, say, an SBFT to a CT enterography would be very different. It would be done by a radiologist who is a practicing member of your own group, easy to contact and consult with.
Is this an idea whose time has come? Is it an idea that would have already occurred were it not for JACHO regulations? Are there other regulations that might inhibit the idea (for example, business regulations, Stark regulations, etc.)?
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