Feature | July 09, 2013

Should Radiologists be the Gatekeepers of Medical Imaging?

Lessons from across the pond

Medical Imaging U.S. Healthcare Overtesting New England Journal of Medicine

July 9, 2013 — Big changes are coming to the U.S. healthcare system — some in response to the mounting scrutiny of medical imaging. New task force recommendations, the Choosing Wisely campaign and Affordable Care Act policies are all attempting to curtail overtesting — with computed tomography (CT) scans, magnetic resonance imaging (MRI) and any other screening often ordered unnecessarily — that can drive up medical costs, lead to waste and unnecessary radiation, and prompt undue anxiety about false positive results.

These are all worthy efforts, but to really make an impact, a paradigm shift in clinical care will have to happen, Saurabh Jha, MB, BS, of the department of radiology in the Perelman School of Medicine at the University of Pennsylvania, suggests in a New England Journal of Medicine article.

Radiologists must become the gatekeepers of medical imaging, as opposed to serving as just service providers for patients, he writes. In the face of tighter guidelines and ultimately less leeway for physicians to order potentially superfluous tests, he calls on radiologists to be the ones who step forward and manage imaging utilization. But first, they need the power to do so.

“The emphasis on service provision, operations and efficiency has pushed radiologists to the periphery of clinical decision making," Jha writes. “To be effective gatekeepers, they will have to move to the center.”

In the piece, titled “From Imaging Gatekeeper to Service Provider — A Transatlantic Journey,” Jha opens with an anecdote, a trip down memory lane that introduces us to “Dr. No,” a radiologist in Great Britain (where he did his surgery residency) known for turning down requests for scans. Dr. No needed a justified reason, as the country’s system faced limited imaging resources. In other words, you had to have a pretty good reason to order that CT, because often the diagnosis could be found another way.

“[In Britain], radiologists acted as gatekeepers,” he writes. “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.”

Here in the United States, Jha came upon a different approach to treating patients. Fear of displeasing referring physicians or even being perceived as “rationing” care, he noticed, had many radiologists acting more like “Dr. Yes” more often than not.

The healthcare system in the United Kingdom is set up differently from the United States, but there are perhaps some lessons to be learned here, Jha suggests, if we want to get out of the “imaging boom.” Mainly, it shows us that a radiologist, acting as the gatekeeper, can exercise restraint in imaging utilization, he says.

Remember, “gatekeepers don’t simply advise on the best imaging method,” he writes. “They question whether a given diagnosis should be suspected in the first place.”

But such a shift will require two key changes to our health system. The incentive system needs to be changed, as are there no rewards for denying an imaging study — one loses a reimbursable exam and expends time in which other reimbursable studies can be read. But there is a bigger obstacle, he writes: the service-provision mindset. Radiologists do not wish to displease referring physicians, lest they take their business to someone who won’t question their test-ordering ability.

So how do they move to the center and away from the fringe? “They’ll have to develop clinical imaging conferences, act as imaging consultants and conduct imaging rounds. Radiology leadership must provide incentives for these activities without compromising efficiency, by developing granular metrics for quality,” he writes.

Benchmarks will also have to be established for the acceptable proportion of negative studies, and bundled payments for accountable care organizations could offer a sentinel opportunity to face these challenges.

Either way, change is coming and radiologists must decide whether to “greet the ebb of imaging passively or by stepping forward to captain and manage a rational decline,” he concludes.

For more information: www.newswise.com/institutions/newsroom/134/

Related Content

Machine Learning Uncovers New Insights Into Human Brain Through fMRI
News | Neuro Imaging | January 11, 2019
An interdisciplinary research team led by scientists from the National University of Singapore (NUS) has successfully...
3-D Reconstruction of Ichthyosaurus Skull

A 3-D reconstruction of the ichthyosaurus skull from a computed tomography (CT) scan. Image courtesy of Nigel Larkin, taken at Royal Veterinary College, London.

News | Computed Tomography (CT) | January 09, 2019
A nearly meter-long skull of a giant fossil marine ichthyosaur found in a farmer's field more than 60 years ago has...
SCCT Releases New Guideline for CT Use During TAVR
News | Computed Tomography (CT) | January 08, 2019
The Society of Cardiovascular Computed Tomography (SCCT) has released a new expert consensus document for computed...
Hypertension With Progressive Cerebral Small Vessel Disease Increases Cognitive Impairment Risk
News | Magnetic Resonance Imaging (MRI) | January 08, 2019
Patients with high blood pressure and progression of periventricular white matter hyperintensities showed signs of...
Artificial Intelligence Pinpoints Nine Different Abnormalities in Head Scans

A brain scan (left) showing an intraparenchymal hemorrhage in left frontal region and a scan (right) of a subarachnoid hemorrhage in the left parietal region. Both conditions were accurately detected by the Qure.ai tool. Image courtesy of Nature Medicine.

News | Artificial Intelligence | January 07, 2019
The rise in the use of computed tomography (CT) scans in U.S. emergency rooms has been a well-documented trend1 in...
First Arterial and Venous Atlas of the Human Brain Released
News | Neuro Imaging | January 02, 2019
January 2, 2019 — Imagine an atlas containing an image bank of the blood vessels of the...
MRI Effective for Monitoring Liver Fat in Obese Patients
News | Magnetic Resonance Imaging (MRI) | December 28, 2018
Magnetic resonance imaging (MRI) provides a safe, noninvasive way to monitor liver fat levels in people who undergo...
CT Technique Expands Possibilities of Imaging Ancient Remains
News | Computed Tomography (CT) | December 27, 2018
Researchers in Sweden using computed tomography (CT) have successfully imaged the soft tissue of an ancient Egyptian...
FDA Approves Exablate Neuro for Tremor-Dominant Parkinson's Treatment
Technology | Focused Ultrasound Therapy | December 21, 2018
Insightec announced that the U.S. Food and Drug Administration (FDA) has approved an expansion of the indication of...