Diagnostic Imaging
November 2003

PERTURBATIONS

Coming soon: Planet of the PAs (a horror film)

Can an orangutan do your job? Radiology may be heading for a Hollywood disaster

"Good morning Mr. Heston. Doktor Zaius will be performing your BE today. Have a seat."

"Dr. Zaius?"

"I can take him right now, Bobbie. Morning, Mr. Heston."

"You look a little young to be a doctor."

"I am a physician assistant extender."

"What's a physician assistant extender? Are you studying to be a doctor?"

"I help get the patients ready for their exams. And, no, I am going to law school, because no one messes with lawyers' fees. OK, take everything off and put on this gown. And Mr. Heston, we don't allow guns in the fluoro rooms."

"It is my constitutional right to have a gun . . . "

"Um, yes . . . ah . . . I see your point, but it's . . . the radiation! It isn't good for the bullets."

"So I took all the bullets out, see?"

"Fine, you win. Doktor, here is Mr. Heston."

"Wait a second. He isn't a doctor!"

"No, Mr. Heston, I am a not a doctor. I am a radiology physician assistant."

"Then why are people calling you doctor?"

"My first name is Doktor. My parents had high hopes. It is a little confusing."

"Well, I want only a real doctor to do my barium enema."

"Unfortunately, that isn't possible. Radiologists just don't do that anymore."

"Well, I certainly don't want some monkey doing my enema."

"Excuse me, Mr. Heston! I am an orangutan."

"Listen, you hairy ape . . . "

"Orangutan! (Psst, Bobbie, I think we may need some help here. Mr. Heston's got a gun. Go next door to the cath lab and see if the gorillas are free.)"

"Sorry, Doktor, but they are doing a TIPS case."

Eduardo Kac is an assistant professor of art and technology at the School of the Art Institute of Chicago who specializes in transgenic art. His most famous and controversial work is the Green Fluorescent Protein Bunny. Using a synthetically enhanced mutation of the green fluorescent gene of the jellyfish Aequorea victoria, he created a fluorescent rabbit that glows green.

Genetic engineering may sound like a great idea, but many risks are involved, most of them unknown. Monarch butterflies have died after ingesting pollen from transgenic corn, and several transgenic projects in humans have been canceled because of unusually high death rates.

Tinkering with the natural order, the social order-or just with job descriptions-can have unforeseen consequences. That is why I am particularly concerned about the American College of Radiology's recent advocacy and approval of radiology PAs. I realize that a lot of groups have been scorched by the radiology shortage, but I am not seduced by an idea I consider the equivalent of eating transgenic corn pollen.

I support the ACR. I think they are working hard for our best interests. But in this instance, a short-term solution will eventually have grave consequences for all of us. I have no doubt that the "brain trust" of the ACR looked at the problem from every conceivable angle before coming up with what they believed was the best solution. Nonetheless, their choice causes me apprehension.

Radiology is under attack from all sides. Fifty percent of all imaging studies in the U.S. are read by nonradiologists, and what little remains is being eaten away by others hungry for new sources of revenue.

Nephrologists have begun putting in their own lines, doing their own thrombolysis, and reading their own ultrasounds. Orthopods and neurosurgeons are buying their own MRs and CTs and reading studies outside their specialties. Cardiologists are buying their own MRs or want privileges to read cardiac/vascular MR in the hospital. Vascular surgeons are taking over vascular labs that were developed and staffed by radiologists, with the blessings of the hospital administrator, who thinks it will bring in more business. ER physicians are doing their own ultrasounds and billing for reading x-rays at night. Even midwives are doing their own ultrasounds.

Will the radiology PA help us in the short term? Maybe. But in the long run, the RPA will be the wedge in a turf battle similar to the one between nurse anesthetists and anesthesiologists. There are now 28,000 nurse anesthetists, compared with 35,000 anesthesiologists. Nurse anesthetists are the sole providers of anesthesia in nearly 50% of hospitals in the U.S., and 29 states allow certified registered nurse anesthetists (CRNAs) to practice without the supervision of a physician.

Will RPAs make our practices more profitable? Since the average CRNA earns about half as much as an anesthesiologist, many hospitals have just replaced anesthesiologists with CRNAs. Studies have shown that they do just as good a job and that an unprofitable anesthesia department can rapidly be made profitable by replacing anesthesiologists with CRNAs. So why not hire them? Do you think a college graduate couldn't be taught to do your job?

The ACR claims that RPAs will work only under the direct supervision of radiologists, but I know how that works. First the radiologist supervises the fluoro cases, then she tells the RPA he can do them alone, and finally she tells him to dictate the case and put her name on it. Many ultrasound technologists already do this. Soon RPAs will be pitching in to read plain films because someone called in sick or is on vacation. I know an orthopod whose PA runs his clinic while he is in the OR across town.

Will it be different for radiology? In the ACR's own words, these guidelines "are not inflexible rules or requirements of practice and are not intended . . . to establish legal standards of care. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician." Can you say you don't know a radiologist or two who would love to dump their work on the PA and leave early? It's just human nature.

The Web pages of the professional organizations for nurse practitioners and PAs make it clear that they have their own agendas for gaining more autonomy. It is not the nature of such groups to give up power once they have it.

Keep this a secret, but I think you could take bright kids right out of high school, send them directly to a radiology residency, and they would do a great job. Do we really want anyone to know that?

Remember the story behind the Planet of the Apes? A shortage of cheap domestic help resulted in society's approving the use of trained primates. Soon the apes were running the world.

Yes, there is a shortage of radiologists. Yes, we need help. But if we flood the market with cheap RPAs, we devaluate ourselves into a mere commodity. Don't be seduced. DeBeers keeps diamonds off the market to maintain their value. I would rather be compared to a diamond than a monkey. Oops, sorry Doktor Zaius-I mean orangutan.

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at ericxray@pacbell.net or fax at 650/728-7206. He also answers questions posed by readers in the "Ask Eric" column on diagnosticimaging.com.