Diagnostic Imaging
November 2003

RADIOLOGY PRACTICE

Forces within and without radiology influence turf battles

Shortages of money and staff, booming technology hinder effective offensive strategies

Several years ago, a new group of neurovascular surgeons fully trained in catheter angiography arrived at Thomas Jefferson University Hospital. Jefferson's neuroradiologists rarely performed interventional procedures, so the new surgeons developed their own market. They have since become major players in the Philadelphia area.

The two groups shared diagnostic catheter angiography duties for a while, but neuroradiologists eventually relinquished control, more for logistical reasons than because of a turf tussle, said Dr. Adam E. Flanders, a professor of radiology and rehabilitation medicine at Jefferson. Events have come full circle with the advent of CT angiography and MR angiography. Now Jefferson's neurosurgeons field fewer calls for catheter angio and instead rely on neuroradiologists to interpret CTA, MRA, CT perfusion, and MR perfusion studies for presurgical evaluation.

"It's an interesting twist," Flanders said. "We gave up one traditional piece of turf and then gained a foothold in this advanced imaging area."

The neurovascular surgeons show no interest in incorporating CTA or MRA into their armamentarium, but that could change in the next five years, he said. It's hard to predict how today's cozy working arrangement will withstand the forces shaping tomorrow's radiology practices: the acute radiologist shortage, increased demand for imaging, the aging population, and technological advances. As the pool of medical dollars dries up and technology continues to become more user-friendly, competing specialties will grab for whatever imaging business they can get.

TURF FOR SALE

There is no typical way for radiologists to lose turf. Every institution solves its incursions differently, depending on local politics. But one area may be immune to covetous eyes: mammography.

"If radiologists want to play it safe and not do battle with other physicians for turf, they should specialize in mammography," said Dr. William B. Morrison, chief of musculoskeletal radiology and general diagnostic imaging at Jefferson.

Morrison's tongue may have been in his cheek, but several truths bolster his statement. Nonradiologists look to areas that provide a significant capital payoff. Mammography reimbursement is low, and the threat of litigation hangs over every case. Competition with surgeons for doing breast biopsies does exist, however. This is not surprising, given that interventions pay handsomely compared with diagnostic studies.

For many other areas of imaging, radiologists need to be on guard. A looming turf battle whose loss would spell disaster for radiologists is cardiac CT and MR, said Dr. David C. Levin, national medical director for HealthHelp, a radiology utilization watchdog organization in Houston.

"If radiologists lose cardiac CT and MR, physicians in other fields, such as neurologists, would be encouraged to start doing their own MR and CT," he said.

Dr. Gabriel P. Krestin, radiology chair at University Hospital Rotterdam in the Netherlands, solved this particular turf battle amicably. He hired a cardiologist, Dr. Prim J. de Feyter, to head noninvasive cardiac research. De Feyter holds a joint appointment and splits his time evenly between radiology and cardiology. As at many universities, the cardiology department at Rotterdam is well funded, and it could easily have purchased a few scanners.

"We have solved that problem, at least for the next couple of years," Krestin said.

In many institutions, vascular surgeons, interventional cardiologists, and interventional radiologists have an uneasy alliance. Everything outside the coronaries-including upper extremities, renals, lower extremities, and the aorta-is now subject to a turf issue. As more patients opt for minimally invasive image-guided percutaneous procedures such as angioplasty, stenting, and thrombolysis, the vascular surgeons, particularly, see their lifeblood seeping away.

"Vascular surgeons, as a group, have decided to take over interventional radiology. In one way or another, they've managed to do that in many places," said Dr. Geoffrey Gardiner, an associate professor of radiology at Jefferson. "For the surgeons, it's a matter of survival, but for cardiologists, it's just a matter of money."

The fading paradigm is that interventional radiologists perform a diagnostic angiogram and, with catheter already in place, they simply treat the patient-with angioplasty or stenting-or schedule a future appointment. But vascular surgeons are already trying to do their own diagnostic arteriograms, said Gardiner, former chief of cardiovascular interventional radiology at Jefferson.

The picture turns even bleaker for IRs with the introduction of MRA and CTA, which don't require catheters. One scenario, however, does favor IRs. It's possible that primary-care physicians will send patients directly for an MRA or CTA exam, skipping the vascular consult. At that point, nobody "owns" the patient, and the primary can decide to send the patient to either a surgeon or an interventional radiologist. It will take three to five years for MRA and CTA to replace diagnostic arteriography, so it's not clear how these dynamics will play out.

"The best thing is for the two groups to work together," he said. "Unfortunately, the surgeons believe they have to take over these procedures or they're not going to have a specialty left."

SELF-REFERRAL

Researchers at Jefferson, led for years by Levin, have compiled reams of utilization data, particularly regarding specialties that self-refer, such as cardiology. Their work is built on the seminal publication by Dr. Bruce J. Hillman and colleagues, who found that nonradiologist physicians who operate imaging equipment in their offices perform more exams (JAMA 1992;268[15]:2050-2054).

In a more recent study, Levin et al found that nonradiologists performed 83.3% of all cardiovascular noninvasive diagnostic imaging in 1998. Cardiologists' slice of the pie amounted to more than 60% (Radiology 2003;228:795-801). Echocardiology and nuclear cardiology-two disciplines largely lost by radiologists-accounted for the lion's share of cardiovascular imaging. But as advanced CT and MR vie for supremacy in imaging the carotids and the coronaries, fresh turf battles will arise. Levin concluded that cardiovascular imaging is important to the practice of radiology and posed the question, What will be-or should be-the role of radiologists in this field?

"Cardiologists have a strong presence in cardiovascular imaging, and they control the patients," he said. "But radiologists have far more technical knowledge of the complexities of CT and MR imaging. Thus, both disciplines offer something of value."

Whether the offering will come as a compromise or a wholesale takeover is anybody's guess. A case in point is abdominal MRA. While traditional catheter abdominal angiography, including percutaneous aorto-iliac, visceral, and renal arteriograms, is decreasing, abdominal MRA is on the rise. In 1997, the number of MRA procedures performed at Jefferson was relatively small, making up 2.5% of all angiography studies versus 97.5% for digital subtraction angiography. By 2000, DSA utilization had decreased to 73.4% and MRA had increased to 26.6%, according to Laurence Parker, Ph.D., who presented the study at the 2003 meeting of the American Roentgen Ray Society.

Who exactly is performing all these MRA studies, Parker didn't say. But cardiologists have taken note of MRA, according to Dr. Edward T. Martin, a cardiologist and director of the Oklahoma Heart Institute's cardiovascular MR center in Tulsa. With downtime in their cardiac MR schedules, many cardiologists have begun to perform MRA just to pay the bills. Martin's top three cardiac MR procedures are evaluation of carotid arteries, renal arteries, and abdominal vessels. Some radiologists say that as the cardiac MR business picks up, cardiologists will relinquish their MRA aspirations. Others contend that radiology cannot be an idle player in this game. Although radiologists and imaging physicists invented and perfected MRA, cardiologists are the ones publishing the bulk of clinical research on the subject. And whoever controls the research controls the modality.

Another factor to consider is the overall increase in MR imaging and the high fees it pays. A study of the U.S. Medicare population by Morrison et al found that while MR represented 2.6% of all imaging procedures from 1996 to 2000, its relative value units accounted for 9.1% of that total. This exemplifies the modality's complexity and, therefore, its comparatively hefty reimbursement, Morrison said at the 2002 RSNA meeting. The Jefferson group also found that MR utilization increased worldwide by 134% from 1993 to 2000. Across all geographic breakdowns, joint MR enjoyed the highest increase, followed by abdomen and spine.

These statistics are not lost on Dr. Elias Zerhouni, director of the National Institutes of Health. In his address at the International Society for Strategic Studies in Radiology in August, Zerhouni encouraged radiologists to conduct more research into musculoskeletal conditions (see accompanying article).

Levin cited other diagnostic turf battles to be aware of: emergency ultrasound and x-ray (ER physicians), prostate ultrasound (urologists), and general abdominal and retroperitoneal ultrasound (primary-care physicians, oncologists, internists, and general surgeons).

CONSUMER IS KING

Despite trends toward consumer-driven medicine, diagnostic radiology will remain a referral-based specialty. Interventional radiologists, on the other hand, are increasingly moving toward owning patients. The positive impact of image-guided percutaneous interventions gives interventional radiologists an immediate opportunity to claim turf. The Society of Interventional Radiology has led a major PR campaign in the last several years to educate the public about uterine artery embolization, endovascular laser therapy for varicose veins, and vertebroplasty. The SIR has bet heavily that these and other new minimally invasive techniques will give name recognition to IRs, ultimately shoring up tenuous turf.

Radiologists cannot assume that a technique they invented and perfected will remain within their custody without a fight. In the March 2003 issue of Clinical Obstetrics and Gynecology, Dr. Bruce McLucas called for the credentialing of ob/gyns for UAE. McLucas, an associate professor of ob/gyn at the University of California, Los Angeles, is one of only a handful of gynecologists who perform UAE, but his call should serve as a warning to IRs that interlopers are eyeing their turf.

Sports medicine is a competitive area for radiologists. At Jefferson, the bulk of musculoskeletal imaging is performed with MR, and orthopedic surgeons refer most of the cases. Some entrepreneurial surgeons install MR scanners in their offices and then contract radiologists to read studies. This breach is not so much a turf infringement as it is a bite into radiologists' dollars (the surgeons collect the technical fee). The real threat comes with interventional procedures.

Nonradiologists are gaining ground in musculoskeletal interventions. Anesthesiologists, surgeons (orthopedic and neuro), and physical medicine and rehabilitation (PM&R) specialists are increasingly performing spine injection procedures. PM&R specialists, who mostly do exams, will increase reimbursals by doing more procedures. In some locations, this dynamic has actually worked in radiologists' favor. Orthopedic surgeons, fearful of losing patients to pain clinics, send their spine injection patients to radiology departments. Generally, though, radiologists are losing turf in these procedures, Morrison said.

KEEPING GROUND

It's no secret what radiologists must do to maintain turf: conduct the research, perform better than the competition, be available to referring physicians, and attend conferences of other specialties. But with staff shortages, financial cutbacks, and increasing workloads, radiologists and hospitals cannot always attend to turf battles. In fact, the musculoskeletal radiologists at Jefferson were not too displeased when orthopedic surgeons started reading their own follow-up fractures.

Academic radiology must take the lead, Morrison said. As things stand today, many residents and fellows of other specialties hardly interact with radiologists. Consequently, when these newly minted physicians open practices, they do not seek out radiologists.

"At Jefferson, when the orthopedic surgery residents and fellows go out into the world, they automatically request that radiology departments hire bone radiologists," Morrison said. "That's because we have developed a good working relationship with them. They know what added value we bring to the diagnostic table."