SPECIAL EDITION
Outlook

By WILLIAM G. BRADLEY, M.D., PH.D.

Washington, DC (API)-The Accreditation Council for Graduate Medical Education announced today that radiology is being removed from the list of approved medical specialties. An ACGME official, who asked to remain anonymous, explained that there is no longer a need for the specialty that had once focused on medical imaging, diagnosis, and minimally invasive interventions. He stated that all functions of the defunct specialty have been subsumed by the Society of Technologist Assistants and Friendly Orderlies (STAFO). In a 30-minute press conference, the official described how the formerly dynamic radiologists lost control of their specialty.

During the first half of the 20th century, radiology moved from a technologist picture-taking status to the rank of medical specialty. This progress was largely the result of efforts of the fledgling American College of Radiology and American Roentgen Ray Society. Because of the work of early volunteers and educators, radiology gradually became accepted as a medical specialty in its own right, with formal examinations conducted by the American Board of Radiology.

During the second half of the century, the ACR grew in influence, particularly in matters of government relations and socioeconomics. Most radiologists were ACR members, and the ACR in turn brought their case regarding reimbursement to the government. At the ACR's peak in 2000, its nearly 300 employees interacted almost daily with the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) and the FDA. RADPAC, the radiology political action committee, lobbied Congress effectively and supported candidates who advocated increasing access to quality healthcare. More than 870 radiologists volunteered their time to ACR activities to advance the specialty. All this happened behind the scenes, but meanwhile radiologists became the most highly compensated of all specialty physicians through these efforts.

BEGINNING OF THE END

Gradually, however, the system began to break down. Radiologists increasingly took the ACR's functions for granted, and members began dropping out, citing the lack of a quid pro quo. Membership in the Radiological Society of North America provided access to the largest annual scientific meeting and several excellent journals.

During the early years of the 21st century, a fall in the stock market necessitated the first hike in ACR membership fees in 14 years.

"Why should I pay $750 a year to join the ACR?" an academic California neuroradiologist was quoted as saying. "Even if I leave the ACR, someone else will keep the organization going. It's not like it's going to affect me personally."

Over a period of several years, membership in the ACR dropped to below 50% of practicing radiologists. The ACR was no longer considered the formal body representing the specialty. This had disastrous effects on the ability of radiologists to influence the reimbursement process. The ACR lost its coveted seat on the AMA's CPT Editorial Panel and similar positions on the RVS Update Committee and the PEAC, effectively taking radiology out of reimbursement negotiations.

Contributions to RADPAC steadily decreased, as nonparticipating radiologists assumed that someone else was going to support lobbying efforts with Congress and that one individual contribution wouldn't make a difference. Although RADPAC was credited with increasing mammography reimbursement during the early years of this century, radiologists quickly forgot the benefits of political action, and RADPAC was disbanded several years later.

Meanwhile, back in Reston, VA, declining membership had forced the ACR to cut staff. The government relations and economics departments were dissolved. The ACR headquarters building went into receivership and was purchased by STAFO. The ACR relocated briefly to a rental unit in a strip mall in nearby Manassas.

STAFO's rise to prominence can be traced to the 1990s, when the realization that there were too many specialists and not enough generalists resulted initially in growth of the primary-care specialties and subsequently in increased use of nurse practitioners, supertechs, and other physician extenders.

Patients had long been asking the technologist assistants and the orderlies who escorted them what the results of their tests meant. In order to answer these questions, technologists and orderlies began receiving rudimentary training in image interpretation. Citing an increasing priority for friendliness and availability over interpretive skills (as a direct result of vigorous lobbying efforts by STAFO), CMS initiated a series of changes known as the Friendliness and Availability Initiative, which effectively equalized the compensation of radiologists, tech assistants, and orderlies.

Outraged when their salaries were cut so drastically in one year, radiologists finally woke up. Arguing that medical care would suffer, they demanded that "their college" defend them against this onslaught by the government. Unfortunately for the former freeloaders, 100 years of infrastructure had already been lost and the college was unable to fight back.

As is now well known to all in the medical community, the CMS F&A Initiative began a cascade of events that resulted in today's announcement by the ACGME. Shortly after relocating to Manassas, the ACR declared bankruptcy, and its few remaining assets were liquidated. With the marked decline in reimbursement for radiological procedures, fewer medical students chose radiology as a subspecialty. The radiology staffing shortage worsened exponentially, and attendance at the RSNA and ARRS meetings steadily decreased. Radiologists' functions were increasingly taken over by technologist assistants and orderlies.

The ACGME spokesman, a prominent tech assistant, concluded by lamenting the passing of radiology.

"Who could have foreseen back in 2002 the effect those radiologist freeloaders would have on the specialty of radiology?" he said. "Now if you will excuse me, I have to talk to some patients about the MR scans I read this morning."

Don't be a freeloader. Support organized radiology now, or there won't be a specialty to support. Join the ACR at 800/227-5463 or www.acr.org.

William G. Bradley, M.D., Ph.D., is chair of radiology at the University of California, San Diego. He has been active with the ACR for more than 20 years. Any views or opinions are solely those of the author and do not necessarily represent those of the ACR.