Daniel D. Saket, MD, MBA

We face a defining challenge with regard to the provision of emergency radiology services. Exploding demand for these services comes at a time of relative staffing shortages, declining reimbursements, and rapid technological advancement, and this demand threatens to overwhelm our practices. Like any other challenge, the demand for emergency radiology services presents us with both great risks and unique opportunities. How we ultimately decide to respond will have far-reaching, long-term implications.

Perhaps no clinical provider is more dependent on our services than the emergency department physician. More than half of the patients who present to emergency departments are now imaged in some form, and the use of CT in this setting has more than doubled at many hospitals over the past several years.1 Many specialty admitting services will not even accept a patient without a justifying radiology report.

In this regard, we are largely victims of our own success. Tremendous advances have enabled us to affect patient care in ways that were previously unimaginable. Though various economic, policy, and legal forces have also played a large part in the growth of emergency radiology, the underlying reason that imaging has replaced the physical examination as the primary mode of patient assessment is that it is more accurate and reliable. Appropriate utilization of emergency imaging reduces inpatient admission rates, length of hospitalization, and unnecessary surgery.2,3 As a result, many young emergency physicians, the core of the emergency department workforce, are being taught to rely heavily on cross-sectional imaging in their training programs. This trend further exacerbates demand, especially in areas with an unforgiving malpractice environment.

As emergency imaging volumes have continued to rise, the complexity of the average examination has also increased substantially, placing additional strain on radiologists. Readily available CT and MRI applications, for example, are being used extensively in acute musculoskeletal trauma, once the exclusive domain of plain-film x-ray. Basic unenhanced head CT is giving way to advanced MR imaging and CT perfusion techniques for directing the management of acute stroke.

Meanwhile, the upcoming explosion of emergency vascular imaging has the potential to transform the current staffing challenge into a major crisis. Coronary CT angiography is poised to become the standard of care for triage of low-risk patients with acute chest pain. Extensive demand for the so-called triple rule-out-combined pulmonary embolism, aorta, and coronary artery study-is on the horizon. Each of these studies contains thousands of images and requires significant postprocessing, which can consume disproportionate amounts of radiologist time.

Many emergency centers are beginning to insist that cross-sectional imaging, including MRI, be performed at all hours for almost any indication. Since emergency centers are strongly focused on patient throughput and disposition, many are demanding interpretations within 30 to 60 minutes-preferably in the form of final reports that will not later change and expose the hospital to potential liability. Some academic emergency departments are even arguing for 24-hour subspecialist radiologist coverage to meet the demand for more nuanced and clinically useful interpretations, as after-hours imaging indications continue to expand.

The challenge for many radiology groups, especially small and medium-sized ones, is how and to what degree to provide such coverage. Groups that do not meet expectations risk being replaced in the marketplace by others who can, whether radiologist or nonradiologist. For some hospital-based groups, which may derive up to 30% of revenues from emergency imaging, this challenge could become a survival issue if not adequately addressed.

Most radiology practices currently employ one of two major staffing models for after-hours services: internal rotating coverage or outsourced teleradiology arrangements. The first model rotates individual radiologists within a practice through overnight and weekend shifts. These rotations are usually arranged on a nightly or weekly basis, and individuals may work either onsite or from home via local teleradiology. Such workload and staffing requirements, however, may contribute negatively to daytime productivity, job satisfaction, physician recruitment, and quality of service.

In recent surveys, radiologists listed "having too much work" as their number one source of stress in the workplace, with 50% to 75% indicating that this contributes negatively to job satisfaction.4,5 Radiologists consistently mention family time as one of their top priorities affecting career choice,6 and they may decide against joining practices that require them to work off-hours. Those from the younger generation are even more inclined to value leisure time and flexibility.

As radiologists become more subspecialized in their training, many may not feel comfortable managing the breadth of services required for the emergency imaging, especially those outside their area of focus. This is currently the case at some large academic institutions, and it has resulted in significant staffing problems during nights and weekends. At the same time, multispecialty radiology groups risk compromising their expertise during the day, as individuals are shunted to general nighttime work from their more specialized daytime roles.

In response to these many pressures, radiology practices have turned to the second solution: outside teleradiology providers. The local radiology group interprets all daytime and evening studies in the usual manner but outsources nighttime and weekend work to commercial teleradiology providers or large regional private practice groups. These companies provide preliminary interpretations in most cases but can, alternatively, issue final reports and often administer their services from a distant locale. The local radiology group then bills for the provided services and pays a flat fee per report to the teleradiology organization, usually $50 to $70 per study. This type of arrangement has become very popular, encouraged by the proliferation of commercial enterprises, at least one of which is publicly traded. Approximately 30% of radiology practices outsource to teleradiology companies,7 and this number is rapidly growing.

It is understandable why this arrangement has become so prevalent, as outsourced teleradiology coverage clearly offers multiple short-term advantages for local practice groups. It quickly and effectively eliminates after-hours staffing problems and the associated job satisfaction, recruitment, and productivity issues. It allows small radiologist groups, which would otherwise struggle to provide after-hours coverage, to continue to contract with hospitals to provide other imaging services without having to hire additional radiologists or merge into larger practices. Centralization of after-hours radiology services improves global workforce efficiency, allowing a single radiologist to cover multiple hospitals, instead of staffing one individual who may not be fully utilized at each location. Outsourced teleradiology has been shown to provide timely and reasonably accurate interpretations, usually within the expectations of emergency departments.8 Finally, outsourced teleradiology is cost-effective. It allows for economies of scale and is much cheaper for individual groups than hiring the one to 1.5 full-time equivalent radiologists required to replace precall and postcall staff during the day.9

Despite these short-term benefits, outsourced teleradiology should be approached with great caution, as its widespread use may have damaging long-term implications for our specialty. The danger of teleradiology is its very real potential to commoditize our field and allow for corporate takeover of our practices. In a scenario in which images are randomly sent to anonymous radiologists for interpretation, we no longer serve as established and trusted medical specialists. We are instead transformed into faceless and commoditized service providers, measured primarily by our costs, compliance, and turnaround times.

The growth of outsourced teleradiology has occurred at a time when other developments have begun to isolate radiologists from the day-to-day practice of medicine. The increasing use of CT and MRI has limited our direct contact with patients, and the spread of PACS has diminished our function as gatekeeper of images.

Much of the remaining value of the individual radiologist today is derived from the professional trust and relationships developed with our referring clinicians. By relying on outsourced providers, we risk sending a harmful message that has the potential to destroy these substantive relationships. By instituting two different standards of care-one during the day and one at night-we signal to clinicians that we do not view our individual services as that important, especially when too bothersome or inconvenient. In such a scenario, there is little to prevent "nighthawk" from expanding into "dayhawk" and eventually replacing our practices-not just in the emergency setting but in all areas. It becomes very difficult to justify our individual value-added salaries and control of imaging.

If radiology services were ever to become fully commoditized, it would create a nightmare scenario for radiologists. Commodities are priced at marginal cost and bought from the lowest bidder, with a decreased regard for quality. Radiology practice has high fixed costs, which may include equipment, office expenses, and basic personnel. Even a small decline in reimbursements can have large consequences, as demonstrated by the Deficit Reduction Act of 2005 payment cuts. Shareholder-owned radiology corporations flush with investor cash would have the ability to substantially undercut prices and withstand any resulting short-term losses until other players were driven out of the market.

Spot markets for radiology interpretations have already been proposed by individuals such as former White House information technology czar Dr. David Brailer. His vision of radiology studies being farmed out across the country for interpretation to the lowest bidder-in a form of reverse supplier auction-was outlined in the September issue of Diagnostic Imaging.10 Other healthcare policy experts, meanwhile, are promoting international teleradiology as an even more effective means of reducing imaging costs. One article states that simply including healthcare in the General Agreement on Trade in Services for World Trade Organization nations would supersede state medical licensing restrictions. This would allow radiology studies to be legally sent to outside countries such as India to be read by foreign radiologists for as little as one-tenth the price.11

Devising and implementing a constructive solution will not be easy or straightforward. To protect against the risks of outsourced teleradiology, some advocate the long-term development of an "emergency-dedicated radiologist" model, in accordance with a blueprint published by Mueller and Yu in the American Journal of Roentgenology in 2002.12

This model treats emergency radiology as a separate subspecialty, staffed primarily by emergency-dedicated radiologists. These individuals are either fellowship-trained emergency radiologists or general radiologists with a strong interest or experience in emergency imaging. They are then primarily responsible for all emergency imaging and work in rotating shifts, in parallel to their clinical complement, emergency medicine physicians.

This arrangement may require as many as four to six full-time radiologists and thus is rarely employed, except in a few academic and large private practices. As practices continue to expand and consolidate to meet changing market requirements, however, forming groups of up to 100 members in some locations, such a model becomes much more feasible. At the same time, smaller groups can be encouraged to join together to develop cooperative regional consortia for after-hours services. This approach would lessen each group's individual staffing responsibilities, pool their more limited resources, and consolidate overnight imaging demand.

The emergency-dedicated radiologist model offers several advantages:

It alleviates pressure on daytime radiologists, improving productivity and job satisfaction.

It encourages and efficiently uses emergency imaging expertise. A single emergency-dedicated radiologist, well versed in the acute presentations of nearly all disease processes, can fill this niche and provide more nuanced and clinically useful interpretations. Building pressures for multiple organ-based subspecialists to be on-call could then be alleviated.

Interaction between the same individuals night after night builds familiarity and trust between us and our clinical colleagues, fostering the professional relationships that are critical for our specialty to thrive. This allows us to develop a tailored and personal service for the emergency department-in contrast to the commoditized service provided by most teleradiology companies.

It encourages individuals who are truly interested in emergency radiology to perform this work, instead of people who may view it as an ancillary commitment. This would only improve our relationships and the quality of service we provide.

This model allows for the same efficiencies of scale as teleradiology, as a single radiologist would likely cover multiple emergency departments, but would also permit us to keep control of imaging services within individual practices.

Multiple obstacles to implementation remain, however, some of which may require changes in how we train and recruit individual radiologists.

Within our training programs, we will need to emphasize emergency radiology as a unique discipline. Currently, emergency radiology is taught as a separate section in approximately 40% of training programs,13 and several academic centers now offer dedicated fellowships in emergency radiology-an excellent start (see accompanying article). All large residency programs should consider setting up such sections, which would transcend the traditional, organ-based subspecialties and ensure high-quality service.

Closer clinical interaction with emergency physicians-with joint rounds and teaching conferences-may also help trainees learn what exactly our clinical colleagues are seeking from us. Expanding the overall number of radiology residents to help alleviate the current overall workforce shortage will also be important. This may require securing outside sources of educational funding, such as from private practice or industry.

Radiology practices will likely need to award better incentives to recruit and retain emergency-dedicated radiologists. Many of these positions are unattractive due to the odd hours and acuity of the work. Teleradiology companies offering similar positions, however, have had little trouble finding radiologists. Individual practices may need to match their generous salaries, flexibility, and vacation benefits. Many of these teleradiology companies allow individuals to work from home, streamline licensing and credentialing procedures, and provide hassle-free work environments, with effective and organized support staff. Local private practice groups may need to emulate these attributes to remain competitive for young radiologists and to build effective services of their own.

No one solution can apply to all radiology practices. Outsourced teleradiology may still be necessary for smaller and rural practices, acute staffing needs, and specific problem-solving applications. Internal rotating coverage may work well for very large practices, especially if too few radiologists decide to focus primarily on emergency imaging. Regardless, we need to address constructively the acute challenges created by the rapid growth of emergency imaging.

The author would like to thank Dr. Saurabh Jha, an assistant professorof radiology at the University of Pennsylvania, for his contribution to this article.

Dr. Saket is chief resident in the radiology department at the University of Pennsylvania in Philadelphia.

University of Washington-Harborview Medical Center

University of Texas Medical School at Houston

Articles

We face a defining challenge with regard to the provision of emergency radiology services. Exploding demand for these services comes at a time of relative staffing shortages, declining reimbursements, and rapid technological advancement, and this demand threatens to overwhelm our practices.

Daniel D. Saket, MD, MBA

Articles

ER-dedicated practitioners may address workload challenges