Vikash Panghaal, MD, MBA

As a younger practicing radiologist with 3.5 years post-fellowship experience, I have seen the partnership track position drying up in radiology.

After coming out of fellowship a few years ago, most of the jobs available were for non-partnership track positions. I interviewed mostly at small and moderately sized radiology practices. After interviewing at a dozen or so jobs, I began to realize that the majority of practices were not interested in offering partnership to new hires. Only a few of the jobs I interviewed at were more accommodating to younger radiologists and even went out of their way to make sure I was aware that the group was looking for radiologists who wanted to have ownership in their practice. Although this was only one of the criteria for looking at potential radiology jobs, I felt that places that offered partnership track positions would be a better fit for me given that they were probably better prepared for future growth and sustainability. 

According to many of my peers recently coming out of residency and fellowship, partnership track radiologist jobs are far and few between. A quick glance at the ACR Career Center confirms the paucity of partnership track positions. Although this may be good for groups in the short term, this may create a dichotomy of practicing radiologists within groups. As the partners continue to get older and eventually retire, there will be no one to carry the torch of running the practice. The newer radiologists will lack the knowledge of being part-owner in a radiology or medical practice. Non-partnership track positions will also lead to increased turnover of radiologists given that employee position radiologists are not committed to any particular group. [[{"type":"media","view_mode":"media_crop","fid":"30086","attributes":{"alt":"partnership","class":"media-image media-image-right","id":"media_crop_114678828207","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3142","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 121px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

 I read recently said that radiologists are working longer and delaying retirement. According to the article, radiology has experienced periods of severe boom and bust in the past two decades. A surplus of radiologists in 1996 led to a shortage in 2001. According to the article, the current demand for radiologists almost exactly matches the number of new trainees entering the workforce. My interpretation is that although the jobs available equal the supply of radiologists needing jobs, there are fewer jobs for new trainees in desired areas and more jobs in remote areas.

Given the increasing number of senior citizens in America, the demand for radiology services will certainly increase. However, the future demand for radiologists and the ability to obtain partnership track positions is certainly unclear and the rate of senior radiologists retiring will certainly play a role in the balance of supply and demand.

I am skeptical that the trend will change in the near future given the current health care climate.

Articles

Employers are no longer offering partnership to radiologists. 

Partnership Track Is Becoming Scarce in Radiology

When I was growing up “mom and pop” grocery and retail stores were slowly being replaced by bigger chain stores. At first, I remember many people were against the trend of stores getting bigger, but as the bigger chain stores began to slowly replace the “mom and pop” stores, people started to get used to the idea of a one-stop-shop where they can get all of their household items in one store. The lower prices also helped fuel public acceptance. During the past decade, the large retail chain stores, such as Walmart, Target, Costco, etc. still exist and continue to flourish. Despite their success, many individuals are shifting away from the large retail chain stores and the pendulum is slowly moving to the smaller retailers who can provide higher quality and personalization, like local farmers’ markets.

The idea that large stores cannot provide high quality merchandise and services is not necessarily true, but it is not the norm. A low price, low quality store that comes to mind is Walmart. As I walk down the aisles of Walmart, I cannot believe how low the prices are for certain items, including food. In today’s agricultural environment where livestock animals are fed unnatural food and crops are grown using genetically modified seeds with a greater quantity of pesticides, one has to wonder the quality of food that is sold at retailers such as Walmart.

Walmart has its hand in many industries including groceries, guns, pharmacy, cigarettes, and eyewear to name a few. Recently, Walmart has decided to get into the healthcare business.  A few weeks ago I watched a segment of 

 discussing Walmart’s new Care Clinic, which just opened up in Georgia. The Walmart Care Clinic will be staffed by mid-level providers, such as nurse practitioners and will charge $40 for walk-in patients. A recent article in 

 pointed out the convenience of going to this type of clinic and dismissed the importance of having a central primary care physician who knows you and your medical problems. [[{"type":"media","view_mode":"media_crop","fid":"28016","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3504781312779","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2797","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 75px; width: 165px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Society is consistently pushing towards low cost everything and we are currently in a similar situation in the healthcare industry, that the grocery and apparel industry faced many decades ago. While the push for low cost healthcare is necessary, quality may suffer. The idea that replacing physicians with mid-level providers to cut costs sounds good initially, however, the back end costs of lower trained providers either misdiagnosing patients or ordering more tests will likely end up costing more money in the long run.

It will be interesting to see which large organizations will stay around and continue to keep the trust of patients. Physicians will need to come together in larger groups to compete with these corporations.

A radiologist longs for the “mom and pop” days of healthcare.

Walmartization of Healthcare

Defensive medicine is prevalent in all specialties of medicine. Physicians may not even consciously realize they are practicing defensive medicine since it has been engrained in our thought process early on in our careers, especially over the past few decades. From my experience, physicians-in-training are usually not exposed to defensive medicine until residency, since medical schools usually shelter us from the “real life” thought process.

In medical school, physician mentors or professors stress the importance of physical examination and history and believe the majority of diseases or disorders can be diagnosed without ordering further tests for consultations. It is not until residency, when we are taking care of real-life patients in the real world, far from the ivory tower medical school atmosphere, that we slowly immerse ourselves into the practice of defensive medicine.

Defensive medicine is usually the result of two issues, one is the fear of being sued and the other is the continued decrease in time spent taking care of a patient. Both result in the increased utilization of additional consultation and testing. The increased utilization of mid-level providers such as physician assistants and nurse practitioners have also attributed to increasing costs, given their lower level of training, which likely ultimately leads to overutilization of services.[[{"type":"media","view_mode":"media_crop","fid":"27527","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1630789094776","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2695","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

 I recently came across an article in Forbes Magazine – 

Defensive Medicine: A Curse Worse Than The Disease

. This article discusses the issue of defensive medicine and how it is engrained in our health care system. One in four health care dollars is attributed to defensive medicine which amounts to about $650 million annually. The article also addresses the likely worsening of the problem due to the Affordable Care Act creating more insured patients, as well as the decreasing physician workforce due to retirement of baby boomers.

From my personal experiences, I see the practice of defensive medicine in all specialties including my own specialty of radiology. In my daily radiology reading grind, I can think of many situations where I may recommend an additional study, or my non-radiology physician colleague ordered a follow-up of a benign nodule. For instance, one case I read today was a renal ultrasound that demonstrated a likely renal cyst but given the slight debris within it (likely artifact), I recommended a CT abdomen. Since I practice in a litigious state, I recommended the study mainly for the fear of a malpractice lawsuit that this likely cyst may turn out to be cancer in a rare instance. Another example is seeing likely cysts within the kidney on lumbar spine MRIs which usually get an ultrasound or CT scan next to verify that they are cysts. I am sure most of you can come up with examples on a daily basis as well.

Another article I recently came across was in the Journal of American College of Radiology - 

Are Chargemaster Rates for Imaging Studies Lower in States That Cap Noneconomic Damages (Tort Reform

)?  The article caught my attention since it seemed to evaluate the effect of tort reform on health care spending.  However, after reading the article, I realized that the authors may have missed the underlying issue of defensive medicine as the real issue is overutilization of health services not increasing charges of individual tests.

The article addressed the significance of whether tort reform (cap awards for noneconomic damages (NED) influences the chargemaster rates by hospitals and diagnostic testing centers for certain imaging studies. The 

 concluded that chargemaster rates for select imaging services were not lower in states that have capped NED and were higher in some cases. One of the states that had tort reform, but had higher chargemaster rates was California. I am not surprised by this, given the high cost of living in California, which would likely increase costs for all business sectors within the state.  Hopefully, future studies will address the correlation between defensive medicine and overutilization of services.

The solution to combating defensive medicine is not an easy one, especially in a system that rewards physicians for doing more. Decreasing the risk of a malpractice lawsuit for physicians and limiting damages paid to patients while maintaining the right for patients is a difficult balance. The article in Forbes points out that the practice of defensive medicine did not significantly change in Massachusetts after legislatures enacted “Disclosure, Apologize, and Early Offer” as well as in Texas despite a cap on damages related to pain and suffering. Georgia and Florida legislatures are considering “Patients’ Compensation System,” which would eliminate the possibility of any physician or hospital ever being sued again. This system would replace our current system and would have a panel of experts to hear the medical claims of patients.

Although there has been much attention on curbing defensive medicine, I am not sure we will reach the “Patients’ Compensation System,” given the lobbying efforts of trial lawyers in this country. Even if we enact such as system, I don’t think the behaviors of physicians will change much in the short term. It may take decades to reverse the defensive medicine behavior in physicians, including myself. Parallel reform of physician compensation from fee-for-service to outcomes-based may also help align the goals of high quality and efficient care.

Radiologists and other physicians have been taught to practice defensive medicine.

Why Defensive Medicine Will Continue

Doctors are in the driver seat of health care but they mostly do not benefit monetarily from the health care spending in the United States. I recently came across an article in 

The New York Times: Busy Doctors, Wasteful Spending

. This article addresses the issue with physicians seeing more patients and performing more procedures in order to compensate for payment cuts which may, in turn, increase health care costs rather than decrease costs.  

 of health care costs are directly paid to physicians, 50 percent of that is used to pay overhead, including practice expenses and medical malpractice, leaving only 10 percent of the pie for physician salaries. The trillion dollar answer on how to curb health care costs is not by cutting physician salaries, which will only directly address 10 percent of the spending. 

Radiologists are at the center of physician payment 

. Over the past decade we have seen reimbursements for our services drop over 50 percent for many procedures. Currently, Medicare will pay on average $11 for a radiologist to read a chest radiograph. I cannot imagine any more cuts in imaging, as I feel as though I am already feeling the pressure of reading more and more each year. [[{"type":"media","view_mode":"media_crop","fid":"26104","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9714229924138","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2483","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; height: 248px; width: 440px; float: right;","title":"Impact on global outpatient payments of Medicare reimbursement cuts for imaging services performed at outpatient imaging centers of Southwest Diagnostic Imaging Ltd. Courtesy of Rodney Owen, MD, FACR. Image Courtesy of Radiology Business. ","typeof":"foaf:Image"}}]]

Cutting physicians’ salaries seems counter intuitive. It would be analogous to placing a mandatory cut on teachers’ salaries to reduce educational costs. In the short term, this would seem logical since by cutting teachers’ salaries, the expenses would decrease, however, the long term effects would be detrimental to the outcome of educating our children. Fewer high-quality candidates would decide to go into teaching, leaving less-qualified or less-educated individuals to teach young Americans, eventually leading to worsening of the U.S. education system.

Similarly, by cutting physicians’ salaries, it would eventually lead to fewer top-tier students going into medicine and would allow middle- to lower-tier students to go into medicine. The perception of choosing a career path in medicine would evolve and would likely not maintain the high level of respect and value it currently receives. Also, the end result of saving lives and improving health care would suffer.

It is interesting to see how many administrators are focusing on the physicians’ incomes when hospitals, ancillary services such as ambulance transportation and durable medical equipment companies, and prescription drug prices are huge factors in the U.S. health care environment. Cutting physician salaries will only plug one of the holes in the sinking ship. A larger overhaul of the U.S. health care system needs to be implemented in order for the industry to continue to move forward and to enhance the lives of our country while maintaining costs.

When it comes to healthcare spending, salary cuts may not be the best approach.

Making a Case for Not Cutting Radiologists’ Salaries

As an avid baseball fan, I have watched the transition of baseball over the past three decades. Growing up in the 80s, I remember baseball greats such as Nolan Ryan, Dwight Gooden and Roger Clemens. These players were work horses and would not be taken out of a game until their arm fell off. It was unusual if they were taken out of a game before the 8

 inning. In those days, pitch count was not even discussed. At age 42, Nolan Ryan threw 164 pitches in a game in 1989. [[{"type":"media","view_mode":"media_crop","fid":"25354","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5704520165454","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2311","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; height: 118px; width: 100px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

During the 1990s and 2000s, baseball teams placed more scrutiny on pitch counts and limited pitchers to around 100 pitches per game. The restrictions created a need for specialty/relief pitchers, as many starting pitchers would not be able to finish a game or even pitch into the 7

 innings. It is not uncommon today that a starting pitcher may only pitch until the 5

 inning before being taken out. This, in turn, created the sub-specialization of baseball. The specialty players were also introduced for position players when managers wanted to substitute a slow player on the base path or as a defensive switch in the outfield at the end of a game. 

The changes in medicine mirror the changes in baseball. Growing up, I remember my family physician would see everyone in my family including my mom, dad and sisters. He would see a wide range of ailments including an upper respiratory infection, broken bones, rash…you name it. He would follow my mom for her diabetes and my dad for his hypertension. It was very rare for my family doc to send me or my family members to a specialist.  When I would see him, I was impressed with his memory about me. He would ask me about my personal life, such as the sports I played, as well as how my cough was doing.

Today’s healthcare is much different than it was. Last week, my mother-in-law had a doctor’s appointment for a general checkup. She used to see a physician at her practice but now the practice has a policy that patients with Medicare must see a nurse practitioner. The evaluation with the nurse practitioner was for about 30 minutes, but not much came out of it other than three referrals for specialists to evaluate her knee pain, back pain and thyroid. My mother-in-law is a healthy senior so I cannot imagine how many referrals are given to sicker individuals. 

The primary care physician is similar to a starting pitcher in baseball. Decades ago, the primary care physician would do the bulk of patient evaluation, management and treatment, similar to how starting pitchers would pitch almost the entire game. Now, specialists are playing a greater role in healthcare, just as relief pitchers are pitching more innings in a baseball game.

Although many innovations have occurred in medicine for diagnosis and treatment of diseases, I feel that the primary care physician must play a more vital role in health care to reduce the fragmentation that currently exists between medical providers. Hopefully, information technology advances will also help reduce the fragmentation of healthcare. It will be interesting to see if the pendulum will swing back in the next decade with a greater role of primary care physicians given the Accountable Care Act and the emphasis on cost sharing.  

The sub-specialization of medicine is just like the sub-specialization of baseball. Here, a radiologist explains why.

The Similarities Between Medicine and Baseball

Radiologists have an upper hand when it comes to becoming a leader in today’s health care environment. The traditional radiologist has been a radiologist working in a single-specialty group, which consists of an outpatient imaging center, a hospital based practice, or both. Given the changes in the health care landscape, a good percentage of radiologists will change their work environment in the near future from a single-specialty radiology group to a hospital employed or multispecialty physician group. This change will bring new opportunities for radiologists to take on leadership roles. 

Although the traditional radiologist worked in isolation in terms of practice management and had little or no interaction with other physician specialists when dealing with billing, coding, purchasing, or strategic planning, the new paradigm of practicing radiology will put radiologists side-by-side with other specialists. 

Given the broad knowledge radiologists possess that covers various medical specialties and the increased contact with fellow physicians in other specialties, radiologists have an underlying advantage that few other specialties have. Since we understand many subspecialty topics in medicine, we are able to converse with fellow physicians about their questions and concerns whether it pertains to designing optimal patient workflow, creating evidence based medicine protocols, or implementing ancillary services.

The work schedule for radiologists also allows for easier transition to leadership positions since the daily clinical work schedule can adjust around the administrative responsibilities that arise in leadership positions. This is much more difficult in medical specialties where physicians see patients or spend a considerable amount of time in the operating room.

From my own experience practicing at a large multispecialty practice, I know the majority of my colleagues because I have read imaging cases for them, discussed interesting or urgent cases with them, or performed image guided diagnostic or therapeutic procedures for their patients. I am not sure I can say the same for my fellow endocrinologists, ophthalmologists or pediatricians to name a few.

The fact that I read or perform procedures for my co-physicians in my group already forms a tie with them and is a great platform to allow me to move to a leadership position for my group. Although leadership positions are not for everyone, I believe our specialty provides us the flexibility and contacts for budding leaders to flourish in the new health environment.  

Radiologists are well equipped to become leaders in the new health care environment.

Why Radiologists are Primed for Leadership in Medicine

With today’s changing health care laws and landscape, the future of how radiology is practiced will surely change. If radiologists are not aware of the changes, they will be left behind wondering how their field has become obsolete. 

The Affordable Care Act (ACA) will undoubtedly increase the number of insured patients, which many radiologists will think will ultimately lead to increases in imaging. However, the ACA will also drive down reimbursements for physician services, including radiology tests, by negotiating lower rates to doctors who join the health exchange plans, as well as giving patients more financial responsibility, which will make patients more price-conscious. 

The new laws are changing the health care landscape. More and more solo practice physicians or small group practices are forming larger groups or joining large hospital systems, most likely due to the perceived changes that will occur, some due to the ACA. The possibility of changing reimbursements from fee-for-service to bundled payment based on patient symptoms and patient outcomes is also fueling the shift from small groups to larger groups. 

Where does the change leave the radiologist? In my opinion, if individual radiologists are not perceived as necessary for a practice or health care system, and the perception is that they are easily replaceable, the differentiating factor between radiologists will just be cost and radiologists will just be a commodity.  With the increased competition among different physician specialists for patients and the turf battles that exist over which physician performs certain services, radiologists will be left out of the loop. 

Interventional radiologists have seen this issue over the last few decades and have slowly transformed their practice to a hybrid radiology practice, where they see patients, read radiology cases, and perform image guided procedures.  The rest of radiology needs to follow this approach in order to survive and keep a place in the ever changing health care landscape.

Changing health care laws contribute to the uncertain future of radiology.

An Uncertain Future for Radiology

As a practicing musculoskeletal interventional radiologist, I use ultrasound often in diagnosing and treating disorders. My colleagues in other specialties of medicine often remark how easy ultrasound is and how they should incorporate the imaging modality in their clinical practice. I usually given them a half nod and go about my business.

I believe medicine is in an ultrasound boom. There are many reasons for this, including increased radiation concerns with other imaging modalities, stable reimbursements for ultrasound, and increased portability of ultrasound machines.

Although non-radiologist physicians can take courses to utilize ultrasound in their practices, many do not understand the basic fundamentals of ultrasound imaging, including the physics behind creating images. As radiologists understand, ultrasound images often have artifacts which can lead to misdiagnosis. Also, unlike other imaging modalities, ultrasound is highly user dependent, and in the wrong hands, can lead to over- or under-diagnosis.

Radiologists are thought of as the imaging expert but in recent years with reimbursement cuts and physicians looking for other avenues to supplement their income, imaging has been shifted to nonradiologist practices. 

I recently came across a posting on KevinMD.com which discusses the 

usefulness of ultrasound at the bedside for general internists.

 This is one of a handful of posts I have come across recently from various medical specialties. The post basically discusses how ultrasound can increase the accuracy of detecting disorders and also diagnosing occult disorders by the general practitioner. 

Although I agree that ultrasound is a great test to help diagnose and treat disorders, it should not be used ubiquitously by semi-trained users, as it may increase detection of diseases but can also lead to a false level of assurance and over-diagnoses.   

During my training, emergency room physicians began to perform ultrasound at the bedside.  After that point the radiology department ultrasound volume increased significantly from the ER. The main reason for this was the ER physicians often thought they found an abnormality on ultrasound and upon further review in our department the finding was either a normal structure or an artifact.

I do agree that portable ultrasound may be beneficial in certain emergency situations, including but not limited to evaluating for a deep venous thrombosis, pleural effusion, and abdominal ascites/hemorrhage. However, for non-emergent situations, the study should be performed by an expert in ultrasound imaging. In today’s healthcare environment where cost along with outcomes are at the utmost importance, imaging should be kept in the hands of the experts and will ultimately lead to better, more efficient care. 

Ultrasound is being used more at the bedside by all specialties. But for non-emergencies, leave it to the experts or risk over- or under-diagnosis.

Leave the Ultrasound Imaging to the Experts

Several times a day I get requests to look at outside images. The protocol at my institution is to have the front desk upload the study into our PACS and then have the radiologist review the images directly with the referring physician or compare it with a study performed at my institution. It is not uncommon that the front desk comes over to me with the CD stating that the CD does not contain DICOM images and cannot be uploaded into our PACS.   

I ultimately end up placing the CD into my laptop computer and view the study with the viewer provided on the CD. As there are several DICOM viewers on the market, most of my time is spent trying to figure out how to use the proprietary DICOM viewer. After several minutes of frustration, I finally begin to review the study. 

The underlying issue has been discussed in many research papers including a 2011 article from Radiology “

Outside Imaging in Emergency Department Transfer Patients

” which demonstrated that CD import to PACS was successful in 78 percent of the cohort and was unsuccessful in 22 percent, mainly owing to non-DICOM format. The study also stated that there were several originating institutions that routinely provided non-DICOM–format CDs containing images in proprietary formats with embedded image viewers.

An editorial in Radiographics in 2009 “

Medical Imaging and Data Sharing: Are We There Yet

?” also commented on this stating that “CDs have been plagued by several problems that collectively can be summarized as a lack of vendor compliance with standards.” The article goes on to say that “although a media profile for medical imaging was developed and disseminated to vendors by the cooperative work of the IHE (Integrating the Healthcare Enterprise) initiative, there is substantial variability in vendor implementation. Some imaging data written to portable media are encoded in proprietary formats instead of the DICOM (Digital Imaging and Communications in Medicine) standard. More substantial problems have been encountered with the design of the embedded image viewer, which must be used to view or ‘consume’ the data on the CD or DVD. Frequently, the image viewers are cumbersome to use, painfully slow, or completely inoperable.”

A 2011 article from Journal of American College of Radiology “

Policies and Procedures for Reviewing Medical Images From Portable Media: Survey of Radiology Departments

” also stated that “concerted efforts to improve the interoperability of DICOM on portable media have been undertaken, though several vendors persist in generating CDs in non-DICOM format that requires proprietary software to import. “

The field of radiology should have a concerted effort to fix this issue. We should create a standard format for all CDs containing medical images to include DICOM images. Although hospital and radiology facilities are shifting to the cloud for transferring radiology images, the use of CDs to transfer radiology images is still prevalent and will be for the near future.

CMS and the FDA should create a policy that all patient CDs containing medical images must be in a DICOM format.  This not only will make the radiologist’s task of looking over the images easier but will potentially reduce unnecessary subsequent diagnostic studies ultimately leading to decreasing health care costs.

CMS and the FDA should create a policy that all patient CDs containing medical images must be in a DICOM format.  

Images on CDs Should Be in DICOM Format

Picture this scenario: You are reading a mammogram and your technologist tells you that the patient doesn’t have her prior studies and we are waiting to obtain them from an outside institution.

Or your technologist left a note on your desk stating that a prior brain MRI was uploaded in the system for you to compare to the study you read last week. 

These situations are not uncommon to radiologists and often are a nuisance given the increasing demands placed on us in the current healthcare environment of reading more cases to offset the decreasing reimbursements.

For most of these cases, I have little recollection of the findings I initially described (as it has been days or weeks since seeing the study) and I spend almost the same amount of time re-reading the case to be able to make a comparison to the prior study. This situation is particularly common in breast imaging. 

A few times a day I read mammograms on patients who had screening mammograms performed somewhere else. For many of these patients we usually obtain prior studies after calling the imaging centers where the patient had them done. In about a third of these cases, we cannot obtain their prior studies either due to patients not remembering where they had the studies performed or if the imaging center is no longer in existence. 

Should patients or radiologists have incentives to obtain prior studies?

In terms of breast imaging, I personally find that waiting to compare outside studies is more work for me than just working the patient up as if the study was a baseline for the patient. However, this is not the best practice as it can lead to increased radiation exposure and costs. Many of these patients often get additional diagnostic mammograms or ultrasounds. The benefit of getting priors is multi-factorial as it reduces radiation, decreases costs of more tests or biopsies, and reduces the emotional toll that patients have to go through when evaluating breast lesions.

Given the benefits of obtaining prior studies for the patient and often the additional resources it takes to obtain and review them, CMS and private insurers should provide an incentive for radiologists to obtain priors and make comparisons.

Obtaining prior studies benefits the patient, but takes extra resources. Radiologists should be incentivized to obtain priors and make comparisons. Do you agree?