Cardiac CTA spawns radiology's next ice age

May 1, 2006

"Bones! You've got to do something."

"Bones! You've got to do something."

"Jim, I am not a miracle worker."

"But if we don't make that lease payment, the Enterprise will be repossessed."

"I don't have the tools or staff. I don't have the necessary reimbursement. Spock, surely you understand the situation here."

"Logic would dictate that in order to raise the necessary funds, the doctor has to either increase his charges or his volume-or find a new source of revenue."

"Listen, you pointed-ear Vulcan, there's nothing more I can do."


"Jim. Maybe, just maybe . . . Scotty, could you go check on the warp engines?"

"I'll do it later."

"What about the transporters, then?"

"Are you trying to get rid of me?"

"No! But there is a bottle of Romulan brandy in my quarters. Would you please be kind enough to . . ."

"I'm on it."

"Now that he's gone . . . Jim, a doctor is just like an engineer. Scotty only oversees the staff-and much like my physician assistants, they are the ones who actually run the ship. I could do his job and bill for it if only we could change the law. "

"Captain, we do happen to be in the epsilon delta quadrant. The prison planet Abramoff 9 is nearby."

"Abramoff 9?"

"Yes, Captain, at the end of the lobbyist wars in the 21st century all lobbyists were sentenced to a distant constellation of barren planets. Over the centuries they have interbred. Now each planet is populated by mutant super lobbyists."

"Spock, doesn't the Galactic Federation of Planets forbid transporting anyone off those planets?"

"Yes, Captain, but I believe that for a few dilithium crystals they would be more than willing to make a few phone calls for us to the right people."

"Psssssst. Jim. Spock just repeats whatever the ship's computer tells him. I could do his job, too."

"And my job?"

"Well . . ."

Creationism? Intelligent Design? Evolution? There is no better proof for evolution than our own field of medicine. There were no doctors in the Garden of Eden or in the primeval forests of equatorial Africa. No, doctors evolved. First, there arose shamans/priests and then witch doctors, which gave rise to actual doctors. Then, an evolutionary branch was introduced and surgeons arose. These two limbs branched off into numerous subspecialty groups, one of which evolved as cardiologists.

In nature, competition results in some life-forms benefiting from natural advantages. For cardiologists, this advantage was control of patients and mastery of large, well-developed opposable lobbyists. These advantages allowed cardiologists to gain control of many profitable procedures and fueled the elimination of many other specialties.

By the 23rd century, as seen on "Star Trek," the only physicians left were cardiologists who had morphed into the typical characteristics of Dr. McCoy. With the elimination of their natural competition, cardiologists grew unchecked. By the year 802,701 A.D., cardiologists had cannibalized most of the earth after evolving into Morlocks, as documented by H.G. Wells. Do we really think the Eloi were a product of Intelligent Design? I think not. What sort of God would allow that?

A meteor wiped out dinosaurs and thus changed the course of evolution. The ice ages also altered nature's progress. And no matter how woolly the mammoths tried to get, they could not survive the advancing glaciers. Today's radiologists are facing the equivalent of an approaching glacier, but in this case it is a disruptive technology-cardiac CTA. Much like the woolly mammoth, I am trying to learn to grow more wool to extend my life span and forestall approaching extinction. That is why I recently took a cardiac CTA course. Should you be doing the same?

After physical injuries and abdominal pain, chest pain is the most common complaint in the ER, with more than seven million visits. Fifty percent of them patients are hospitalized, and the majority of these are ruled out for an infarct. However, 2% of patients with an acute infarct are inappropriately discharged without the correct diagnosis. A 1996 article in the American Journal of Emergency Medicine by Karcz et al showed that missed acute myocardial infarction is one of the most frequent causes of medical malpractice in adult medicine.

In 2005, the Annals of Emergency Medicine featured another paper by Katz et al that concluded that malpractice fear accounts for significant variability in ED decision making. They found that such fears are tied to increased hospitalization of low-risk patients and increased use of diagnostic tests. Why should any of this matter? Money. In 1998, 4.9 million cardiac cath procedures were performed. At $5000 each, that's a lot of money.

Five years ago, I could go a week without reading more than one V/Q scan. But the advent of pulmonary CTA now means that I literally read dozens every night. The patients haven't changed, but the test has. It is now easier to perform. The triple rule-out CT of the abdomen has become ubiquitous. The same will soon happen with a triple rule-out for chest pain to exclude pulmonary embolism, dissection, and myocardial infarction.

ER doctors do not want to be sued. The new 64-slice CTs, and the soon-to-be released 256-slice scanners, mean that patients will be undergoing cardiac CTA 24/7. Based on my recent experience, these are going to create a lot of work to read. Who do you think is going to do that? Radiologists? Great! But thinking about buying a second vacation home with all the new income? Think again.

If you review the Web page for the Society for Cardiovascular Angiography and Interventions, you will find that income increases for invasive cardiologists outpaced almost all other specialties. But with the new Medicare fee reductions, the SCAI predicts cuts in income as high as 30%. Invasive cardiologists will experience an even greater hit once coronary CTA becomes common. When that occurs, up to 84% of cardiac caths and stress tests will no longer be necessary.

Cardiologists know this. Most cardiac CTA courses are sold out, and the majority of attendees are cardiologists. The American College of Cardiology Foundation training guidelines for adult cardiovascular medicine endorse programs that will lead to cardiologists being in charge of cardiac CT and MR. The Society of Cardiovascular Computed Tomography already has more than 2200 members, most of whom are cardiologists.

In his cardiac CTA course, Dr. David Dowe, medical director at Atlantic Imaging in Galloway, NJ, tells a story about approaching a local insurance company with evidence that cardiac CTA that costs between $500 and $1000 is less expensive and nearly as accurate as a $6000 cath procedure. But the insurers would not agree to pay for the CTA exam for fear of "pissing off the cardiologists." Cardiologists hold a power over many hospital administrators that rivals Svengali-and over insurers as well-even though they drive up costs.

The Medicare Payment Advisory Commission's (MedPAC) report to Congress in 2004/2005 reported an alarming growth in imaging by nonradiologists, and a large percentage was attributed to cardiologists.

As documented by Dr. David C. Levin of Thomas Jefferson Hospital in Philadelphia, cardiologists have taken control of most cardiac imaging, and their self-referral practices have fueled overutilization. Between 1996 and 1998, utilization of radionuclide myocardial perfusion by cardiologists increased 10 times compared with utilization by radiologists. In general, self-referring nonradiologists perform up to 7.7 times as many studies and charge up to 7.5 times as much as radiologists. And since there are 15 cardiologists for every radiologist, we are greatly outnumbered. They have more money, more powerful lobbyists, and better clout with hospitals than us. Brrrr. Is it me, or is it getting colder?

What can you do? If ER physicians are worried about missing 2% of heart attack victims, then I would start scaring cardiologists about the fact that 35% to 37% of cardiac CTA studies include significant findings outside of the heart, including lung nodules, lung cancers, and pancreatic cancers. Are cardiologists going to assume responsibility for these findings as well? Address this with your medical staff well before they take control. A radiologist must be present when these credentialing issues are being discussed.

Radiologists need to become the dominant participants at cardiac CTA courses and learn this technology sooner rather than later. After the course, take the initiative and start performing these studies at your facility. While I was attending Yale, Dr. Arthur Rosenburg taught me to always try and find something on each study that no nonradiologist would find. His reasoning: "It will scare the crap out of them and teach them to value you more."

In retrospect, the idea of evolution and being eaten by Morlocks seems less and less appealing. Creationism is starting to look better. We should all begin praying for another flood and hope the Morlock's ancestors don't make it onto the Ark-otherwise, we could all end up as cardiologist's canapes.

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at or fax at 650/728-5099. He also answers questions posed by readers in the "Ask Eric" column on

Editor's note: maintains an updated list of cardiac imaging training opportunities. You can find them at