Changes prove that some things never change

April 15, 2005

I entered private practice on a full-time basis in 1984, having quit my position in a state-run general hospital following a disagreement over lack of funding for continuing medical education. The imaging center that I joined had just been granted permission to buy a CT scanner. This would not be news today. But 20 years ago, establishment of a private CT center in Sarcelles, a suburban town 15 km north of Paris, was news indeed. CT scanners were scarce in France, and procedures required users to attain a certificate of need, which was a very cumbersome process.

I entered private practice on a full-time basis in 1984, having quit my position in a state-run general hospital following a disagreement over lack of funding for continuing medical education. The imaging center that I joined had just been granted permission to buy a CT scanner. This would not be news today. But 20 years ago, establishment of a private CT center in Sarcelles, a suburban town 15 km north of Paris, was news indeed. CT scanners were scarce in France, and procedures required users to attain a certificate of need, which was a very cumbersome process.

We initially received CT referrals from eight districts in the greater Paris area, covering 10 million inhabitants. Some patients we scanned on our "medium range" system had been referred from university hospitals. Our catchment area today is much more local, and patients are examined on a 16-slice scanner.

Our center also became the first private practice outside of Marseilles, and the third in France, to install an MR imaging unit. The 0.5T scanner arrived in July 1987. When we came to upgrade the system a few years later, we faced problems with our request to purchase a higher field system. French health authorities, it seemed, wanted to limit the availability of 1T (and higher field strength) scanners to university hospitals. Our appeal eventually brought the necessary permission, and we were able to buy a 1T scanner.

We currently work with a 1.5T scanner and would like to buy a second MR system. Permission will be granted only if we can satisfy a regional committee, comprising administrators and union representatives, of our need. Making a strong case for medical matters in such a somber courtlike environment is not always easy. We can only hope that the decision has not already been made before we begin our plea.

The number of mammography and breast workup procedures we perform at Sarcelles has increased markedly as well over the past two decades. This higher workload prompted creation of a full senology department, equipped with digital and screen-film mammography systems, ultrasound, and a stereotactic vacuum biopsy unit. Unfortunately, digitalmammography is not reimbursed by the state in France, although reimbursement of stereotactic biopsies was introduced in February 2005.

The switch to soft-copy workflow has been a memorable adventure. We have worked with four different RIS purveyors over the past 18 years. The first supplier went out of business, the second maintained our installed base but did not develop the software, and the third lasted a little longer but was killed by the development of PC-based networks. Our current supplier appears to be on solid ground, but we shall wait and see. We are on our second PACS. Budgetary limitations prevent further upgrades at present, though prices continue to fall and performance is improving. The French government provides no financial incentives to purchasing a RIS or PACS, despite its stated objective of achieving nationwide electronic medical records in 2006/2007.

The latest addition to our center's imaging armamentarium is a hybrid PET/CT scanner. We received permission to acquire PET/CT in April 2002, and the system arrived four months later and was installed next to an in situ cyclotron. Radiologists receive no reimbursement for reporting PET/CT procedures at present, so the CT images are read by a nuclear medicine specialist with no explicit radiological training.

Our medical imaging center has thrived over the past 20 years and kept up with advances in technology. Of course, the center would be nothing without its patients, who are drawn from the diverse, multiracial population of Sarcelles. Today's average patient is much more demanding and informed than ever before but is still unwilling to pay for even the most state-of-the-art imaging studies. The number of plaintiffs is also increasing.

I confess that I never envisioned all the administrative work and financial issues that form part of private practice radiology. The apparent war between public and private healthcare sectors is needless. Figures showing the wealth earned by French private radiologists are usually misleading. Prejudice against private practitioners using top-end equipment is also nonsense.

Debates about economics and medical imaging are likely to go on. It can sometimes seem as if we radiologists have been struggling against the same problems for the past 20 years. The battle will continue, regardless of new rules or reforms that make it increasingly difficult to retain technical and financial control of our specialty. But whatever the future brings, the prospect of further innovations suggests that a career in radiology will remain as exciting as ever.

DR. LAVAYSSIERE is a private-practice radiologist in Sarcelles, France. He has been a member of DI Europe's Editorial Advisory Board since 1987.