ER practice may save us from neutering

"John, Roberta has been ordering a lot of cone-down and magnification views on patients."

"John, Roberta has been ordering a lot of cone-down and magnification views on patients."

"Well, David, she is a mammographer."

"I know, but this was on a chest CT. She saw some calcifications in the chest wall and ended up getting all kinds of additional views, which wasted a lot of time and money."

"Well, that is her job."

"In an 18-year-old girl in a motor vehicle accident?"

"Maybe not."

"John, we just can't keep wasting money on expensive errors like this."

"David, we have been responding to intense pressure from the administration and medical staff to hire more subspecialty radiologists. Are you complaining that we have too many experts?"

"I appreciate that you just hired a new radiologist, Dr. Winchester, but we think he is a psychotic. Last weekend he tried to shoot a patient; we caught him with a gun before he had a chance to do anything."

"Dr. Winchester is a highly regarded professor of radiology. He has written hundreds of articles and several textbooks. What exactly was wrong with the patient he tried to shoot?"

"He had a broken leg."

"Maybe we shouldn't have hired Dr. Winchester from that veterinary school."

Errors can be expensive. I'm sure the hospital's lawyers are anticipating lawsuits from patients who were neutered and spayed based on Dr. Winchester's recommendations. Another expensive error many radiology groups make is failing to anticipate and adapt beforehand to changes just appearing on the horizon. Changes are afoot right now that will have a significant impact on both the performance and compensation of radiology groups. The most immediate of these is "The emerging role of pay-for-performance contracting for health care services," the title of an article by Dr. James Thrall in the December 2004 issue of Radiology. Capitation and at-risk contracts have failed to control double-digit increases in healthcare or to address quality-of-care issues. A study called "The quality of health care delivered to adults in the United States," published in The New England Journal of Medicine in 2003, found that patients received care consistent with quality indicators only 54.9% of the time.

As healthcare represents 15% of the gross domestic product, and government pays for approximately 50% of healthcare, it is not surprising that the Centers for Medicare and Medicaid Services has jumped on the pay-for-performance bandwagon not only to decrease costs but to improve the quality of care. Few physicians realize that CMS has begun entering into pay-for-performance contracts with many hospitals by offering them higher reimbursement rates if they provide detailed quality performance data. Based on these data, hospitals will be aggressively judged against one another. It's a safe bet that this process will eventually evolve to include the performance of individual physicians.

Numerous healthcare plans are already targeting individual physicians' performance with similar "carrot and stick" plans. Hospitals that typically have razor-thin operating margins will be particularly vulnerable to such contracts and in turn will inflict even greater scrutiny on radiology departments. Increased utilization of expensive high-tech imaging has attracted calls for cost-containment, particularly since the Government Accounting Office has determined that 30% to 40% of imaging studies are unnecessary.

How can radiology groups address this issue? Let's take a look at another intersecting trend that began over 40 years ago, which could offer some solutions. Prior to the 1960s, most emergency departments were staffed by a variety of physicians drawn from the local community. It was not until 1961 that the first dedicated emergency medicine group was founded. The American Board of Emergency Medicine did not gain primary board status until 1989. Emergency medicine is now an established field.

A similar trajectory has been seen in medicine's newest and fastest growing specialty: the hospitalist. The Society of Hospital Medicine claims there are now 10,000 hospitalists, and that number is expected to triple by the end of the decade. This growth has been fueled by numerous studies showing that care by hospitalists reduces errors, improves quality of care, decreases costs, and shortens hospital stays. As a result, some hospitals are awarding exclusive contracts to such groups to provide in-hospital care.

What does this have to do with radiology? In many hospitals, 30% to 50% of all imaging studies arise from the emergency department and urgent-care clinics, and emergency room visits have been increasing by 5% to 20% a year in some hospitals. Yet emergency radiology continues to be the poor stepchild to other radiology subspecialties. Many groups provide emergency coverage by a mammographer one night, a neuroradiologist the next night, an interventionalist the next, and so on. The result is a wide variability of care, increased errors, and additional studies/costs. The lesson learned is that individuals focused on one area of expertise can provide better care at a lower cost.

It is not surprising that progressive and forward-thinking radiology groups are anticipating these trends and hiring radiologists with a more specialized interest in emergency radiology. Demand has increased for fellows from the five emergency radiology fellowship programs in the U.S. The American Board of Radiology has recognized this need and sought to add emergency-related questions to the written and oral boards.

The American Society of Emergency Radiology ( has taken the lead on many of these issues and is promoting emergency radiology as a dedicated subspecialty. Much of the research and political clout of the ASER derives from the time and energy contributed by the academic radiologists who run the society, but an increasing number of radiologists in private practice are recognizing the organization's benefits. In addition to an excellent journal, the ASER sponsors an outstanding CME course every year. As a member of the ASER, I strongly encourage practicing radiologists to consider joining.

Based on my own practice providing night coverage for radiology groups throughout the U.S., I see an incredibly broad range of ways that groups implement emergency radiology imaging protocols, policies, and procedures. Consultations provided to emergency room physicians regarding the best imaging studies and algorithms for working up patients can also vary significantly, not only from night to day but from physician to physician.

In light of the looming pay-for-performance trend, it makes sense for groups to consider how they provide imaging coverage for emergency services at their hospitals. Looking to an organization such as the ASER for guidance on national standards could ultimately avoid unnecessary spaying or neutering of patients.

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at or fax at 650/728-5099.