The Ethical Radiologist

March 19, 2015

This edition of the Business of Radiology series focuses on ethics in radiology.

Editor's Note: It’s no longer enough for radiologists to be imaging experts. Health care is becoming big business and radiologists need to understand how to navigate the system. Diagnostic Imaging’s Business of Radiology series provides radiologists with the business education they need to succeed.

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The bedrock code of being a physician and provider is to first, do no harm. Implied in that statement, industry experts said, is a requirement to always act in an ethical manner. It’s one of the easiest ways to safeguard patient safety and present the best quality care.

In radiology, abiding by the highest level of ethical behavior is a sure-fire way to show your colleagues and the health care community that they can have confidence in your work product.

“If you really care about the patient, really care about your colleagues and community, it will shine through,” said Richard Gunderman, MD, an Indiana-based radiologist who has written and published about radiology ethics. “We have an ethical responsibility to put the best interest of the patient above the hospital or health care system that might happen to employ us.”

The American College of Radiology (ACR) Ethics Committee serves as the industry’s highest ethical authority, and it routinely publishes guidelines and policies to help you navigate ethical situations. But, remembering and monitoring ethics at a more local, day-to-day level is also important.

Establishing Ethics
The ACR Ethics Committee is viewed as the industry’s overall policy-making and policing body for ethics, but there are grassroots ways to ensure ethical and moral practices, as well, said Jim Hamilton, chief administrative officer for Medical Imaging Physicians, Inc., in Ohio and past regional president for the Radiology Business Management Association.

In many cases, contracts between radiology groups and hospitals address ethical issues and how to properly assess a group’s overall behavior. For example, contracts might call for routine quality assessments that review whether radiologists provide study-reads to emergency department doctors or surgeons in a timely fashion.  Others might mandate that radiologists who provide expert testimony in litigation turn over any fees earned to the group rather than keeping it.

Group ethics policies are generally unique to each organization, but they provide a guide map for anyone questioning particular behaviors.

“If there’s ever a question of whether something is or isn’t ethical behavior, all someone has to do is ask,” Hamilton said.

Broaching those questions can be particularly important when an individual radiologist disagrees with a group policy. For example, a practice might push a radiologist to read too many studies in a day, jeopardizing the quality and accuracy of work. Or, a group might decide not to offer a particular type of study because it won’t make money for the practice. In those types of instances, it’s important to remember that safety and quality are number 1 priorities.

“It comes down to how you handle the patient and whether you do the right thing for them,” Hamilton said. “

If your group or practice has a good ethics policy, consider publishing it or presenting it at a professional conference, Gunderman said. No one group – not even the ACR – has a lock on how to best address all ethical situations, he said. Radiologists across the country can come up with ideas and policies that have not yet been tried.

Facing Challenges
According to Gunderman, radiology’s biggest ethical challenge stems from the industry’s solitary nature. Radiology risks, daily, becoming detached from those it serves, particularly now that many providers are no longer self-employed, but on staff at a hospital or health system.

“When radiologists become isolated from patients and referring physicians, it can insidiously erode away our sense of being responsible. If you just talk every day in a microphone and never interact with a person, that can make it harder to be mindful of the fact that they’re real human beings whose lives and abilities to work may depend on our findings,” he said. “We don’t want patients to be mere abstracts in our minds.”

It can also be a challenge to foster a culture where individual providers can question long-standing ethical practices. You can create that type of environment by setting aside time in a monthly or quarterly meeting to discuss ethical issues, much like you would financial or compliance concerns, Gunderman said.

There are times, though, when it might not be possible to answer ethical questions within your own practice. But, don’t ignore them. Instead, take them to a higher venue, Gunderman said, such as a hospital board or a multi-specialty group.

“We have an ethical responsibility to make sure these concerns are heard,” he said. “Just don’t forget that radiologists have the greatest experience to contribute to any conversations that deal with the ethics and appropriateness of imaging.”[[{"type":"media","view_mode":"media_crop","fid":"33239","attributes":{"alt":"radiology ethics","class":"media-image media-image-right","id":"media_crop_3336198226097","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3500","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: 150px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Svinkin/Shutterstock.com","typeof":"foaf:Image"}}]]

Radiology’s Biggest Ethical Situation
Maintaining ethical behavior is vital for patient safety and providing quality care, and the industry has tackled other ethical issues, such as Medicare fraud or provider misconduct. But, radiology’s most significant ethical responsibility lies with providing expert testimony in malpractice cases, said Richard Mintzer, MD, chair of the ACR Ethics Committee.  

“If you don’t have enough experience or expertise to give good, scientific explanations, don’t testify,” he said. “For instance, a pediatric radiologist has no business testifying in an adult neurology case.”

Radiologists must hold themselves to the highest standard of ethical conduct for testimonies because the outcomes of litigation can be significant for all parties involved – the plaintiff, defendant, and radiologist.

Policing Ethics
According to Illinois-based Mintzer, the Ethics Committee learns about ethical situations in two ways. First, any member, referring physician, or other specialist can alert the committee to a radiologist’s potential unethical behavior. Additionally, the committee can learn about possible problem situations through the National Practitioner Database. In those situations, the group decides whether it should weigh in with an opinion on the matter.

Having the Ethics Committee review a case is significant, he said, because the ACR is the leading voice for ethical behavior within radiology. But, its options for disciplining radiologists who have acted inappropriately are limited. The legal system can punish providers with fines and jail time. The committee’s highest recourse – erasing a provider’s name from the ACR roll – is powerful still, Mintzer said.

“Expulsion from the College is the highest level of punishment we can exercise. It’s an event that’s transmitted to the national practitioner database, and it goes into a provider’s national record,” he said. “That information can be used by insurance companies or a state licensing board to deny licensing. And, hospitals can refuse to allow a provider who’s been expelled to be part of their staff.”