Nurse Apples and Radiologist Oranges

August 17, 2020

Looking at the existing push for non-radiologists to interpret exams.

I’ve written a few times about noctors. That is, folks who are not doctors, but think they can (and/or should be allowed to) do various things that have previously been restricted to physicians. Prescribing meds, performing interventional procedures…practicing medicine, essentially. Maybe they’re truly practicing independently or with varying shades of being “supervised” by an actual doc – sometimes it’s with only a pretense of such supervision.

There are, of course, plenty of appropriate roles in healthcare for nurses, PAs, etc. I doubt that anybody seriously believes it is a simple/easy matter to draw a line between what is appropriate for them to be doing versus what should require a physician. Further, any such line would be far from immutable with the changing of times.

That said, it’s not uncommon for those of us in the healthcare field to encounter developments that seem to be pretty blatant examples of line-crossing. Maybe we can immediately think of scenarios where patients will be put at risk, or resources will be wasted. Maybe something in and of itself doesn’t seem all that bad, but appears to be paving the way for worse moves down the line. Or maybe, it just doesn’t pass the “smell test.”

Related Content: More Noctor Nonsense

Case in point: The California Assembly Bill (AB) 890, which allows nurse practitioners to “order, perform, and interpret” X-rays, mammography, and ultrasound.

Let’s review what it takes for a diagnostic radiologist to be able to do this stuff. Putting aside what was needed just to get into med school, that’s typically four years (classroom stuff and clinical). Then four years of residency training in radiology…plus a preceding year of internship, unless they’ve done away with that since my day. Those four years of residency training consist of virtually nothing but learning how to “perform and interpret” diagnostic imaging.

Oh—and, then, there’s the little matter of three different steps of the USMLE, and the ABR’s core and certifying exams, which together represent multiple days of proving you’ve learned your stuff and have a competent grasp of the material. Y’know, before you’re unleashed on the general public as someone who can be trusted to interpret their diagnostic studies.

Now, I haven’t gone to the trouble of digging up the details of what a nurse practitioner needs to do in terms of education, training, and examination, in the state of California or elsewhere. But, I don’t feel the need to do so when I say that it’s nowhere near as much as what’s summarized above. And it’s certainly nowhere near as focused on the interpretation of diagnostic imaging. I, hereby, pose an open challenge to anybody who wants to prove me wrong on this.

In summary: If a nurse went through the same education, training, and examination that a radiologist has, he or she would be a physician with residency training in radiology. Instead, we’re talking about someone who has not earned radiological credentials, but wants to go ahead and render professional services as if they had.

We’re talking about apples and oranges. If we’ve determined that oranges are what’s needed for a specific purpose, and used oranges for decades, but now you come along and tell me that apples are just as good…I think the burden of proof is on you. And, forgive my skepticism if you just happen to be an apple-farmer (or, stepping away from the metaphor, someone whose interests are aligned with the nurses who want these new privileges).

I think you owe it to the orange/radiologist-using public to show us evidence that your apple/nurse-rad proposal is just as good and won’t harm anybody rather than expecting society to come along on your “Let’s try it, and see what happens” experiment. Don’t have any evidence other than your subjective opinions and feelings? Go do some randomized/double-blinded studies, and let us know when you have come up with something that isn’t embarrassing to your cause.

All of which boils down to: Has California (and, for all I know, other states contemplating the same) figured out that, for the past however many decades, we’ve been demanding way too much training and examination of people who want to interpret diagnostic imaging? And, it’s time to open up the floodgates for other folks who want a piece of the action?

Or, as I’ve suggested in previous columns, is this simply a matter of money (and power) talking? Nurses cost less than doctors, so healthcare facilities can pocket more of what they bill for imaging studies if radiologists are written out of the equation…or governments and insurers can ratchet down reimbursements more freely when NPs instead of MDs are doing the work. Oh, and guess which type of healthcare provider tends to be easier to control by such overseeing entities?

There are any number of reasons why folks with insufficient education and training should not be blithely allowed to hold themselves forth as capable professionals, especially in healthcare with people’s well-being on the line. I won’t go into them here; an interested reader could easily find them online in a variety of discussion boards.

Okay, okay, I’ll give you one common example: Let’s say for the sake of argument that a nurse and a physician both have an equal chance of identifying a humeral fracture on X-ray. Which one would you trust to also identify the subtle underlying lytic lesion that means this patient has an as-yet undiagnosed cancer? Or to notice and appropriately manage the small nodule in the lung at the other margin of the study?

My suggestion would be that, if nurses want/need to be allowed to practice radiology, let those nurses do what a would-be rad would do: Go to med school, become a doctor, and complete residency training. If that’s seems too difficult, time-consuming, and/or costly…maybe they should ask themselves why.