Radiology faces challenge to keep role in cardiac MR, CT

Once again, radiology finds itself facing a major emerging turf battle. It has waged this one before-and lost-but this time, radiology has a different set of tools and, conceivably, even bigger stakes. Continued progress in MR and CT scanning, particularly the latter, has opened up the heart to imaging in ways never before possible. Cardiac imaging with MR and CT should be familiar ground for radiologists, but it isn't always. And cardiologists are looking at the new scanners and thinking that they want a share of the image interpretation process as well.

The good news is that many in radiology have caught on to the gravity of the situation and are taking steps to assure that the specialty moves forward with the skills and knowledge needed to assure a continued role in cardiac imaging. You'll find many of these efforts described in this month's cover story. The bad news is that cardiologists will try to repeat their success with cardiac cath, echo, and nuclear cardiology, and they believe they are fully within their rights to do so.

Probably the best illustration for that view is found in a Sept. 15 editorial by Dr. Alfred A. Bove, editor-in-chief of the online journal Cardiosource. In the editorial, "Who owns images of the heart?" Bove argues that specialty training (and not just in cardiology) qualifies nonradiologists to interpret images within their respective specialties.

"While the radiologist is adept at examining all forms of images, the specialist concentrates on images relevant to the specialty and becomes expert at interpreting images in the context of the clinical data," Bove wrote.

Many radiologists would challenge that assertion, but it goes to the crux of the turf discussion: Does a cardiologist's familiarity with patients and their records translate to a greater ability to use the images generated by MR and CT? This might, in fact, confer something of an advantage, but it's probably not as great as the cardiologists would have you believe, for several reasons. First, competence in cardiac imaging is not that easily attained. Radiologists who choose to concentrate on cardiac imaging can maintain an edge that will keep them ahead of the curve. Second, cardiologists may have the patients, but they don't have a lock on all patient information. As medicine advances, much of this information will be readily available to interpreting radiologists in electronic medical records, just as images are becoming available throughout the medical enterprise today. Radiologists will need to learn and understand more about cardiology, but if they do, they can easily counter the argument that patient knowledge confers an edge in image interpretation.

Other factors will play into this turf battle:

- Possible limits on self-referral. Success for the ACR in winning support in Congress and among insurers for limits on self-referral could dampen cardiologists' desire to own their own scanners and interpret the images. Concerns about spiraling healthcare costs could help the ACR achieve this goal.

- The need to check for incidental findings. As adept as cardiologists might become at reading heart images, they won't be able to check for lung nodules that might also crop up in cardiac scans, and there is no way they can escape that responsibility.

- Local circumstances. In some instances, cardiac practices will find it too expensive to purchase and maintain a scanner, even the discounted cardiac CT models that are becoming available. In other instances, collaborations between radiologists and cardiologists will mitigate turf battles.

One thing is certain, however. Radiologists will have to work hard to maintain a strong role in cardiac imaging.

What are your thoughts on this topic? Please e-mail me at jhayes@cmp.com.