Rivalry between ACC, ACR surfaces at founding meeting

The historic turf battle between radiologists and cardiologists bubbled to the surface when the Society of Cardiovascular Computed Tomography held its inaugural meeting in July in Washington, DC. During a session on accreditation and credentialing, radiologists angrily denounced the society's decision to endorse a document from the American College of Cardiology over one from the American College of Radiology.

The SCCT, formed last year, has more than 2000 members, two-thirds of them cardiologists. The meeting's 800-plus attendees reflected the same ratio. The society aims to represent radiologists and cardiologists equally. But when Dr. Matthew Budoff, cochair of the SCCT accreditation, certification, and guidelines committee, detailed the state of accreditation for cardiac CT, he was accused of favoring the ACC over the ACR.

For political reasons, two competing guidelines exist for cardiac CT. One was jointly written by the ACC, American Heart Association, and a few other organizations and requires physicians to perform 50 contrast exams and interpret 150 exams, 50 of which must be live and interpret 50 noncontrast exams to reach level II.

The ACR's interim clinical statement on cardiac CT will be replaced in October by guidelines and standards that were formally adopted at its annual meeting in May. Physicians with prior qualification in thoracic CT will be required to complete 50 supervised interpretations of cardiac CT exams (the old requirement was 75), excluding calcium scoring studies. Unlike the interim clinical statement, which was exclusively for radiologists, the new guidelines are for any specialist. Physicians without thoracic CT experience will first need to complete preexisting guidelines on performing and interpreting CT, which include completion of an ACGME training program, 200 CME hours in CT performance and interpretation, and the interpretation of 500 CT cases, 100 of which are thoracic.

"Any of these numbers we pick out are somewhat arbitrary," said Dr. Paul Larson, chair of the ACR commission on quality and safety. "There's no clear science behind any set of numbers. The important thing is that this is not a trivial task and both sets of guidelines recognize that."

At the meeting, Budoff explained that the SCCT has endorsed the ACC/AHA guidelines, detailed how the society is developing ways to verify training, and expressed a preference for ACC guidelines over the ACR requirements. Dr. Jong Kim, a radiologist with Advanced Diagnostic Radiology in Cumberland, MD, complained that as a radiologist and SCCT member he feels caught in the middle as to which credential to pursue. Budoff said that the SCCT is not siding with either the ACC or the ACR. The ACC invited the society to participate in the development of the guidelines, and so the society endorses them. The ACR did not solicit input from the SCCT.

Another radiologist countered that Budoff gave his opinion that the ACR document is inferior to the ACC's. Budoff reiterated that it is his personal opinion that interpreting 75 cases (now 50) is not enough to qualify someone to go out and start doing cardiac CTA exams. The attendee then said that radiologists may look at it differently because they have already interpreted many CTs.

"We may feel you need to interpret thousands of CTs and go through four, five, six years of training before you can interpret cardiac CTA," he said.

The main issue for the SCCT is to fill a need for people who don't otherwise get covered by other credentialing, said Dr. John Lesser, cochair of the SCCT accreditation, certification, and guidelines committee.

"If you are a radiologist and you've fulfilled the radiology guidelines, then you're fine. Cardiologists are the ones having trouble getting CT privileges," Lesser said.

Dr. Arthur Stillman, director of cardiothoracic imaging at Emory University Hospital and a member of the original ACR guideline writing committee, said that the emphasis on training guidelines and competency criteria for cardiac CTA is somewhat premature. The application must first be proven, shown how it stands up against other noninvasive imaging tests, and have its role clearly defined. He lamented the polarized atmosphere.

"If you look at the patient case numbers for both, they're hardly adequate to be expert for either one," Stillman said. "But the ACR document has been politicized as being watered down. When, in fact, they're both watered down. It's just a matter of how you look at it."