Subspecialization rushes ahead, in both Europe and in the U.S.

In May, my European counterpart, Philip Ward, commented on a trend to subspecialization in European radiology. Just the headline of his commentary in Diagnostic Imaging Europe, "Subspecialization drive casts doubt on the future of general radiologists," should be enough to send chills down the spine of any general radiologist.

That concept did send shockwaves through the audience at the Management in Radiology congress last October, according to Ward. Dr. Nicola Strickland, a radiologist from the Hammersmith Hospital in London, gave compelling reasons as to why the future of imaging lies in ever-greater specialization by body part and disease process. She argued that specialist knowledge of the breast, lungs, and gynecological, neurological, and vascular organ systems is essential for today's radiologists and that they can play a meaningful role at multidisciplinary team meetings only if they can add value to the interpretation of an image over and above that provided by nonradiologists.

"Whether we like it or not, radiology as an independent specialty will cease to exist," Strickland said. "Radiology is becoming a subspecialty of organ-based clinical team members."

European practice is far different from U.S. practice, and I'm not prepared to argue that radiology as an independent specialty will cease to exist. I do agree, however, that forces at work here are pressing radiology to an unprecedented degree of subspecialization.

In this issue, we have a feature article on cardiac teleradiology, the latest manifestation of the drive to bring remote Internet-based interpretations to a greater number of facilities. It has certainly occurred to more than a few radiologists that teleradiology creates the opportunity for some fairly high levels of subspecialization.

Glimmerings of this process have been evident in recent years, as when musculoskeletal imaging became a hot topic in teleradiology. Now that some big teleradiology companies are moving into specialized cardiac image interpretations, the glimmer has become an established fact: The ability to zap radiologic images across the country (or around the world) with relative ease creates the opportunity for previously unheard of subspecialist groupings in radiology. A hospital that once might have needed an onsite neuroradiologist now needs only the equipment and connections required to send the image off to a waiting panel of highly qualified and experienced neuroradiologists located somewhere else-or in several locations.

This has lots of implications, some of them good:

• Widespread access to subspecialty expertise. Subspecialty radiology has long been a fact of life in large urban hospitals and academic facilities. Teleradiology will bring this level of subspecialty care to smaller and medium-sized hospitals that can't afford it now.

• Improved quality of care for more patients. The obvious advantage here is wider access to subspecialty interpretations via teleradiology, but there are corollary benefits as well. These include validated and more consistently applied imaging protocols that are insisted upon and propagated by the subspecialists, and faster access to imaging information in emergency settings such as coronary failure or stroke.

But it also has some negatives, such as less opportunity for facility-based radiologists to gain subspecialty expertise and potential weakening of their bargaining power.

This should not be taken as a lament. Specialization, subspecialization, and even sub-subspecialization have been going on in medicine ever since it started. It is clear, though, that the technology advances that allowed teleradiology to develop have introduced a new dynamic: The process of subspecialization will pick up speed and so will the good and bad developments that come with it.

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