Who’s going to read the X-rays? (And, who wants to?)

February 10, 2020

Do radiologists really want the responsibility of reading all X-rays?

Working from a home office for nigh unto a decade, I don’t have anywhere near the access to “water cooler talk” I once did. I don’t really miss it, let alone the water coolers themselves…I mean really, when’s the last time you saw one of those things getting properly cleaned? And, the less said about typical coffee-offerings nearby, the better.

Still, working from home can isolate you from all sorts of scuttlebutt, and if you don’t find some way to replace that you’ll be living under a proverbial rock in terms of knowing what’s going on in our field. Fortunately, the same internet that makes telerad viable can be used to keep somewhat up-to-date in various ways, including online radiology forums.

So it was there that I recently encountered a discussion-thread about how the ACR “does not want mid-levels to read imaging,” with links to an article on the matter. It was followed by almost 150 comments from folks with opinions of sufficient strength to prompt their posting on the thread.

That’s not an insignificant threshold, by the way. Just think of how much social-media nonsense you see on a daily basis that doesn’t motivate you to write a response. If you’re going to spend even a few seconds to stick your virtual neck out there and offer up your thoughts as troll-bait, you’ve got to care about whatever it is.

It makes sense that we’d have opinions on the matter, and that many of them would be strong ones. How much time, trouble, and, of course, money does a typical radiologist put in to be allowed to read these imaging studies? Not to mention ongoing time/trouble/money investments to maintain such privileges. Why should other people be allowed to do what we do without meeting such standards? And how, exactly, is it going to be determined that their reads are up to snuff and doing right by patients?

Again, such opinions are going to be strong, and probably deeply rooted since this issue has come up before (indeed, has it ever really gone away?) But, if I knew anybody who was getting his or her gums in an uproar over the matter, my advice would be to, in the immortal words of Demolition Man, “enhance your calm.” Your input, no matter how strongly you feel about it, is probably zero.

Believe it or not, the decision has already been made. Even if the official pronouncement has not. Anybody arguing that doctors are capable of doing X (rays, or otherwise) by dint of their education and training, whereas noctors are not, is talking about closing the barn doors long after the cows, and whatever other livestock, have gone out to roam the countryside.

It’s not that other specialties enabled this by their use of “physician extenders,” such as anesthesiologists using nurse-anesthetists to cover multiple ORs, or primary care docs employing NPs and PAs to staff an urgent care…although such things surely got the ball rolling faster. The harsh reality is that this is just another instance of “Follow the Money.”

It’s a constant drumbeat: healthcare costs too much. There aren’t enough docs to meet demand. Yet, the powers that be want to be able to say that they got low-cost access for everybody. You might have heard of the “Iron Triangle” of healthcare: There can be low cost, widespread (if not universal) access, and/or high quality…pick any two, but the third will suffer in making it happen.

I don’t know how prevalent it yet is for noctors to read imaging studies. I do know that non-radiologist docs have been doing it forever, whether they bill for it. They might be wonderful at interpreting the stuff they know about…but, how about the incidental stuff on the images near their areas of interest? Is the surgeon going to notice and/or properly interpret the small renal-cell carcinoma that their lumbar MR happened to show or the lung lesion at the edge of the field-of-view for their shoulder X-ray?

I’ve also seen more than a few “How could he have missed that?!?!” cases from other radiologists over the years. Of course, nobody’s perfect, myself included. But, before we rads start throwing stones, we should probably remember that our own houses have some decent-sized windows in them.

The matter of supply/demand is a worthwhile consideration, too-just how many rads really want to have exclusive reading rights for X-rays? Unless you’re one of those increasingly rare old school guys who can look at a chest X-ray and predict that the patient has mitral-valve prolapse, you probably regard them as ever-more-voluminous busywork. And, perhaps at earning $5 a pop for them (while retaining your sky’s-the-limit med-mal liability for each one), maybe you’d really rather someone else took care of them while you focused on higher-RVU stuff.

One of my concerns with noctors officially taking over X-ray reads is that, not uncommonly, these imaging studies are being ordered by other noctors. At least, when a radiologist is on the receiving end, there’s a physician in the equation. Otherwise, the risk of “the blind leading the blind” looms larger.

And, since part of how we came to this pass was on the basis of cost and utilization: how many more of those X-rays are going to morph into advanced imaging when a noctor honestly states, “Gosh, I don’t know what that is,” or “I’m not sure I can rule that out?” Whereas, perhaps, a radiologist seeing the same image might have confidently reported a benign lesion needing no further action, or simply “Normal study.”