Radiologists and Surgeons: Can’t We All Just Get Along?

Advances in surgical technology and demand for real-time multispecialty expertise are often putting radiologists and surgeons side-by-side in the operating room and changing the way they interact.

When the relationship works well, respect is mutual and each clinician is able to take full advantage of the other’s expertise. When it doesn’t, tensions arise and frustrations build.

The relationship is particularly important in reconstructive surgery, Oren Tepper, MD, plastic and reconstructive surgeon at Montefiore Medical Center in the Bronx, New York, said.

“There’s definitely more of the back-and-forth collaboration between surgeons and radiologists that people hadn’t seen before,” he said. “There’s an increasing desire and a need to sit and go over the films together.”

At Montefiore, Tepper works with radiologists on skull and facial reconstructions and traumatic deformities. Together they map out blood vessels via magnetic resonance angiograms to locate the best places to take tissue from and the best location for attaching.

Years ago, if a patient came in with severe facial trauma and multiple bones had to be put back in place, he or she would have been taken to the radiology suite for scans and then back to the OR. Now surgeons and radiologists can look at the images together in the OR, Tepper said.

“More than ever there’s a need to have radiology input in real time,” he says. “It’s not unusual for us to have a head-and- neck radiologist come to the operating room and review a CT scan while the patient is on the operating room table.”

15-minute Window at Beth Israel
Respecting the other’s need for efficiency helps strengthen the relationship between radiologists and surgeons at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, said Robert Kane, radiologist and co-chief of ultrasound.

“We schedule our cases as much as possible and we have a 10- to 15-minute response time,” Kane said. “Surgeons will send a call down to us that they’ll be ready to scan in 10 to 15 minutes and our part of the bargain is we’ll be up there ready to go… So neither of us stand around waiting for something to happen.”

A. James Moser, MD, FACS, executive director for the Institute for Hepatobiliary and Pancreatic Surgery at Beth Israel works with a team including Kane on image-guided surgery. He gave an example of how the relationship plays out during pancreas surgery where many of the lesions are small and you can’t feel them in a minimally invasive operation because you don’t have the tactile feedback.

The team looks at an image that Kane produces in the console so they have both a 3-D image of the operative field and an ultrasound in the same image.

“So the interface of somebody with Kane’s skillset is extremely important,” he said. “The surgeon’s view of the operating field changes dramatically when it’s being done in a minimally invasive fashion.”

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3-D vs. 2-D
The nature of how surgeons and radiologists visualize images can potentially lead to frustrations in communication

As chairman and CEO of EchoPixel, a San Jose, California-based, company that develops medical imaging solutions, Ron Schilling, PhD, works with both surgeons and radiologists.

He says when tensions develop between the two groups, it usually comes down to two things: language and money.

Regarding language, the trouble comes when radiologists, who see images two-dimensionally, try to explain their findings to surgeons, whose view is 3-D.

EchoPixel and other companies have developed software that translates data acquired through CT or MR or other modalities and produces an image in the dimension that is most meaningful to the physician requesting it. Any doctor can access the patient data and have an anatomically meaningful view.

But without a common language, the gap between the ways images are viewed can lead to built-in tensions when radiologists and surgeons discuss images, Schilling said.

 “At the Mayo Clinic, you will not find tensions like this…but in a lot of other places I can see when those tensions arise, especially when the radiologist is throwing their material over the wall and the surgeon gets it, but it doesn’t relate to the surgeon the way it should…. as we go forward with Obamacare, it’s going to demand that there’s an excellent interaction among all docs.”

The other factor that builds tensions centers on reimbursement, he said. He gave the example of a cardiologist who recommends an angiogram, using a catheter to determine whether there is disease in the arteries. The radiologist may recommend a minimally invasive CT angiography or MR angiography for the patient, which is much less expensive. 

The cardiologist may be less likely to recommend the less expensive procedure, “Because that’s taking money out of the cardiologist’s pocket,” he said.

At the root of a good surgeon-radiologist relationship is an appreciation for what the other does, Schilling said.

Weekly Conferences at Emory
In that spirit, at Emory Healthcare Network in Atlanta, Georgia, where radiologists make up 125 of the 1,800 physicians on staff, radiologists and surgeons are part of a weekly oncology conference which also includes specialists such as radiation therapists and pathologists. Together they discuss roughly 25 cases each week.

 “Because we bend over backwards to support [surgeons], they are very supportive of us,” says Emory radiologist William Torres, MD, FACR. “The radiologists who do biopsies, drains and ablations often go to the operating room and work with the surgeons to do these procedures. In some places that’s not true and the ablations in the operating room are done by the surgeons themselves, but at least in our institution, we have a very collaborative way of doing things.”

The relationship is particularly important with the complexity and volume of MRI, especially body MRI, at Emory. “We do as many as any place else in the world,” Torres said. Surgeons need radiologists’ expertise to see the whole picture, he said.

The sheer volume and the number of sequences – often 20 for each body MRI – has made the radiologist-surgeon relationship even more critical in oncologic surgery, gynecologic surgery, transplants and general surgery, he said.

Having PACS has made it less common for surgeons to come to the reading room to view images, so in-person collaboration has become both choice and necessity, Torres said.

 “If a radiologist wants to sit in a dark room and read, they are not going to have the same kind of relationship as we do…you want to make yourself useful and relevant and the only way you do that is by working with the surgeons and find out what they need and be able to provide it to them.”