Another Perspective on NPPs in Radiology

There’s a health-care aphorism I have referenced in this blog over the years. I would say you can find it online, but a moment’s effort hasn’t yielded the precise quote. It goes something like: “You can have quality health care, you can access it when you want (no rationing or wait lists), or you can have it cheap (some optimistic versions might say free). Pick any two.”

You can mentally walk it through for yourself. I won’t waste your time explaining why it makes sense for a lot more than just health care.

Once you’ve accepted the basic truth of the aphorism, it’s surprising how many circumstances can summon the principle to your surface thoughts. I am reminded of it whenever there is talk of how less than 100 percent of the population is getting the health care they need or want. That includes discussions of the current radiologist shortage.

I’ve previously written about my belief that, in the push and pull between the three options (quality, access, affordability), quality will be the sacrificial lamb chosen by societal leadership. Once you accept that, the “solution” of having non-radiologists interpreting imaging studies practically falls into your lap. There are many more of them to do the work (access), and they cost less.

Some folks embrace this a lot more readily than others. Between the extremes of “let’s do it already!” and “you can have my Dictaphone when you pry it from my cold, dead fingers,” there is a large gray area where people propose how non-rads might (try to) do rad-level work. You can call it negotiation or rationalization. I tend to think of it as the “bargaining” stage of grief.

One common wrinkle is “Okay, we will let non-radiologists interpret simpler types of study, like X-ray (XR), fluoroscopy, maybe ultrasound.” Among other reasons folks find this palatable is the notion that more advanced stuff like CT, MR, and nuclear medicine really does require the four-plus years of post-grad training that radiologists go through, not to mention med school, even if you stipulate that XR doesn’t.

Rads might go along with this because …

A) there is just too much work to get through otherwise;

B) XR/fluoro pay pathetically badly and they would just as soon not spend half their day droning about tubes and lines on ICU films; and

C) they have a notion that this will somehow maintain a barrier that would prevent non-rads from ever being able to “crossover” and start reading the more advanced imaging as well.

Some of us see that as a logical misstep. Once you let non-rads cross the line from not reading studies to reading them, why on Earth would you think that they would later be unable to cross lines between different types of imaging? It’s the proverbial camel’s nose inside your tent.

(Editor’s note: For related content, see “The Rise of NPP Image Interpretation: What New Radiology Research Reveals” and “Emergency Department Radiology: Study Shows Higher Imaging Orders by NPPs.”)

Lest any readers think that second line is in no danger of being crossed, allow me to share a study just published in Current Problems in Diagnostic Radiology. There are a couple of salient points in the study. During the course of the study, from 2016 to 2020, in about 3.35M imaging interpretations by “non-physician practitioners” (NPPs), the study authors noted that 21 percent of the studies were CT or MR.

In other words, a lot more of the camel is inside the tent than just its nose. The critter is also pushing further into the tent: During the years of the study, the rate of NPP study interpretation went from 2.6 to 3.3 percent, a growth of 26.9 percent.

Another interesting detail was where this is occurring. The study pointed out that a lot of the argument for NPPs reading imaging is to help out where radiologist shortages are worst in rural areas. However, there was nostatistically significant growth there. Instead, the rate of growth in metropolitan areas was 31.3 percent. Not only is the camel pushing further into the tent than intended, it is not even the tent originally agreed upon.

Good luck getting the hairy beast out of your metaphorical camping domicile. For reasons I have previously written about (long story short: follow the money), we’re not likely to reclaim any territory. All that can realistically be done is safeguard what is left, and trying to come up with more barriers feels at best like a delaying action.

Barriers focus on who you want to keep out. Your argument has to be about why they’re less than, and you can start to look like a villain, picking on those poor NPPs who say they only want to help. It dovetails with the evil/selfish/greedy doctor caricature that already has way too much of a foothold in public sentiment.

I think the best move, going forward, is to focus more on what actual radiologists bring to the table that others do not. Nobody is going to dismiss the value of a decade’s worth of med school and post-grad training (not to mention having the chops to earn admission in the first place).

If someone who hasn’t managed that wants to claim their fewer years, accessed by less competition, are somehow just as good, let the burden of proof rest with them. Alternately, if they want to argue they’re “good enough,” let them explain to patients why “good enough” is all they deserve. Even proponents of NPPs would rather have the best possible care for themselves.

How does one leverage that? Perhaps whenever a radiologist has to correct an NPP’s misread or gets asked by a referrer to review a NPP-read study, the rad should get full RVU value for the study, rather than whatever fraction a second read usually receives. Maybe the incident gets flagged and reported to a national database so the differences in quality can be tracked for all to see.

Further, it seems reasonable that clinicians should be able to write “interpretation by physician only” on orders for imaging. Just like they can write “medically necessary” or “DAW” to prevent insurance companies from substituting one med for another.

Many referrers get offended if not outraged when they request a subspecialty consultation and find out that their patients were seen by a PA in the subspecialist’s office. This should be no different. Let referrers decide whether they want their patients’ studies read by non-docs and, by all means, let patients know when their docs or insurers have allowed it to happen. I would go so far as to say it should be a formal patient’s right.