It’s time for radiologists to step up

Diagnostic radiologists are the most important physicians patients will never meet. They are the M.D. equivalent of pharmacists, taking orders from attending physicians and filling orders, hovering in the shadows of medical care, and observing what's going on but not participating.

The day is coming, however, when this will change. At least it should, according to Dr. Charles Marn, chief of radiology at the Ann Arbor VA Hospital in Michigan.

Imaging is becoming a bigger part of medicine. As imaging systems provide more and more details, the ability of this equipment to generate incidental findings is increasing markedly. And that's why Marn thinks the time has come for radiologists to step out from behind their clinical colleagues.

"I am not sure we can reliably believe that referring physicians are going to properly manage all these incidental findings," he said.

The devil of these findings is in the details: the renal mass discovered during CT colonography or the lung nodule that pops up during a cardiac CT. Neither was pursued, because the referring doc was looking for something else. Today's system of medicine calls for the radiologist to report these findings to the referring physician, then move on.

Marn and his colleagues at Ann Arbor VA have taken a different tack. They modified their IT system to support special codes for images that unexpectedly show signs of cancer. Staff search out these codes periodically and check whether the referring physician has followed up with the patient.

This change in procedure came after a patient there narrowly dodged a medical bullet - the appearance of lung nodules suggestive of cancer that was not properly addressed by the referring physician. Fortunately, when the patient came back for a routine check-up six months later, the nodules were found to be benign. But the near-miss spurred Marn and his staff to find out what had gone wrong.

This response was anything but typical.

Usually, medical institutions and their staff look the other way when mistakes crop up, Marn said, especially when litigation is involved. Looking for the reasons behind a mistake may constitute tacit admission of medical error. If the plaintiff's attorney finds out, it's lights out, baby.

"So you leave the broken system in place for three to five years as the malpractice case plays itself out, risking every subsequent patient who is in a similar circumstance to have the same outcome?" he said. "We can't do that."

Marn envisions a time when radiologists are in the thick of everything medical. This has already begun in mammography, as radiologists perform screening followed by diagnostic procedures when indicated, communicating directly with the patient.

"I imagine a system where radiology staff call up a patient two weeks after that person has left the hospital to make sure the patient knows about an abnormal chest exam and, if not, ask where to fax the report or send the images," he said. "This would open up a whole area that we need to explore in the near future."

Radiologists, more than anyone else, understand imaging. Interpreting images is their world. This should put them at the center of medical practice, not its periphery.

Marn's advice is to look at medicine the way the National Transportation Safety Board looks at aviation. When something goes wrong, objectively search for the error, fix the problem, and let the chips fall where they may. In medicine, that could mean an increased exposure to malpractice claims.

"If this is what it takes to save patients, we have to do it," he said. "I would rather expose some people to medicolegal risks than expose patients to medical error."

As radiology faces cutbacks in reimbursement amid questions of its value in medicine, what better way to distinguish the profession than as a champion of patient welfare?