Radiologists as the Medical Imaging Gatekeepers

Radiologists should become the gatekeepers of medical imaging if they want to play a more critical role in managing rising healthcare costs and imaging utilization, according to an opinion piece published in the New England Journal of Medicine. 

“Utilization is being questioned, and overutilization of imaging is frowned upon,” said author Saurabh Jha, MBBS, an assistant professor of radiology at the Hospital of the University of Pennsylvania. But he asked who will orchestrate the changes needed to lower the number of unneeded tests and manage the “scarce resources.”

In Jha’s experience as he trained in the United Kingdom, rationing of diagnostic imaging was done through the radiologists when they questioned referring physicians as to why the ordered tests were necessary. If the radiologists agreed with the assessments, the tests were performed. If the radiologists did not agree, believing that the diagnostic tests would not change the treatment course, the requests were often refused.

In the United States, radiologists are not approached as to whether a test may be done, but rather they are approached with the expectation that the tests will be performed.

The culture in the U.S. is somewhat different as imaging machines are much more available than they were when Jha was training in the U.K. And, since the American radiologists benefit from these referrals, would it be in their best interest to limit their participation in tests to only those that they believe to be medically necessary?

Whether a radiologist is well placed to determine a test’s necessity is also a consideration. Jha pointed out that some clinicians may not be comfortable with a radiologist, who has not seen the patient, questioning their recommendations. However, Jha also pointed out that this is being done already with the insurance companies as doctors must justify their test requests in order to be compensated.

There is hope that guidelines and evidence-based medicine would help direct proper imaging. However in Jha’s experience, guidelines tend to increase testing rather than decrease it, as physicians work to cover all angles for fear of neglecting or missing something important.

Currently, radiologists are not in the forefront when it comes to making decisions about imaging tests and if they want to be, they need to take charge. “Radiologists must decide whether to greet the ebb of imaging passively,” Jha said, “or by stepping forward to captain and manage a rational decline.”