Working with 'the enemy' means everybody wins

The growing cost of funding healthcare means that budgets must be managed carefully. Clinicians and radiologists are under increasing pressure from payers to economize. At the same time, many specialties face a shortage of trained healthcare professionals. This is creating room for others to step in and manage what was traditionally regarded as another professional's turf.

This issue is particular pressing in radiology. Data presented by Prof. David Levin of Thomas Jefferson University in Philadelphia at the 2005 RSNA meeting revealed that only 64% of noninvasive diagnostic imaging procedures performed in the U.S. between 1999 and 2004 were done by radiologists. Cardiologists took 17% of the workload, primary-care physicians 6%, and orthopedic surgeons 5%. The data also showed growth of over 70% in the number of noninvasive imaging procedures carried out by cardiologists versus 19.5% for procedures performed by radiologists.

What share of imaging is performed by radiologists in Europe? It is hard to say. We can identify some battlefields that exist today: cardiovascular imaging, neuroradiology, interventional work, nuclear medicine, molecular imaging, and ultrasound. Some of these could potentially become more competitive in the future as new techniques and technologies emerge.

The battle between radiologists and cardiologists is a particularly sensitive topic. The spatial and temporal resolution of cardiac MRI and cardiac CT has improved considerably. Specialists who previously used invasive tests to diagnose heart problems are now eager to use these noninvasive imaging tools. Cardiologists argue that they know more about heart disease, so they should interpret imaging results. Scanning patients in the cardiology department would also speed up report delivery.

Radiologists are similarly keen to retain ownership of these modalities, as they are ideally positioned to fully utilize CT, MR, and PET scanners. Having undergone extensive training in CT and MRI, radiologists could identify and evaluate a large spectrum of pathologies, including incidental noncardiac findings. They seldom self-refer, keeping imaging costs under control. Primary-care physicians and other noncardiac specialists are also more likely to refer patients to radiology for cardiac imaging.

Radiologists should develop expertise in cardiac imaging and ensure that examinations are performed on high-end machines. That way, the referring physician and the patient will benefit. Radiologists also need regular feedback from clinicians on their findings. If this does not happen, perhaps through inexperience or lack of organization, then cardiologists may rightly prefer to buy a new machine and perform-and be paid for-the examination themselves.

I am convinced that this is not the proper way to proceed.

The French Society of Cardiology and the French Society of Radiology have signed an agreement on the way to manage cardiac imaging together. Both partners are now agreed that radiologists should perform cardiac CT and cardiac MRI and discuss the results at multidisciplinary team meetings.

With ultrasound, the situation is slightly different. The purchase of imaging equipment is less tightly regulated, and a greater number of medical professionals perform ultrasound examinations. Any battles over turf depend on which country you are practicing in. In France, ultrasound has always been an important part of radiology, but in Germany, most examinations are performed by internists.

Here in France, we recognize that to make progress on issues such as reimbursement, safety, and quality, it is better for specialists using ultrasound to speak with one voice. After all, we all have the same payers! So after many years of fragmentation, the French ultrasound society is now formally reestablishing a new national federation that will include clinical subspecialty groups, such as obstetric and vascular ultrasound.

Collaboration makes financial sense. If resources are limited, then it is better to invest together in quality tools and techniques. Abandoning turf battles and working with the "enemy" is much better for patients as well. As a potential patient myself, I have asked the question, "What system would I prefer? Many experts working together on my diagnosis or one specialist who is expected to know everything?"

I personally favor the model of cooperation. It is a win-win situation for all parties.

PROF. CLAUDON is a professor of radiology and chief of the department at the Children's Hospital and the University of Nancy, France. This column is based on a lecture by Prof. Claudon at ECR 2007.