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"What are you doing here at this hour of the night? For Pete's sake, it's 2 A.M. I thought all radiologists would be home in bed and sound asleep by now!"
"Actually, I'm on call and came in about an hour ago to do an abdominal CT on that gentleman in bed 4 who was thought to have a left ureteral calculus. I tell you, our new highspeed helical CT is really something. There was no calculus. But it clearly showed diverticulitis of the sigmoid colon as the cause of his left lower quadrant pain. Impressive. We just finished a couple of minutes ago and I thought I'd clean up the stack while I'm here. Can I help you with something?"
"Would you mind going over Mrs. Casey's films with me? She's the lady in bed 6 who was involved in that MVA on Market Street around midnight—the one with the broken pelvis. What do you think of her C-spine? I'm concerned that she may have a dislocation. C-spines in the elderly really spook me; there's so much going on: degenerative changes, malalignments, and God knows what all. I'm always afraid that I'm either going to miss a fracture or have tongs put in someone who doesn't need them. What do you think?"
"Well, let's take a look.... I see what you mean. But there's no fracture or dislocation here. The malalignment at C4-C5 is an anterolisthesis caused by the degenerative facet arthropathy at that level...as you can see here. No, that is definitely not a traumatic dislocation. You can rest assured that she just has degenerative arthritis. There is no fracture or dislocation."
"Thanks, I appreciate the help. It is always nice to have a radiologist with us here in the ED."
The preceding, though fictitious, is likely a frequent occurrence, played out as above, or in a similar fashion, in cities and towns all over this country and abroad. Radiologists are welcomed in emergency departments by their clinical colleagues at all hours of the day, but particularly the "off-hours," in the evening and at night, between 7 P.M. and 7 A.M. The reason this should be so is no great mystery. Radiologists are welcome because they have something to offer clinicians and their patients: expertise in the performance and interpretation of all forms of imaging.
There are medical and surgical specialists who would like to engage in imaging and receive compensation for this service. And granted, of course, in certain specialties they already do. But the availability of imaging is a particular bone of contention in the emergency department. Not because radiologists can't do the examinations correctly but because often a radiologist is not there to do them at all. Without immediately available imaging, the quality of care is compromised. And if radiologists aren't willing to make themselves available, our clinical colleagues will jump into the breach.
This will occur despite the fact that most studies have shown, as do Eng et al. [1] in this issue, that the performance of radiologists in the interpretation of various imaging examinations is better than that of their clinical counterparts. Indeed, most physicians will concede that radiologists do imaging better.
Debates about the performance of imaging procedures by nonradiologist physicians are "quickly focused on emergency department coverage and the unwillingness of radiologists to commit to doing the job 24/7," as pointed out by Max Cloud [2], then Chairman of the Board of Chancellors and now President of the American College of Radiology, in a monthly memo to the membership. The fact that radiologists may be able to perform imaging better is thereby severely compromised and the point of our greater expertise quickly lost in such scuffles. Dr. Cloud then cuts to the heart of the matter stating, "The crux of the problem is this: How on the one hand can we espouse the principle that the patient is best served when the radiologist interprets films, and on the other hand infer that the principle applies only during certain hours?" You simply can't have it both ways.
Are these nonradiologists simply looking for an excuse to increase their income by obtaining reimbursement for interpreting imaging examinations, or are there actually other factors at play in this dispute? What is at the root of this outcry for full-time coverage in the ED?
I believe there is another factor at play that is so close to us, so inherent, that we may be overlooking it. The quality of imaging directly affects the quality of care; better imaging means better care. And what doctor does not want to render quality care?
Imaging has become essential to the practice of medicine. Imaging used to be ancillary, optional but not essential. Radiography was either insensitive or nonspecific in many disorders. With the introduction of highspeed CT and advances in MR imaging, radiology has been greatly improved and, as a result, has assumed much greater importance in the evaluation of the sick and injured. With these techniques, imaging has much greater sensitivity and specificity than ever before and achieves vastly improved positive and negative predictive values.
As a result, imaging is now essential in the diagnosis of the most common acute medical and surgical illnesses—for instance, appendicitis, bowel obstruction, renal calculi, cholelithiasis, diverticulitis, and pulmonary embolism—to say nothing of the importance of imaging in the evaluation of trauma. And while becoming better, immaging has not become easier. Training and experience are required. So, not surprisingly, radiologists have more skill in the performance and interpretation of imaging procedures than do our clinical counterparts.
The problem of coverage in the ED lies not in our skills or capabilities, but in our attitudes and availability. Radiologists in the ED make a difference. Be there. If not there, make yourself available. Get plugged in through teleradiology and then come in when required.
Heed the call. What radiologists have to offer in the ED is important to the quality of care rendered by our clinical colleagues and vital to the patients they, and we, serve.
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This article has been cited by other articles:
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  R. B. Hoffman Heeding the Call: Radiologists in the Emergency Department Am. J. Roentgenol., July 1, 2001; 177(1): 253 - 254. [Full Text] [PDF]
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R. A. Kottal Radiologists in the Emergency Department Am. J. Roentgenol., June 1, 2001; 176(6): 1602 - 1602. [Full Text] [PDF]
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