| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Commentary |
1 Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston,
MA 02115.
2 Cardiovascular Imaging Section, Department of Radiology, Brigham and Women's
Hospital and Harvard Medical School, Boston, MA 02115.
Received October 10, 2006; accepted after revision October 10, 2006.
The opinions expressed in this policy brief are those of Frank Rybicki and
Marcelo Di Carli; they do not necessarily reflect the viewpoint or position of
the editors, reviewers, or publisher of the American Journal of
Roentgenology. Readers are encouraged to submit letters to the editor in
response to this Policy Brief.
Keywords: cardiac imaging • radiology practice
Cardiac CT angiography (CCTA) is a rapidly emerging technology that has sparked considerable debate recently on utilization, reimbursement, physician qualifications, and turf. The October issue of AJR included a Policy Brief/Commentary on "How to Win the Coronary CTA Turf War." This month's Policy Brief/Commentary, coauthored by a radiologist and cardiologist, features a different perspective.
The introduction and acceptance of cardiac CT and MRI as clinical tools have renewed the intensity of discussions over who should perform and interpret cardiovascular imaging studies. Radiologists argue that their training and experience in cross-sectional imaging with CT and MRI make them ideally suited for the task. Cardiologists counter that their knowledge about cardiac anatomy and understanding of the clinical issues provide a better set of skills for performing and interpreting these imaging studies.
While there are examples of cardiovascular imaging programs operated by radiology alone and cardiology alone, those with shared, multidisciplinary input will be poised for long-term success and growth, and most importantly, improved patient care. The noninvasive program at our institution benefits from shared input from both cardiologists and radiologists at all levels, including co-directorship between a cardiologist and a radiologist. Our multidisciplinary sharing of ideas and workload extends to our trainees who come from both radiology and cardiology backgrounds.
The cardiologist who works without radiology may be inexperienced using the technology, and errors in technique can lead to errors in interpretation. The radiologist who works alone may render an interpretation of coronary artery disease without putting the results of the study in the context of other cardiac examinations that have been performed and interpreted by cardiologists. If both groups develop a shared and well-balanced program, these pitfalls can be avoided.
Having radiologists and cardiologists working side-by-side has several advantages, beginning with choosing the best test for an individual patient. If a radiology practice manages one technique (e.g., CT) and a cardiology practice manages another (e.g., nuclear cardiology), a competing "technique-centric" program could develop. A program in which equipment and services are shared equally among specialists will minimize unhealthy bias. Dialogue focused on image acquisition and interpretation may be spearheaded by a radiologist, but in the very same conversation, placing those imaging findings in the context of a treatment plan may be led by the cardiologist. Radiologists interested in cardiovascular imaging may not understand that care for coronary artery disease differs from other disease processes. In a patient with a cough and a fever, the radiologist reports a pulmonary consolidation and the referring clinician chooses an antibiotic. Using cardiac MRI as an example, even the choice of pulse sequences depends on detailed understanding of the patient's problems and available treatment options, and those options that would be best suited for the individual patient.
There are other lost opportunities from thinking alone. In our experience, the majority of clinical cardiologists strive to surround their patients with the best imaging available. In discussing and negotiating with interventional cardiologists (after a sincere dialogue is established), both parties can entertain the concept that the negative predictive value of cardiac CTA can benefit each. Radiologists can enjoy the productivity of noninvasive imaging, and interventional cardiologists can focus on the practice that many thrive on, namely interventions.
Cooperation rather than competition also provides for the best training. Advanced training in cardiovascular imaging (especially CT and MRI) during radiology residency and cardiology fellowship is grossly inadequate, even in leading training programs. Incorporating all techniques into a single program offers novel training opportunities, both at the resident and postgraduate levels. Our training program has equal allocation of trainees to cardiac CT, cardiac MRI, nuclear cardiology, and vascular MRI/CT. Although intense, we offer this curriculum in a single-year fellowship program. If a trainee seeks additional experience focusing on one or more techniques, additional fellowship time can be offered. Integrating educational opportunities for radiologists and cardiologists promotes gainful collaboration among the trainees, shaping leaders into a role where it is natural to work together, not competitively.
Radiologists in practice also learn best in a cooperative setting. While continued medical education is critical in our practice, the strongest training does not come from a course, even one proposed as "hands-on." The training required for a successful program comes from experience with a stable referral base, and that referral base usually comes from cardiology.
Despite the fact that CT scanners are being sold to cardiology practices, open communication can still result in a sharing of expertise. For example, once a collaborative effort has been established, the radiologist has the opportunity constantly to provide expertise and education with respect to the technology. At present, advances in CT technology are driven primarily by the promise of cardiovascular imaging, and the changing face of the equipment is important to stress as a major difference between coronary catheterization and coronary CT. Healthy collaboration between staff can mean the successful integration of techniques and services. The more that the reading room becomes a "common room" for noninvasive cardiovascular imaging, the better the service operates. At our institution, the cardiovascular imaging section includes four equal services: cardiac CT, cardiac MRI, nuclear cardiology, and vascular MRI/CT. Having a single interdisciplinary group co-manage all techniques minimizes bias in selecting the most appropriate examination. Since the cardiovascular imaging "one-stop-shop" has not been realized to date, it is important to minimize redundant testing and recognize that input from all techniques is critical to the success of the program. For example, before the growth of cardiac (and in particular coronary) CT, cardiac MRI enjoyed rapid growth, in part because it offers the best evaluation of global and regional cardiac function, plus MRI can detect ischemia (via perfusion sequences) and scar (via myocardial delayed enhancement images). In addition, MRI made gains in coronary imaging, in particular for the evaluation of suspected coronary anomalies. Since then, CT has eclipsed cardiac MRI in noninvasive coronary imaging, and CT has received more attention than MRI over the past several years. However, with respect to a complete cardiovascular imaging program, it remains important to avoid "putting all eggs in one basket," namely CT. Integration among cardiologists and radiologists will help to avoid this pitfall. As another example, nuclear cardiology remains a workhorse in cardiovascular imaging and can be used to supplement findings obtained from other techniques. Often, coronary CT reveals a 50% stenosis. A practice that includes cardiologists may be more likely to ask, "What does that lesion mean?" Scintigraphy can provide valuable insight. For example, a study that shows no ischemia can be reassuring that a 50% stenosis is not hemodynamically significant.
From the perspective of the radiologist, an open dialogue will flush out those cardiologists who staunchly consider themselves competitors. For the radiologist who practices in a geographic territory that will not support the patient volume of multiple practices, an early appreciation of the presence and goals of such a group is critical. The fact is that a cardiology group can completely manage a cardiovascular imaging service on their own (though not and when the practice includes the expertise of radiologists). For example, consider the marketing strategies of our CT vendors. Precious software resources have focused on image postprocessing that transforms CT data into standard cardiac catheterization projections, despite the fact that these projections do not optimally capitalize on the ability of CT to view all lesions orthogonal to the direction of the artery.
Failure to communicate in cardiovascular imaging typically results in groups taking sides and resorting to discrediting others. This can occur at multiple levels, all of which decrease the quality of patient care. Overt examples (e.g., how can a cardiologist understand complex artifacts such as beam hardening adjacent to coronary calcification) can be readily identified and should be eliminated. However, more subtle examples have negative impact as well. Consider a cardiac viability patient. Imaging can be performed with either scintigraphy or MRI, with literature supporting both. However, a patient who would be better imaged with MRI may not get this opportunity if a referring clinician controls only the nuclear cardiology program.
There are caveats to this type of program. A shared practice between radiology and cardiology has the potential for self-referral since cardiologists who see patients will, with increasing frequency, recommend coronary CTA. In our "50-50" practice, this problem is eliminated, as those cardiologists who perform and interpret cardiac studies are dedicated cardiovascular imagers. However, smaller groups formed with a cardiologist with shared responsibilities must remain wary of self-referral. As the utilization of CT continues to grow, it may be the case that dedicated training programs open to cardiologists produce more individuals who opt for a career of imaging alone.
There is also the potential for profit loss or at least the perception of a potential for profit loss. Revenue sharing is a critical step in the negotiation between radiologists and cardiologists. A service based on equal distribution of workload can then equally share capital expenditures and revenue. In our academic practice the issue is minimized as all of the members work, salary based, for the same physicians' organization. However, for smaller private practice groups, a potential advantage of working together is a strong program that can successfully compete with others for the expected large demand of imaging services.
In summary, development and maintenance of a cardiovascular imaging program should rely on contributions between radiologists and cardiologists who work collaboratively, not competitively. The strength of such programs is a sum that is greater than the parts. The most robust program will include all techniques (nuclear, CT, and MRI), and the anatomic domains should include the heart and the entire vascular system. This approach gives our referring clinicians one centralized location for imaging care of all patients. The benefits of such a multidisciplinary and multitechnique approach extend from an improved workplace to better training programs and ultimately to better patient care.
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  P. M. Colletti Cardiac Imaging: Radiologists Prepare, Participate, and Publish Am. J. Roentgenol., December 1, 2007; 189(6): 1271 - 1271. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
