Subspecialization and Teleradiology: An Uneasy Alliance

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Why would orthopedic surgeons bypass a nearby hospital or imaging center when referring patients? If they happened to be in the Midwest, they might prefer the subspecialized interpretations offered by Linda L. Dew, MD, FRCPC. After more than two decades as a practicing radiologist, Dew has developed expertise in imaging of the feet, ankles, hands, and wrists.

Choosy surgeons have come to rely on her, and they have no qualms about asking patients to go slightly out of their way for an interpretation that they can trust. Dew, who works for a teleradiology company (headquartered in Southern California) that has a strong presence in Illinois, says, “Orthopedic surgeons and podiatrists do not tolerate mistakes, and they know, soon after surgery begins, whether what you said is correct or not.”

Consistently excellent interpretations are important for radiologists, wherever they happen to practice, but Dew believes that the extra focus on subspecialization is particularly prominent within teleradiology companies. With patient outcomes and valuable pieces of the referral pie at stake, subspecialization is increasingly perceived as a necessity in a profession that has always embraced the latest in medical technology.

Barry D. Pressman, MD, FACR, agrees that subspecialization benefits patients and referring physicians, but he is unwilling to concede that ground to teleradiology. This past president of the ACR® believes strongly that local radiologists can embrace subspecialization—and that they must, if they hope to remain relevant.

As chair of the S. Mark Taper Foundation Imaging Center and Department at Cedars-Sinai Medical Center (Los Angeles, California), Pressman has populated his staff with radiologists who have undergone additional training (primarily as fellows) and are experts in multiple subspecialties. The full subspecialization of the radiology department at Cedars-Sinai Medical Center essentially means that thoracic radiologists are reading chest CT exams and chest radiographs; neuroradiologists are reading spine CT and MRI exams, as well as spine radiographs.

Pressman, who began practicing in 1975, says, “I don’t care what the modality is; it’s the body area that matters. There are some places that come at it via modality, but through that route, they become specialists in body imaging. Fully subspecialized means having people who cover the entire imaging spectrum of the human being, with subspecialty areas.”

Everyone in such a practice should be doing work in his or her field of subspecialization, and no part of the body should fall into the category of “We’ll just have someone read that,” he says. In the past, that philosophy has been reserved for general radiology, a term that Pressman rejects in favor of broad-based, nonsubspecialized radiology.

Far from disparaging the nonsubspecialized practitioner, Pressman views broad-based radiologists as well-trained specialists experienced in gastrointestinal and chest radiography. Many generalists have branched into other areas, such as body CT and neurological CT, without fellowship training.

“People who are doing multiple things, but have not done any subspecialty training, I call multidisciplinary radi-ologists,” Pressman says. “To me, there is no such thing as true general radiology anymore. Radiology has gotten subspecialized to the point that I do not know what a general radiologist is.”

Pressman’s message has not received unanimous acceptance within the profession, as evidenced by the reaction to a presentation1 that he made a few years ago. “I gave a presidential speech at the ACR on this subject, and many people in the audience were pleased and agreed with me—and some wanted to kill me,” he says (with a chuckle).

“They were people who considered themselves general radiologists, and they felt I was deprecating what they do. I was saying, ‘Here is what you need to do to survive, going forward.’ Subspecialization is a crucial thing for the survival of radiology as a specialty. The alternative is to be subsumed by clinicians who do their own imaging and interpretation.”

Prescription for Disaster

Pressman and his staff take care of all the night coverage at Cedars-Sinai Medical Center, in an arrangement that staff physicians strongly prefer. “They want to know the radiologist well and would never accept a teleradiology arrangement,” Pressman says. “The other reason we do not use teleradiology is that I have always felt it was a prescription