Subspecialty Radiology: Beyond the Debate

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The question of whether general radiology is on the path to obsolescence has sparked considerable debate in recent years, with much of the controversy centered on the contention that subspecialty radiologists are responsible for fewer errors than their generalist counterparts. Whether this contention is true or not, the trend toward subspecialization is undeniable. In fact, a recent article in the Journal of the American College of Radiology¹ pegs 91.5% of residents and fellows surveyed as intending to pursue a subspecialty.

Myriad factors continue to fuel the subspecialization fire. Demand from hospitals tops the list. Robert E. Epstein, MD, is president of East Brunswick, New Jersey-based University Radiology, which owns or operates 10 sites in the state’s central corridor, covers five hospitals, and interprets 950,000 procedures per year. University Radiology’s staff includes 84 radiologists; of these, 72 subspecialize: four in pediatric radiology; six in nuclear medicine; 10 in interventional radiology; nine in neuroradiology; six in musculoskeletal imaging; 14 in body imaging (CT, MRI, and ultrasound); 14 in women’s imaging; four in neurointerventional radiology; and five in cardiovascular imaging.

Epstein says, “As technology and the subspecialties themselves have become increasingly sophisticated, hospitals are definitely demanding more and more radiology subspecialist services. Take PET/CT: It involves complex equipment. In regional hospitals’ view, it is unacceptable for a general radiologist to be reading exams conducted using such advanced equipment. Their reasoning is that if there is a subspecialist in the practice serving them, that is the person they want.”

Epstein adds that in University Radiology’s case, provisos for certain types of subspecialist coverage are being incorporated into contracts. He cites mammography and interventional radiology as two areas of service that have been carved out in this way, attributing the trend, in part, to the fact that while cries for radiologists in both of these subspecialties are especially loud, demand far outstrips supply.

In some cases, a need to maintain accreditation and/or attain specific business objectives spurs hospitals to push the subspecialty envelope. For example, University Radiology works with several New Jersey hospitals that must, in order to qualify as Joint Commission designated stroke centers, offer advanced neuroradiology services. Attending physicians generally demand that head CT and similar exams be read within 30 minutes, according to University Radiology’s CEO, S. Thomas Dunlap. On the business side, Dunlap notes, “Hospitals are saying that they want to work with a women’s imaging subspecialist who will become the face of their mammography services, as this brings in more patients for cancer surgery and treatment.”

“As technology and the subspecialties themselves have become increasingly sophisticated, hospitals are definitely demanding more and more radiology subspecialist services.”

—Robert E. Epstein, MD, president,
University Radiology, East Brunswick, NJ

Even if hospitals do not insist that contracts be written to guarantee specific subspecialist services, some assume that such services will be provided, in accordance with an unwritten general rule. That has been the experience of West County Radiology Group, headquartered in St Louis, Missouri.

The practice is staffed by 35 radiologists, with five subspecializing in radiation oncology, five in neuroradiology, five in body imaging, three in pediatric radiology, three in musculoskeletal imaging, three in nuclear medicine, and three in vascular/interventional radiology. Four radiologists are subspecialists in women’s imaging; of these, three spend about 98% of their time on breast MRI, but they also possess expertise in body imaging, and they assist in that area as needed. The remaining four radiologists handle some body imaging, as well as general radiology. West County Radiology Group serves two hospitals and six to eight freestanding imaging centers in the St Louis area.

Jeffrey L. Thomasson, MD, is West County Radiology Group’s president and vice chair. He says, “Our contract with the hospitals reflects that we will provide radiology services, and subspecialty services are perceived and implied to be part and parcel of that because it is what we do anyway.”

A similar perspective is shared by Geoffrey G. Smith, MD, FACR, a partner at Casper Medical Imaging in Casper,