Subspecialty Radiology: Beyond the Debate
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, Wyoming. Casper Medical Imaging has seven FTE radiologists on its staff, serves 120 to 140 physician clients, and performs 110,000 exams per year. Its team comprises two general radiologists, two general radiologists who also subspecialize in interventional radiology, one nuclear-medicine subspecialist, one neuroradiologist, and one subspecialist in both musculoskeletal imaging and cardiothoracic radiology. Smith describes a buyer’s market in subspecialty radiology, noting that hospitals “make it clear that if a radiology practice does not offer a desired subspecialty or is not willing to explore the possibility of doing so, they will go elsewhere to fulfill their patients’ needs.” Clinician Expectations There are other catalysts at work on the hospital front. Indeed, requests from individual attending physicians and other referrers continue to spur the call for subspecialist services. Charles J. Gatt Jr, MD, is a partner in University Orthopaedic Associates, LLC, which has offices in New Brunswick, Princeton, and Somerset, New Jersey. Gatt, who subspecializes in sports medicine, believes that the quality of care that his practice can provide is heavily affected by his ability to obtain interpretations from musculoskeletal-imaging subspecialists.
“Hospitals make it clear that if a radiology practice does not offer a desired subspecialty or is not willing to explore the possibility of doing so, they will go elsewhere to fulfill their patients’ needs.”
—Geoffrey D. Smith, MD, partner,
Casper Medical Imaging, Casper, WY
“It’s not really data in the health-care literature, and certainly not marketing by teleradiology companies, that send me in this direction,” Gatt observes. “In my experience, getting rapid, subspecialist reading means a higher caliber of care, at least most of the time.” While demand for subspecialists in all areas clearly exists, some subspecialties are more sought after than others. There is markedly high demand for subspecialists in breast imaging and in interventional/vascular radiology, with the trend stemming largely from technological advances and continued enhancement of image quality. “The advent of 3D ultrasound, breast MRI, and computer-aided detection in mammography has made breast imaging a foremost subspecialty,” Thomasson notes, adding that neither hospitals themselves nor referring physicians prefer that these exams be handled by generalists. “The same is true with vascular and interventional procedures. Diagnostic tools are better today than they were in the past,” he says; general radiologists, as a result, are not always seen as the ideal candidates for leveraging these technologies. Thomasson deems pediatric radiology an especially desirable subspecialty, most notably where attending physicians are concerned. “It is commonly accepted that there not only is a certain skill set needed for children’s imaging, but a distinctive ability to relate to both kids and their parents,” he explains.
“Multiple PACS and disparate systems form big roadblocks. The objective is for imaging information to flow freely into a robust, simple system, but with disparity, this does not happen.”
—S. Thomas Dunlap, CEO,
University Radiology, East Brunswick, NJ
Subspecialty patterns, however, do not entirely jibe with demand. Liability concerns remain a force in discouraging many radiologists from subspecializing in breast imaging. Practicing interventional radiology necessitates leading a restrictive, pressure-laden life, preventing many radiologists from pursuing fellowships and board certification in that arena. Conversely, many aspiring subspecialists find neuroradiology, musculoskeletal imaging, and body imaging most attractive. “Here, there is less of a risk of malpractice litigation, and there are opportunities to use high-tech equipment and live a less frenetic professional life,” Epstein says. Facing Challenges While the appeal of individual radiology subspecialties varies, the challenges presented by subspecialization as a whole do not. “Besides a blurring of the line between certain subspecialties, we see real-world limitations in the form of challenges,” Dunlap says. Cost ranks toward the top of the list. The volume of cases in any subspecialty must support the higher financial outlay for the IT support and equipment needed to route images to the appropriate reader. Some are compelled to pay higher salaries to subspecialists in areas in which there are more positions to fill than radiologists to fill them; interventional radiology and breast MRI are among these areas. Technical obstacles have emerged. For example, in some cases, there exists a lack of interconnectivity between a practice’s PACS and its other IT systems. Disparate hospital systems put forth a separate set of obstacles. “Multiple PACS and disparate systems form big roadblocks,” Dunlap says. “The objective is for imaging information to flow freely into a robust, simple system, but with disparity, this does not happen.” University Radiology mitigates many of the headaches caused by system disparities with the assistance of an in-house, 19-person IT team. Recruitment roadblocks also exist. For example, while the consensus apparently holds that the increasing number of fellowships, the formation of larger practice groups, and the general tendency among individuals to want to hone their radiology skills only in areas that interest them will lessen the role of general radiology over time, there will always be a need for radiologists who can move quickly from reading one type of study to reading another. Many subspecialists, however, are less willing to accept positions in which they cannot focus primarily on their area of expertise. “Of course, occasionally, this kind of challenge can work in one’s favor,” Dunlap observes. Recently, University Radiology was able to attract a highly qualified interventional radiologist, recruiting him away from another practice that had too much general work (and insufficient interventional work) for him to perform. Moreover, staffing needs do not always correlate with the available pool of subspecialists. “We need to recruit in line with what is warranted by the needs of the medical community, and to remedy the situation if we are not fulfilling its requirements in terms of areas of expertise,” Smith states. “Still, that is easier said than done.” Over the past few years, Casper Medical Imaging has been attempting, on and off, to fill a recognized need for a full-time musculoskeletal-imaging subspecialist. “Last year, we got serious about it and started to look actively,” Smith reports. “We had inquiries from 12 candidates; of these, eight to 10 came to visit. Not long before that, there were just a few. We haven’t filled a slot yet, and now, there are 26 residents who are interested in checking us out; recruitment has an ebb and flow.” For its part, West County Radiology Group has had fairly good luck on the recruitment front, but Thomasson chalks up a portion of the group’s good fortune to creativity and flexibility. “Candidates have been through the rigors of medical school and fellowship, and quality of life is a big issue for them,” he notes. “They don’t want to be locked into 50-, 60-, or 70-hour work weeks, so they want to be guaranteed some kind of night-coverage arrangement. They are not interested in waiting five years for a partnership. Even more important, they want reassurance, up front, as to how much time they will be spending in their defined practice areas.” In addition to the requisite reassurance and guarantees, Thomasson and his partners sweeten the pot with such perks as signing bonuses and reimbursement of relocation expenses. Wherever possible, they will agree to special arrangements such as the promise of time off for an already-scheduled future trip or a deferred starting date. Scheduling problems for subspecialists persist in many groups and departments. Epstein observes that the more a practice raises the subspecialty bar by adding staff with different areas of expertise, the greater the pressure becomes to ensure coverage in all subspecialties. This is not necessarily a problem for larger groups, but smaller groups with fewer resources might struggle with it. Scheduling Dilemmas Solutions to scheduling problems have been developed by trial and error. At West County Radiology Group, each subspecialty section does its own scheduling. Radiologists arrange their own schedule trades; Thomasson says that this increases their willingness to cover for each other when necessary. Meanwhile, Casper Medical Imaging leverages PACS to prevent scheduling complications from interfering with subspecialty care. “If we have a complex case that a referring physician only wants a particular radiologist to handle, but that radiologist isn’t scheduled, we will assign someone on call to render the report,” Smith explains. “Then, the radiologist specified by the referrer can weigh in later and communicate the findings to the referring physician.” It’s not surprising that practices of all sizes depend on teleradiology organizations to close at least some of their scheduling gaps. West County Radiology Group has a hybrid system wherein a teleradiology provider handles evening call. The group’s radiologists, however, have the opportunity to make themselves available to read procedures from home, if needed, during the night. “We do have some subspecialists who want the extra hours, but teleradiology is here to stay, especially for body imaging, neuroradiology, MRI, and ultrasound,” Thomasson says. “It’s not for plain films, but truly, you can neither recruit nor schedule fairly without it.” As a large practice, University Radiology is able to offer its own teleradiology services (which it provides to hospitals, emergency departments, and private practices) to plug scheduling holes and ensure adequate subspecialty coverage around the clock. These services are provided via fully redundant, on-site, HIPAA-compliant servers using virtual private networks, HL7, and broadband Internet gateways. Casper Medical imaging uses a teleradiology provider to provide preliminary reading of bread-and-butter procedures from 10 pm until 6 am daily. “We use teleradiology companies only about 5% of the time, but we do what we must to support subspecialization,” Smith concludes. “There will always be a role for general radiology, but the subspecialty piece (whether practiced only partially or entirely, depending on the group and the needs of the community) is the way of the future.” Julie Ritzer Ross is a contributing writer for Radiology Business Journal. Additional Reading - Studies Support Error Theory