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The way to peace in the radiology ‘turf wars’ is to be open to change

Radiologists should allow others to participate in this area but retain ownership and responsibility for running a hospital-wide essential imaging infrastructure

Professor Gabriel Krestin
Professor of radiology
Erasmus University Medical Centre

Advances in imaging have drawn other specialists on to the turf of the radiology department. Boundaries are being crossed, and conflict and competition have become inevitable. In my own institution, the new chairman of vascular surgery maintains that endovascular interventions are the province of the vascular surgeon. Our department of neonatology has announced plans to buy its own 3-T magnetic resonance imager (MRI) for the children’s emergency service. Even the cardiologists, with whom we have an intensive and long-running collaboration, are considering getting their own CT and MRI scanner. The role of the radiologist is being challenged as the use of images by clinicians becomes increasingly important.
It is appropriate to step back and reflect upon the role of radiology as a distinct clinical specialty within healthcare. Radiologists must be open to change and accepting collaborative imaging. Perhaps biomedical imaging services should be organised as a single, comprehensive entity, lead by radiologists, but accepting that other stakeholders will benefit and contribute. If the patient-handling experience and understanding, together with the specific clinical skills of the non-radiology specialist, could be combined with the broader technological, organisational, and image-interpretation skills of the radiologist, our profession might not only survive but thrive in an environment of mutual respect.
In my lecture at the European Congress of Radiology in Vienna in 2006 I called attention to the factors that have fuelled these radiology ‘turf wars’, and in Radiology in March 2009 I described a resolution. Here is a summary of the guiding principles and the practical structures that need to be established to achieved a solution.

In favour of an integrated structure
Physicians and patients demand optimised imaging services. Factors to consider include:

  • Access to the best possible equipment
  • Quality assurance
  • Room design
  • Informed consent
  • Communicating, transporting and overseeing the patient (all aspects of timeliness)
  • Standardised (hopefully evidence-based) examination protocols
  • Professional communication
  • After hours service
  • Emergency and disaster preparedness.

An integrated, hospital-wide imaging service can better meet such high demands but basic principles must be agreed. Diagnostic imaging and image-guided interventions are the domain of radiology and nuclear medicine but collaboration with clinical specialties is necessary and beneficial. Establishing an integrated organisational structure for the ‘discipline of imaging’ throughout the hospital can deliver cost-containment, high quality and efficiency. Four key starting points are listed below.

1. Professional integrity of the specialty of radiology remains a sine qua non
Radiologists and nuclear physicians remain in charge and responsible for performing all imaging procedures. Their expertise, in collaboration with related professionals (clinical physicists, radio chemists, etc) guarantees quality, safety, efficiency and, as far as possible, the evidence-based (not self-referred) use of diagnostic imaging and image-guided interventions. Ideally, the distinct specialties of radiology and nuclear medicine should be brought under one umbrella.

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2. Establish collaboration with other clinical specialists wherever there is evidence for a qualitative improvement of patient care
Improvement can be derived from the clinical expertise of the specialist involved, the development of imaging expertise by some specialists and, sometimes, from increased efficiency. For such collaboration to be effective and safe, user-specialists need to establish and maintain their imaging expertise. Training in clinically specific imaging is included for some specialists: abdominal/endocavity ultrasound for gastroenterology; catheter angiography and echocardiography for cardiology.
To achieve accreditation, these specialists in training clearly need to access equipment to perform a number of procedures. For other specialties that do not certify physicians for imaging but may still benefit from expertise – such as neuroscientists – another method of certification is needed. Perhaps the local radiologist community could provide this on an individual basis?

3. Delivery and management of imaging services by a central organisation
Guidelines and quality standards for service delivery must be consistent throughout the hospital. One aspect would be the provision of double reading and expert supervision, or the application of standardised appropriateness criteria for referral and examination protocols.

4. An enterprise-wide electronic patient record, and image/picture archiving and communication system be established
PACS technology ensures that all providers of imaging services are connected and committed to a similar workflow (electronic order entry, Dicom-compatible image acquisition and storage, electronic/structured reporting, etc). The enterprise-wide PACS is managed primarily by the department of radiology or the joint imaging service in conjunction with the IT department and guarantees quality standards and availability of imaging data to all authorised users.

Practical application of these principles
We recommend that diagnostic imaging and image-guided interventions in a hospital should be organised with two main characteristics.

1. Specialist radiologists have overall respons­ibility and control of imaging services
Diagnostic and interventional radiologists must preserve the integrity of the specialty, both as individuals and within a specialist department of radiology (or medical imaging if they merge with nuclear medicine). Increased volume of  examinations, plus extended collaboration with clinical specialists operating within multidisciplinary teams, will inevitably call for high-quality, sub-specialised training for radiologists working in different diseases and different organ systems.
System- or disease-based radiologists should take the lead in innovation, development and validation of new imaging technologies. The aim of radiologists will be to cater for the needs of referring physicians by delivering high-quality examinations and reports, and in particular, by providing highly specialised consulting services. For practical and historical reasons, some limited areas of diagnostic imaging and image-guided interventions will continue to be provided directly by clinical specialists themselves – such as dedicated ultrasound procedures or cardiac catheterisation by cardiologists.
In addition, X-ray fluoroscopy is being made available for diagnostic, and more particularly image-guided interventions, under the management of the radiology department, or to assist paramedical personnel acting alone, without a radiologist (in the operating theatre). Such limited decentralised services need to be the result of mutual agreement between the various clinical departments and the department of radiology. Finally, in some specific areas, like non-invasive cardiac imaging and endovascular intervention, a collaboration between radiologists and clinical specialists on an equal basis is the best approach for delivering high quality patient care.

2. Centrally organised and managed imaging services are rolled-out hospital-wide
Responsibility for all imaging equipment would be centralised within the radiology/imaging department, which would be responsible for harmonised work-flow and quality assurance. It is beneficial, from a management point of view to have all image-producing and related equipment and paramedical personnel run as a single hospital-wide ‘imaging facility’, controlled and monitored by radiology specialists. This way, comparable workflow with standardised referral procedures, acquisition protocols, data storage, image post-processing, image interpretation and consulting services is guaranteed.
Centralisation also guarantees high-quality equipment operation by trained paramedic personnel, with quality assurance and maintenance by clinical physicists and medical technicians. Other specialists can collaborate where their expertise is beneficial but without needing their own expensive equipment which would be  less efficient.

Further reading
Krestin, G. Radiology, 250 (3)