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Lessons from Across the Pond: Should Radiologists be the Gatekeepers of Medical Imaging?

Big changes are coming to the US health care system—some inresponse to the mounting scrutiny of medical imaging.  Newtask force recommendations, the ChoosingWisely campaign, and Affordable Care Act policies are all attempting tocurtail overtesting—with CT scans, MRIs and any otherscreening often ordered unnecessarily—that can drive up medical costs,lead to waste and unnecessary radiation, and prompt undue anxiety about falsepositive results.

Jha3486These are all worthy efforts, but to really make an impact,a paradigm shift in clinical care will have to happen, SaurabhJha, MB, BS, of the department of Radiology at the Perelman Schoolof Medicine at the University of Pennsylvania, suggests this week in a NewEngland Journal of Medicine “Perspective” article.

Radiologists must become the gatekeepers of medical imaging,as opposed to serving as just service providers for patients, hewrites. In the face of tighter guidelines and ultimately less leeway forphysicians to order potentially superfluous tests, he calls on radiologists to bethe ones who step forward and manage imaging utilization. But first, they needthe power to do so.

“The emphasis on service provision, operations, andefficiency has pushed radiologists to the periphery of clinical decisionmaking,” Dr. Jha writes. “To be effective gatekeepers, they will have to moveto the center.”

In the piece, titled “From Imaging Gatekeeper to ServiceProvider—A Transatlantic Journey,” Dr. Jha opens with an anecdote, a trip downmemory lane that introduces us to “Dr. No,” a radiologist in Great Britain,where he did his surgery residency, known for turning down requests for scans.Dr. No needed a justified reason, as the country’s system is faced with limitedimaging resources. In other words, you had to have a pretty good reason toorder that CT, because often the diagnosiscould be found another way.

“[In Britain}, radiologists acted as gatekeepers,” hewrites.  “To get through the gate, clinicians had to be at the top oftheir game. To triage effectively, radiologists had to think like the referringphysicians. Both sides pushed each other, and the net clinical acumenimproved.”

Here in the US, Dr. Jha came upon a different approach totreating patients: Fear of displeasing referring physicians or even beingperceived as “rationing” care, he noticed, had many radiologists acting morelike “Dr. Yes” more often than not.

The health care system in the UK is set up differently fromthe US, but there are perhaps some lessons to be learned here, Dr. Jhasuggests, if we want to get out of the “imaging boom.” Mainly, it shows us thata radiologist, acting as the gatekeeper, can exercise restraint in imagingutilization, he says.

Remember, “gatekeepers don’t simply advise on the bestimaging method,” he writes, “they question whether a given diagnosis should besuspected in the first place.”

But such a shift will require two key changes to our healthsystem. The incentive system needs to be changed, as are there no rewards fordenying an imaging study—one loses a reimbursable exam and expends time inwhich other reimbursable studies can be read. But there is a bigger obstacle,he writes: the service-provision mindset. Radiologists don’t wish to displeasereferring physicians, lest they take their business to someone who won’tquestion their test-ordering ability.

So how do they move to the center and away from the fringe?

“They’ll have to develop clinical-imaging conferences, actas imaging consultants, and conduct imaging rounds. Radiology leadership mustprovide incentives for these activities without compromising efficiency, bydeveloping granular metrics for quality,” he writes.

Benchmarks will also have to be established for theacceptable proportion of negative studies, and bundled payments for accountablecare organizations could offer a sentinel opportunity to face these challenges.

Either way, change is coming and radiologists must decidewhether to “greet the ebb of imaging passively or by stepping forward tocaptain and manage a rational decline,” he concludes.

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