Masters of Radiology Panel Discussion: Who Is Accountable for the Appropriateness of Studies—The Radiologist, the Referring Physician, or Both?

Abstract

M. C. Javitt is an unpaid consultant to Code Ryte and her husband owns stock in Code Ryte. D. B. Larson is a case contributor to Amirsys and is reimbursed on a contract basis. INTRODUCTION. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: I’d like to ignore the medical–legal aspects of this issue for purposes of our immediate discussion because they are well covered by Dr. Berlin and others. As well, I’d like to set aside, for the moment, the cost-containment issues one might raise, such as the role of radiology benefits management firms (RBMs). Instead, I want to use this topic as an opportunity to talk about the responsibilities of the radiologist and the clinician in providing the best care to patients. So, what is the radiologist’s responsibility and what is the clinician’s responsibility in making decisions about a patient’s imaging examinations, which include ionizing and nonionizing radiation diagnostic imaging? I frequently hear individuals in private practice say that in terms of imaging, their basic motto is that of Nike, “Just do it.” But at other times, I’ve heard people say that, whether in academic or private practice, radiologists have no ability to control utilization and therefore basically give up their responsibility to clinicians. I have always felt very uncomfortable with that line of thinking because I believe we’re the ones who best understand imaging. Beauchamp: Radiologists have to play a big role in determining what study is done for a patient. I believe their primary role is helping to establish educational patient-centered appropriateness guidelines, as opposed to being the imaging study gatekeeper making go–no go decisions at the point of study ordering. By educating—not obstructing—the radiologist becomes a partner— not an adversary. In terms of this guidance, the radiologist ultimately knows best, or should know best, whether a particular study can provide answers to the clinical question being posed. But this knowledge must incorporate input from our nonradiology clinical colleagues who have a great deal of knowledge to contribute as well. The best examples are provided by the policy formation of the American College of Radiology (ACR). For example, when it came to setting criteria for breast imaging, the ACR consulted with the American College of Surgeons, and when it came to cardiac imaging, it was the American College of Cardiology. Succinctly, it takes a village, and we need both radiology and nonradiology clinical input to get buy-in and the best possible outcome. Once established, one needs to determine how to operationalize these criteria so that the process is not an impediment. The methodology should not require that a radiologist review every study ordered. It has to be done so that these guidelines are readily accessible and easily implemented into the workflow, and it’s only by exception that a radiologist should be brought in to consult as a guide. The buck does stop with radiologists, but with education we will get to a bestuse approach much more expeditiously and sustainably. Kazerooni: I strongly agree with Dr. Beauchamp. Radiologists are ultimately responsible for the tests we perform or oversee our staff in performing. We are accountable to the patients on whom we perform tests and procedures, whether it’s because of the radiation or contrast we may be delivering or the cost we are adding to their health care. Begun in 1993, the ACR Appropriateness Criteria now cover 167 topics, most including variants of the primary clinical condition being discussed [1]. Not only can they be found online at www.acr.org/ SecondaryMainMenuCategories/quality_safety/app_criteria.aspxf, but also they recently became available for handheld devices. They have been developed by 10 diagnostic imaging expert panels and an interventional radiology panel in conjunction with 20 medical specialty Forman et al. Masters of Radiology Panel Discussion