State of the Specialty: Imaging’s Research Crisis

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Christoph LeeRadiology has been in the regulatory crosshairs for almost six years, ever since the DRA eliminated billions in reimbursements for imaging—and the profession can expect the trend to continue, if it doesn’t invest in research now. That’s the contention of Christoph I. Lee, MD, a UCLA Robert Wood Johnson Foundation clinical scholar, and Howard P. Forman, MD, MBA, professor at Yale University, in a May 2011 American Journal of Roentgenology article.¹ They argue that as evidence-based medicine becomes a federal mandate through health-care reform, radiology will find itself unable to demonstrate its value sufficiently without a renewed commitment to health-services research. “We have a target on our backs because imaging is expanding at such a rapid pace,” Lee says. “If we can’t prove that our imaging services have value for patient care, we won’t be able to fight against things like the DRA.” Lee cites the recent attention to CT radiation exposure as an example of the specialty’s inefficacy at defending itself. “We haven’t been able to lead the charge, even though we’re sounding the alarm,” he says. “We just don’t have the manpower working on these issues.” Cultural Conundrum In their article, Lee and Forman make the point that “nearly all of the evidence that will steer future health care financing directly affecting radiologists will come from investigations performed in the field of health services research.” Lee says, however, that there are only a handful of radiology health-policy programs in the country, while, as the article notes, “Most prominent internal medicine departments in the country currently have dedicated clinician-researchers affiliated or leading a center or institute for health services or policy.” Lee says, “There are not enough radiologists interested in doing this research. They forget that there’s a broader health-care world that is watching our specialty carefully.” He observes that the culture of radiology might have something to do with the specialty’s underrepresentation in such decision-making bodies as the US Preventive Services Task Force or the newly established Patient-Centered Outcomes Research Institute (PCORI). “We’ve been relegated to the back basement darkroom—we’re literally isolated from the rest of patient care. Even though we spend almost as much time reviewing patients’ images and looking at their history as clinicians at the bedside do,” Lee says, “we don’t have the direct patient contact. Our work is invisible.” The PCORI, Lee notes, will include vascular surgeons, psychologists, obstetrician/gynecologists, internists, and more—but diagnostic radiology is not yet represented. “The numbers seen at the national-policy level reflect the number of people working on this at centers of academic excellence nationwide,” he observes. “Almost every other specialty and subspecialty out there has seen the importance of health-services research, but radiologists are falling behind.” Initiating the Change Lee and Forman see several ways that the specialty can begin to address this issue. The first is the development of stronger programs for radiologists interested in health policy and health-services research. “We need to educate radiologists about why these issues matter and why this type of research is so critical,” Lee says. “We need to motivate the brightest residents out there to pursue this as a career. The national radiology societies will have to elevate the profile of radiology health-services research, and academic departments should be encouraged to establish and advertise these divisions.” The article also observes that the salary differential between radiologists conducting research and those in clinical practice should be decreased. “Increased funding opportunities, both from the federal government and private foundations, may allow academic radiologists to pursue this subspecialty while contributing clinically part-time and maintaining a salary commensurate with their colleagues,” Lee and Forman state. The field, however, will probably have to demonstrate its value to patient care before it sees its funding ship come in, they add. Lee is not discouraged by this. He cites a few examples of areas in which radiology health-services research has already had a national impact. One is the Washington State Health Technology Clinical Committee’s research into which modality is best for diagnosis in back pain. Lee says, “Their work, in terms of deciding whether radiography, CT, or MRI is appropriate and cost effective has really changed the way back-pain imaging is managed.” He also mentions the work of David C. Levin, MD, professor and chair emeritus of radiology at Thomas Jefferson University. “His research has shown that a large proportion of self-referring physicians are cardiologists, neurologists, and orthopedic surgeons, and that they’re taking advantage of the system,” Lee says. “That research has reached the national-policy level and started a discussion surrounding the Stark laws.” By following the example of these and other radiology health-services researchers, Lee believes, the specialty can capitalize on health-care reform’s focus on outcomes-based medicine (instead of being victimized by it). “Radiologist scientists have to reach out to their health-services colleagues in different specialties and collaborate on innovative research surrounding medical imaging and appropriate use,” he says. Otherwise, he warns, “We run the risk of continuing to be relegated to the back seat, responding to the issue rather than leading. We’re going to be told how to practice radiology by other specialties if this trend continues.” Cat Vasko is editor of and associate editor of Radiology Business Journal.