University of Pennsylvania radiology professor Saurabh Jha, M.D., wonders about the role radiologists must play in managing the decline of imaging utilization in the U.S., while looking back at the role they play in the U.K., where he trained as a surgeon, according to a new perspective published last week in the New England Journal of Medicine.
Since imaging in the U.K. is a much scarcer commodity than in the U.S., radiologists there act as gatekeepers, meaning that if a clinician wants a study performed, he must "be at the top of his game" in order to convince a radiologist of a scan's appropriateness. The radiologist determines how that scare resource--imaging--is to be dispensed.
In the U.S., however, the abundance of imaging has turned radiologists into service providers instead of gatekeepers. But now that imaging utilization is being questioned--and overutilization of imaging is "frowned upon"--there is a "contrived" march to imaging scarcity, Jha says, and the question is who will "judicially dispense the scarce resources?"
It's a question continually addressed in print and at meetings. For example, as reported in a recent article in the Radiology Business Journal, the topic was discussed in a session from RSNA 2012, "The Radiologist As Gatekeeper: Should We Take a More Active Role?"
Radiologists, Jha said, are the natural choice for managing utilization, but that involves overcoming obstacles. For instance, there are no rewards for denying an imaging study. In fact, a denial only means that a radiologist will lose a reimbursable exam. A bigger obstacle, he writes, is the service-provision mindset in which radiologists don't want to displease a referring physician who may be more than willing to take his or her business to someone who "won't question their test-ordering ability."
Jha adds that it might be difficult for radiologists to take on a gate keeping role because there could be a stigma attached to the idea of "rationing" in the U.S.
"It will be harder for U.S. radiologists to be gatekeepers than it is for their NHS counterparts, simply because imaging is so abundant here--one can easily justify rationing of something that's truly scarce," he says.
And because U.S. radiologists have emphasized service provision, operations and efficiency, that has pushed them to the periphery of clinical decision making, according to Jha. In order to become effective gatekeepers, he says, they'll have to move back to the "center" by acting as imaging consultants, conducting imaging rounds and developing clinical-imaging conferences.