PERSPECTIVES The Invisible Radiologist

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REVIEWS AND COMMENTARYn PERSPECTIVESNote: This copy is for your personal, non-commercial use only. To order presentation-ready copies fordistribution to your colleagues or clients, contact us at Invisible Radiologist1Gary M. Glazer, MDJulie A. Ruiz-Wibbelsmann, PhDPublished online10.1148/radiol.10101447Since the discovery of the x-rayin 1895, radiology has become aprominent medical discipline. Radiologists are central to the function ofhospitals and academic medical centers,and their training programs are producing leaders in medicine. The profession’sstrong research agenda is also greatlyadvancing medicine, and there is now animportant imaging resource with interests strongly aligned with radiology: theNational Institute of Biomedical Imagingand Bioengineering at the National Institutes of Health. However, according to a2004 survey of 66 teaching departmentsand private facilities, 80%–90% of radiologists do not meet their patients (1),and a 2008 national survey by theAmerican College of Radiology revealedthat one in two Americans still does notknow “whether a radiologist is a personwho interprets or a person who administers the scan” (2). During four 2-hourfocus groups in two states, adults aged 35and older were split as to “whether aradiologist is a licensed physician or atechnician” (2). Because radiologists havelimited contact with patients, radiologistsare physically invisible to them, and theirrole as physicians also remains hidden orinvisible to most patients.How did radiologists become so invisible to their patients? What were themajor factors driving radiologists towardinvisibility as the discipline evolved during the past century after the discoveryof the x-ray? What is the long-termeffect of losing visibility to patients?Radiology 2011; 258:18–221From the Department of Radiology, Stanford UniversitySchool of Medicine, 1201 Welch Rd, Room P-263, Palo Alto,CA 94304. Received January 20, 2010; revision requestedAugust 12; revision received August 12; final versionaccepted August 12. Address correspondence to G.M.G.(e-mail: conflicts of interest are listed at the end of thisarticle.qRSNA, 201118The Early Years and Struggle forIncreasing Professional StatusAfter the discovery of the x-ray, earlyradiologists attempted to affirm theirstatus as medical professionals by claiming ownership of the radiographic imageand its interpretation.Many radiologists in the early 1900slacked medical degrees and were typicallyphotographers, physicists, or amateurexperimenters (3). Even after establishing the American Roentgen Ray Societyin 1908, radiologists were still oftenconsidered glorified tradesmen bothby the public (4) and two of the earliest medical disciplines: surgery (5) andinternal medicine (6).Initially, radiologists had direct contact with patients because they performed radiographic examinations andinterpreted the results, which they sometimes communicated directly to theirpatients (7). In hopes of increasing theirprofessional status, radiologists stoppedgiving images to patients, so that patients would know that they were paying for a medical consultation and not aphotograph (8). The medical communityaffirmed that the image was not the patient’s property, and, in 1916, the American Roentgen Ray Society advised radiologists to communicate results only toreferring physicians and not to patients(9), so that referring physicians wouldregard radiologists as medical experts.By 1922, the American Registry of Radiologic Technology was established(10), which described the qualificationsand licensure requirements for technicians. To enhance professional prestige,a practice model was created in whichradiologists limited their role to interpreting results and used technologiststo perform examinations. By ceasing toperform imaging examinations and communicate results to patients, radiologistsbegan to become invisible to patients.Hospital economics further displacedthe radiologist from patient contact. Theincreasing expense of radiologic equipment in the 1930s made hospitals anattractive place for radiologists to practice because of lower overhead expenses(11). However, rather than create separate departments of radiology, mosthospitals included a radiologist as amember of a section in the departmentof surgery (12), an organizational designradiology.rsna.orgnRadiology: Volume 258: Number 1—January 2011

PERSPECTIVES: Invisible RadiologistGlazer and Ruiz-Wibbelsmannfurther distancing the radiologist fromdirect patient contact and recognitionbecause the service and its operationwere under the direction of surgeons.Although radiologic studies beganto generate substantially increased revenues, hospitals restricted the radiologist’s access to this income stream, diverting it instead to cover the costs ofother departments while maintainingradiologists as salaried employees. Bycollecting both the fee for the technical and the professional components ofradiologic examinations, hospitals maderadiologists invisible to patients throughthe billing system and prevented themfrom exercising their rights as physicians to bill for their services independent of the hospital (13).This disappearance from the billing system was further entrenched by amarked rise in hospital insurance contracts in the 1930s, with the dominantplayer, Blue Cross, categorizing radiologyas a hospital service, not a medical service,thus removing the radiologist’s access tofee-for-service compensation (14). By theearly 1940s, radiologists no longer billedpatients for payment of imaging services,which were instead billed and collectedby the hospital.Invisibility in the Predigital EraThe creation of new radiologic techniques and clinical applications, as wellas the initiation of formal radiologictraining, signaled an increase in statusfor radiology within the medical community in the decades that followed(15). By 1961, 69% of radiologists hadadded their names to hospital billheads(16), which made it clear to patientsreceiving radiology bills that a radiologisthad interpreted their studies. This trendtoward greater professional visibilitygained momentum through the passing of the Medicare bill in 1965, whichclassified radiology as a medical serviceand allowed radiologists to bill patientsdirectly according to a fee-for-servicemodel like other hospital physicians. AnAmerican College of Radiology surveyindicated that 3 years later 70% of respondents were billing their own professional fees (17).Radiology: Volume 258: Number 1—January 2011nAs the professional reputation ofradiologists grew, the demand for theirservices increased, and radiology departments in academic medical centers wereflourishing. In the 1960s, the demandfor radiologic procedures was growingby 7% each year (18). According to a1964 study by the U.S. Public HealthService, 100 000 000 diagnostic examinations were performed annually in theUnited States, which was equivalent, onaverage, to one diagnostic procedure forevery two individuals in the populationeach year (18). By 1968, radiology wasranked fourth (8%) of 10 specialties interms of the number of U.S. graduatesentering residency training (18).Despite this increase in professional status, academic departments ofradiology did not develop programs totrain their residents to communicatewith patients. Most radiologists stilladhered to the older model of hospitalbased practice, which eschewed directpatient interaction. Not surprisingly, asurvey by Eastman Kodak in 1956 confirmed that radiologists were essentiallynonexistent to their patients, with lessthan one in four patients aware of thecrucial role of a radiologist in patientdiagnosis (19).The Invisible Radiologist inthe Digital EraSince the development of computed tomography in the 1970s and magneticresonance imaging in the 1980s, diagnostic radiologists have generally become less visible to their patients, withthe exception of a few subspecialties,such as interventional radiology and gastrointestinal radiology, in which the radiologist performs the examination. Inmost subspecialties, a technologist performs the procedure, and the radiologistis invisible to the patient. Furthermore,picture archiving and communicationsystems and teleradiology have enabledradiologists to provide radiologic services for multiple sites but have simultaneously reduced contact between radiologists and their patients (20).Some radiologic subspecialties haverecently taken the lead in reversing thisradiologist-patient disconnect, includingradiology.rsna.orgnuclear medicine, mammography, pediatric radiology, and ultrasonography. Indiagnostic mammography, radiologistsroutinely speak with patients regardingtheir mammographic results (21). In a2006–2007 survey of 243 radiologists,77% often or always communicated theabnormal results of diagnostic mammographic examinations to their patients,although less than 47.3% communicatedthe normal results of diagnostic examinations (22). Similarly, some pediatricradiologists communicate the resultsof imaging examinations to their patients,or patients’ parents (23), as do someradiologists in ultrasonography (24).Concurrently, several medicolegal decisions have emphasized the radiologist’sduty to communicate results directly topatients (25). The development of Webbased models of communication hasprovided another avenue to enhanceradiologist-patient contact (20). However,patients value a visible radiologist withwhom they can talk about their imagingstudies (26).Despite these attempts to increasedirect communication, numerous structures within the hospital environmentcontinue to impede full visibility between radiologist and patient. Hospitalradiologists are often physically separated from patients by geographicallydistant offices. Unlike other hospitalphysicians, radiologists lack consultingrooms and are typically not providedwith a care delivery team composedof nurses and physician extenders,whose services would allow radiologistsmore time for communicating withpatients.Hospital practice models are basedon a system created during the 1920sand 1930s. Today, the common classification of radiology as an “ancillary service” by hospitals and insurance companies reflects the perpetuation of thisoutdated practice model. One of theearliest uses of ancillary in reference toradiology appears in the surgical literature from the mid-1920s, which characterizes radiology as ancillary and as asupplement to surgical diagnostic methods (27). Considered an ancillary hospital service, radiology was not regardedas integral to medicine according to one19

PERSPECTIVES: Invisible Radiologistradiologist from 1939: “There has beenan unfortunate tendency for some hospitals to look upon the radiologist asa technician employed by the hospital,filling an ancillary role in the practice ofmedicine” (28).In many respects, the role of the radiologist has not changed substantially.Viewed as subordinate or supplementary to the services of the primary carephysician by hospital administrators,the role of the radiologist can be similarto the Latin word from which ancillaryis derived: ancilla, which means handmaid (29). Hospital administrators arereluctant to give ancillary services, suchas radiology, resources that might increase radiologist-patient interactions,such as consulting offices, offices nearpatient care areas, and the expansionof patient-care delivery teams.Even the shift from hospital-based inpatient imaging to radiologist-controlledoutpatient imaging centers in the past 2decades has not solved this dilemma ofminimal radiologist-patient interaction.Increased imaging volume is the primary reimbursement criteria rewardedby third-party payers, particularly foroutpatient imaging centers. This rewardsystem acts as a disincentive for physician engagement in activities that aretime-consuming and that lack a concomitant increase in imaging volume, suchas direct patient consultation. Compounded by a dearth of historical models forradiologist-patient interaction and insufficient medical school training in communication, this reimbursement system creates a disincentive for direct interactionbetween radiologists and patients becoming the accepted standard of practice.The Necessity to ChangeThe problem of limited patient contactalso pervades pathology. Like radiology, pathology has historically been ahospital-based specialty that is essentialto diagnosis in patient care with dependence on technology and with limitedor no patient contact. Consequently,pathologists are mostly invisible to theirpatients as evidenced by a 1996 surveyin which half of the patients interviewedhad no idea what a pathologist’s role20Glazer and Ruiz-Wibbelsmannwas, while 30% thought that the pathologist’s responsibility was limited toperforming autopsies (30).The evolution of pathology demonstrates the importance of patient contact in the successful development andsurvival of a medical discipline. Both radiology and pathology have achievedvery high status in medicine over thecourse of time. While radiology is stillhigh in status, pathology has declined,partially because of a lack of demandfor its services previously held in highregard, such as autopsy. More recently,the commoditization of pathologic studies, particularly blood testing in clinical laboratories, has been one of themajor factors diminishing the status ofpathology.In the early years of the 20th century,pathology was considered the scientific foundation of medicine, which ledto the founding of many powerful pathology departments in academic medical centers throughout the United States(31). However, in the 1930s, the statusof pathology began to diminish. Unlikeother medical specialties, pathologistsdid not directly consult with patients,and many physicians did not believe pathologists could help with their diagnoses, so there was not adequate demandfor pathology services. Also, autopsybegan to lose its value as a diagnostictool (32).Pathology had become a “specialtywith a glorious past but no future” bythe 1950s, according to William Rothstein, PhD (32). Rothstein concludedthat “[t]he boom years of pathology areover” (32). By the 1970s, academic pathology in some medical centers was “adiscipline without a specialty,” and somepathology departments were headed bychairs from other departments who hadbeen appointed by the dean (32).As academic pathology departmentsdeclined, clinical pathology laboratoriesexperienced a surge at community hospitals in the 1950s (32). Hospital pathologists served a critical function by helping “public health officials learn aboutcommunicable and infectious diseasesin the community” (32). Because mosthospital pathologists focused more oncommunity health than the individualpatient, hospital pathology became “amajor means of monitoring community health” (32). By 1969, clinical pathologists were being used to overseelay laboratories in such large numbersthat clinical pathology “changed from amedical specialty to an industry” (32).What in the past had been a consultative service to other physicians and topatients had become a commoditizedtest.This trend continues in the present.The industrialization of blood chemistries, cost and reimbursement issues,as well as a lack of patient contact haveall contributed to the transformation ofhospital laboratories into “cost centers.”Automation has reduced labor-intensivework to technology-intensive work, andlaboratory results (and some anatomicpathologic diagnoses) have becomecommodities, not services (33). Becausethey have limited patient contact, laboratory professionals are “endangered,”serving as dispensable workers who produce products rather than indispensablemembers of a health care team whoprovide services individualized for eachpatient (33).Anatomic pathologists are also experiencing a similar commoditizationof pathology services. Because of thegrowth in information technology, anatomic pathologists have become invisible producers of information about testsrather than providers of services, suchas the interpretation of test results andconsultations with physicians as well aspatients (34).Recognizing the great value of directpatient contact, some pathologists arenow struggling to become more visibleto patients through the direct communication of results (35), advocating fora future of pathology “at the patient’sbedside” (32) and in a more patientcentered medical discipline (36).ConclusionThe history of pathology holds an important lesson for radiology. Like ourprofession, pathology is a hospital-baseddiscipline with limited or no patientcontact and with advanced technology,which has led to robust, reproducibleradiology.rsna.orgnRadiology: Volume 258: Number 1—January 2011

PERSPECTIVES: Invisible RadiologistGlazer and Ruiz-Wibbelsmanntest results regardless of the locationof the laboratory or which physician isoverseeing the laboratory. Because identical test results can be obtained no matter which laboratory processes them,the only factor differentiating clinicalpathology tests is cost; this standardization has caused the commoditization ofpathology.Many of the factors that led to thecommoditization of pathology are alsooperating in radiology. Today, some claimthat our discipline is being commoditizedby the growth of teleradiology and picture archiving and communication systems, which have enabled the remoteinterpretation of images by an invisible radiologist isolated from patients(20,37). Our efforts to eliminate variation in image acquisition and interpretation have improved the overall qualityof imaging; however, a by-product hasbeen the threat of the commoditizationof imaging that can only be differentiated by price (37). However, this is notcompletely accurate because cost is notthe only factor differentiating imagingservices, such as the prescribing of examinations and the interpretation of images.Unlike pathology tests, these servicesare not commodities because they varyaccording to the expertise of the radiologist who personalizes them by determining, on a case-by-case basis, the appropriate imaging test, the specifics ofimage acquisition, and the interpretationof images.However, the invisibility of radiologists perpetuates the misperception thatmany imaging services are commodities. By offering an even higher level ofpersonalized service through direct communication, radiologists can dispel thisviewpoint by showing patients that theycustomize imaging examinations to fiteach patient’s individual health careneeds. While a key component in increasing radiologist-patient interactionsis the direct communication of imagingresults, there is little consensus on howand when to communicate results topatients, and the arguments range from“don’t tell,” “tell if asked,” “ask to tell,”and “always tell” (38). Although directcommunication may not be appropriate in every instance, we strongly agreeRadiology: Volume 258: Number 1—January 2011nwith the American College of Radiologythat direct communication of results topatients should be the overall, long-termgoal of our profession (39). In the meantime, there are small steps radiologistscan take to accomplish this goal, suchas introducing themselves to patients,explaining imaging examination procedures, creating patient-friendly imagingreports, and designing radiologic facilities that promote comfortable doctorpatient interactions.An important trend in medicine isthe movement toward more personalized health care by using techniquesand therapies of molecular medicine.Radiology plays an important role inthis trend through early disease detection as well as through the monitoringof personalized medicine and targetedtherapies by using anatomic, functional,and molecular imaging. Because a medical care delivery model for personalizedmedicine has not yet been established,we have a great opportunity to shapethis model and improve patient care bybecoming a more visible member of apatient’s health care team. This will helpthe patient, as well as the discipline ofradiology, by creating a new culture ofimproved health care.Disclosures of Potential Conflicts of Interest:G.M.G. Financial activities related to the presentarticle: none to disclose. Financial activities notrelated to the present article: has been an adviserto Theranos and received stock options for this.Other relationships: none to disclose. J.A.R. Nopotential conflicts of interest to disclose.References1. Margulis AR, Sostman HD. Radiologist-patientcontact during the performance of crosssectional examinations. J Am Coll Radiol2004;1(3):162–163.2. The Face of Radiology Campaign Presentation. American College of Radiology (ACR)Web Site. Accessed August 15,2008.3. Eisenberg RL. Early radiology. In: Radiology:an illustrated history. St Louis, Mo: MosbyYear Book, 1992;58.4. Hernaman-Johnson F. The place of the radiologist and his kindred in the world ofmedicine. Arch Radiol Electrother 1919;24:181–187.radiology.rsna.org5. Richardson MH. The practical value of theroentgen ray in the routine work of surgicaloffice practice. Times Register 1897;33(4):137–141.6. Dock G. X-ray work from the viewpoint ofan internist. Am J Roentgenol Radium TherNucl Med 1921;8:321–327.7. Bowen DR. Medical ethics in relation toroentgenology. Pa Med J 1913;17(1):15–23.8. Howell JD. Clinical use of the x-ray machine:the newest technology at the oldest hospitals. In: Technology in the hospital: transforming patient care in the early twentiethcentury. Baltimore, Md: The Johns Hopkins University Press, 1995;127.9. Medical ethics for the roentgenologist [editorial]. AJR Am J Roentgenol 1916;3(12):593.10. Linton OW. American Registry of RadiologicTechnology. Acad Radiol 2008;15(9):1211.11. Dodd GD. Radiology and the marketplace. AJRAm J Roentgenol 1985;145(6):1120–1121.12. Gagliardi RA. Glen W. Hartman Lecture:American Roentgen Ray Society. Radiology:a century of achievement. AJR Am J Roentgenol 1995;165(3):505–508.13. Stiles RG, Belt HC. Socioeconomic and political issues in radiology: a historical analysis. Radiology 1991;180(3):823–829.14. Linton OW. Radiology’s three crises. AJRAm J Roentgenol 1997;168(4):885–888.15. Ahnfeldt AL, Allen KDA, McFetridge EM,Stein MW, eds. Preface. In: Radiology inWorld War II. Washington, DC: Office ofthe Surgeon General, Department of theArmy, 1966;xv.16. Linton OW. The 1960s: expanding the mission. In: The American College of Radiology: the first 75 years. Reston, Va: AmericanCollege of Radiology, 1997;56.17. Linton OW. Compensation of radiologists.AJR Am J Roentgenol 1994;163(2):265–269.18. Morgan RH. The emergence of radiologyas a major influence in American medicine.Caldwell Lecture, 1970. Am J Roentgenol Radium Ther Nucl Med 1971;111(3):449–462.19. Linton OW. Who are you? and who cares?Acad Radiol 2008;15(9):1212.20. Maynard CD. Radiologists: physicians or expertimage interpreters? Radiology 2008;248(2):333–336.21. Sasson JP, Zand T, Lown BA. 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PERSPECTIVES: Invisible Radiologistcontent of verbal communication betweenradiologists and women receiving screeningand diagnostic mammography. Acad Radiol2009;16(9):1056–1063.23. Goske MJ, Reid JR, Yaldoo-Poltorak D, HewsonM. RADPED: an approach to teaching communication skills to radiology residents. Pediatr Radiol 2005;35(4):381–386.24. Ragavendra N, Laifer-Narin SL, Melany ML,Grant EG. Disclosure of results of sonographicexaminations to patients by sonologists. AJRAm J Roentgenol 1998;170(6):1423–1425.25. Berlin L. Communicating results of all outpatient radiologic examinations directly to patients: the time has come. AJR Am J Roentgenol 2009;192(3):571–573.26. Brandt-Zawadski M, Kerlan RK Jr. Patientcentered radiology: use it or lose it! AcadRadiol 2009;16(5):521–523.27. Moynihan B. The relationship of radiologyand surgery. Br Med J 1925;2:47–51.22Glazer and Ruiz-Wibbelsmann28. Cahal MF. The business side of radiological practice. Radiology 1939;33(1):510–512,650–653.29. Oxford English Dictionary. Oxford University Press Web Site. e 1&querytype word&queryword ancillary&first 1&max to show 10. Accessed June 2, 2010.30. Laposata M. What many of us are doingor should be doing in clinical pathology: alist of the activities of the pathologist in theclinical laboratory. Am J Clin Pathol 1996;106(5):571–573.31. Rosai J. Pathology: a historical opportunity.Am J Pathol 1997;151(1):3–6.32. Rothstein WG. Pathology: the evolution of aspecialty in American medicine. Med Care1979;17(10):975–988.33. The future of pathology and laboratory medicine: an ASCP task force report. Crit Values2008;1(1):26–32.34. Murphy WM. The evolution of the anatomic pathologist from medical consultantto information specialist. Am J Surg Pathol2002;26(1):99–102.35. LiVolsi VA, Leung S. Communicating criticalvalues in anatomic pathology. Arch PatholLab Med 2006;130(5):641–644.36. Burke MD. Laboratory medicine in the 21stcentury. Am J Clin Pathol 2000;114(6):841–846.37. Krestin GP. Commoditization in radiology:threat or opportunity? Radiology 2010;256(2):338–342.38. Smith JN, Gunderman RB. Should we inform patients of radiology results? Radiology 2010;255(2):317–321.39. Patti JA, Berlin JW, Blumberg AL, et al.ACR white paper: the value added thatradiologists provide to the health careenterprise. J Am Coll Radiol y: Volume 258: Number 1—January 2011

18 n Radiology: Volume 258: Number 1—January 2011 The Invisible Radiologist 1 Gary M. Glazer MD , Julie Ruiz-Wibbelsmann ,A. PhD Published online 10.1148/radiol.10101447 Radiology 2011; 258:18–22 1 From the Department of Radiology, Stanford University School of Medicine, 1201 Welch Rd, Room P-263, Palo Alto, CA 94304.

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