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The 2006 ACR Forum: CardiovascularImaging: Learning From the Past,

Strategies for the FutureRichard B. Gunderman, MD, PhDa, Jeffrey C. Weinreb, MDb,

James P. Borgstede, MDc, Bruce J. Hilman, MDd, Harvey L. Neiman, MDe

This paper summarizes the 2006 ACR Forum, which explored the history of the relationship between radiologyand cardiovascular imaging and sought to explore strategies by which radiology could cope with similarchallenges in the future. Key topics include: competition between radiology and other medical specialties, theimportance of cardiac imaging, the relative merits of cardiologists and radiologists as cardiovascular imagers,and specific recommendations for radiology leaders in the areas of education, research, clinical practice, and policy.

Key Words: Cardiovascular imaging, radiology, radiologists, education, economics

J Am Coll Radiol 2007;4:24-31. Copyright © 2007 American College of Radiology

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erb Abrams, one of the pioneers of cardiac imaging androfessor emeritus of radiology at Harvard Universitynd Stanford University, recalls a 2-hour conversationith one of the United States’ most prominent radiolo-ists. This leader was lamenting radiology’s imminentemise. Neuroradiology was being captured by the neu-ologists and neurosurgeons, gastrointestinal radiologyy the gastroenterologists, uroradiology by the urolo-ists, musculoskeletal radiology by the orthopedists, ando on. What was precipitating what he called the “end ofadiology?” Key factors included a lack of interest amongadiologists, insufficient training and research, and aearth of role models. As a result, radiology was about toe picked apart by other specialties, and no one seemednclined to do much to stop it.

Although this gloomy forecast sounds familiar, thisonversation did not take place earlier this year, but some6 years ago, in 1961. The more things change, the morehey remain the same. The bearer of this dark forecast,eo Rigler, MD, did not foresee the introduction ofompletely new imaging modalities such as ultrasound,omputed tomography (CT), and magnetic resonance

Indiana University School of Medicine, Indianapolis, Ind.

Yale University School of Medicine, New Haven, Conn.

University California, San Diego, San Diego, Calif.

University of Virginia Health System, Charlottesville, Va.

American College of Radiology, Reston, Va.

Corresponding author and reprints: Richard B. Gunderman, MD, PhD,ndiana University School of Medicine, Department of Radiology, 702 Barn-ill Drive, Room 1053, Indianapolis, IN 46202-5200; e-mail: rbgunder@

iupui.edu.

4

MR), as well as the development of new techniques inngiography and interventional radiology, innovationshat would not only revive radiology but endow it withnprecedented strength. And yet his pessimistic forecastas not completely without merit. Radiology would

oon largely cede to other specialties a number of theseains, including much of obstetrical ultrasound and mostoronary angiography.

What happened, and what lessons can be drawn fromhis experience for radiology’s future? To address theseuestions, the ACR convened its annual Forum in June006, in Reston, Va. The Forum is an annual long-rangelanning event of the college, which brings together in-ividuals with varied viewpoints and perspectives on aopic considered to be of strategic importance to thepecialty. The 2006 Forum was titled “Cardiovascularmaging: Learning From the Past, Strategies for the Fu-ure.” The Forum explored the history of the relationshipetween radiology and cardiovascular imaging andought to devise strategies by which radiology could copeith similar challenges in the future.Although cardiovascular imaging served as the focal

oint of the discussions, the ultimate goal was to lookeyond the heart to better understand and respond to thehallenges that radiology faces from other specialistscross all organ systems and imaging modalities [1].

hat follows is a synthesis of the discussions that tooklace among the Forum participants. The article con-ludes with consensus recommendations to the specialtyn how radiology can better contribute to cardiac imag-

ng.

© 2007 American College of Radiology0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2006.08.020

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Gunderman et al/2006 ACR Forum 25

OMPETITION BETWEEN SPECIALTIES

adiologic imaging of the heart takes a number of forms,ncluding plain radiography, cardiac catheterization andoronary angiography, nuclear medicine, echocardiogra-hy, CT, and MR. Since the 1960s, however, cardiolo-ists have virtually replaced radiologists in performingchocardiography and catheter cardiac imaging, and nu-lear cardiac imaging has been slowly migrating fromadiologists to cardiologists [2]. Forum participants iden-ified a number of reasons for cardiology’s success withhese procedures.

Most significantly, cardiologists see patients clinicallynd are able to play the roles of both referring physiciannd imaging consultant, which is almost never the caseor radiologists. In addition, the American Board of In-ernal Medicine required training in these cardiac imag-ng modalities to sit for its cardiology examination,hereas the American Board of Radiology’s oral exami-ation had no specific cardiac section. (A “virtual” car-iac section has recently been added to the Americanoard of Radiology’s oral examination.) Many more car-iologists than radiologists received training in cardiacatheterization and coronary angiography, and cardiol-gy contributed a greater proportion of the research [3].s of 2003, radiologists were still performing more than0% of cardiac CT and MR, but cardiologists are show-ng great interest in these modalities [4].

Today, just as in 1961, some radiologists see the spe-ialty as under siege, even using the term turf war toescribe the state of affairs [5,6]. They regard cardiac CTnd MR as one such turf war, in which every gain byardiology is a loss to radiology. One difficulty with thisiege mentality is that it usually portrays radiology in theole of the besieged. In fact, however, radiology is not aerpetual loser. Over the past few decades, radiology hascquired much more territory than it has lost. As exam-les, interventional techniques have supplanted generalurgery in areas such as abscess drainage and hemostasis,T has largely replaced diagnostic peritoneal lavage and

xploratory laparotomy in the evaluation of abdominalrauma, and positron emission tomography frequentlyeplaces surgical biopsy and resection.

One area in which the role of radiologists has ex-anded dramatically is neuroradiology. Decades ago,ost neuroradiology was performed by neurologists,

eurosurgeons, and orthopedists. Over time, however,he new radiologic specialty of neuroradiology was intro-uced, and now radiologists do most neuroradiology.hat happened? First, despite uncertain career pros-

ects, a small number of radiologists dedicated them-elves full-time to neuroradiology. Second, the specialtyas formalized through fellowships, followed by formal

esting by the American Board of Radiology. Third, the b

ational Institutes of Health provided funding for suchellowships, which promoted substantial research in theeld by radiologists.Another area in which radiologists have assumed

reater responsibility is breast imaging. This includes aubstantial role in patient intake through screeningammography; in diagnosis through diagnostic mam-ography, aspiration, biopsy, and needle localization;

nd in management through active collaboration withurgery, oncology, and radiation oncology. Keys to thisuccess included aggressive quality assurance measuresuch as accreditation, stringent continuing medical edu-ation requirements, board certification, and mainte-ance of certification. Organized radiology was highlyupportive of the federal Mammography Quality Stan-ards Act, which many believe was responsible for per-uading nonradiologists to give up performing low-vol-me, low-quality mammography.Radiology’s history has been characterized by succes-

ive waves of innovation, in which radiologists develop,urture, and refine new techniques, getting them reim-ursed and simplifying them to the point that otherpecialties begin to move in. As long as radiology remainsependent on referrals from physicians in other fields,his is situation is likely to persist. One means of thrivingn such a niche is to keep innovating, thereby ensuringhat radiology is always at the front of the next new waven innovation.

ardiac Imaging

hat makes cardiac imaging worthy of attention? Ac-ording to the American Heart Association, approxi-ately 6.5 million US patients visit emergency rooms

ach year with a chief complaint of chest pain [7]. Al-hough in many cases, the cause of the pain turns out toe noncardiac, cardiac disease is usually the most impor-ant diagnosis to exclude. Moreover, the American Heartssociation estimates that there are 13.2 million patients

n the United States with coronary artery disease. Imag-ng of the anatomy of the heart and coronary arteries andarious aspects of cardiac function is crucial in establish-ng such diagnoses. Ongoing research suggests that car-iac CT and MR may be able to provide imaging of thesetructures that is quick, noninvasive, very low risk, andubstantially less expensive than other diagnostic alterna-ives.

Radiologists have other reasons to take a special inter-st in cardiac CT and MR. For one thing, if radiologistsre willing to cede CT and MR of the heart to cardiolo-ists, other specialists may ask why they should not as-ume responsibility for cross-sectional imaging of theirarticular organ systems. For example, neurologists andeurosurgeons may seek to take over responsibility for

rain and spinal imaging. Orthopedists may argue that

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26 Journal of the American College of Radiology/Vol. 4 No. 1 January 2007

hey should control the imaging of joints such as thenee, hip, and shoulder. Gastroenterologists may seek toake over responsibility for such studies as computedomographic colonography. And urologists may arguehat they should be responsible for cross-sectional imag-ng of the urinary tract. Indeed, these transitions arelready under way, propelled in part by decreasing vol-mes and reimbursements for traditional services in thesepecialty areas.

The appeal of cardiac imaging is likely to vary accord-ng to modality. For example, MR of the heart is moreime consuming, necessitates more technical knowledgend physician involvement in image acquisition, requiresore extensive postprocessing, and offers less potential

evenue than routine studies such as brain MR. Becausef longer examination and interpretation times and lowerevels of reimbursement, an MR scanner might generatene fifth or even one tenth the daily revenue performingardiac studies that it would produce performing braintudies. For these and other reasons, cardiac MR mayemain a “niche player” for the next 5 to 10 years, focusedainly on evaluating parameters such as flow, function,

nd perfusion.High-speed, multidetector CT, on the other hand, is

he first generally applicable noninvasive test for coro-ary anatomy and pathology, and it is likely to be widelymbraced. Cardiac imaging has been perhaps the greatestingle driving force behind the development of 64-slicend dual-source computed tomographic scanners, a clearndication that equipment vendors recognize the poten-ial magnitude of the market.

Aside from the sheer number of patients undergoingardiac imaging and the potentially very large revenuessociated with it, there are other reasons for interest inardiac CT and MR. One is the intrinsic interest of thetudies themselves. Heart disease is a major cause of deathnd disability among US adults of all ages, and the abilityo image the anatomy and physiology of the heart offersreat opportunities for disease prevention and therapeu-ic intervention.

From an economic point of view, the opportunityo put cardiac CT and MR to work in prevention isompromised somewhat by the fact that there are cur-ently no government or private payer policies thatrovide coverage for imaging asymptomatic patientsith risk factors for cardiovascular disease. At present,

uch patients need to pay for such studies out ofocket. Even more significantly, there still is muchesearch to be done to demonstrate that the applica-ion of these technologies to population-based screen-ng actually reduces morbidity and mortality fromardiovascular disease. Currently, no generalizable

tudies support this contention. i

he Case for Cardiologists

hould cardiologists assume responsibility for most car-iac CT and MR? Cardiologists advance a number ofrguments to this effect. They claim a better understand-ng of cardiac anatomy, physiology, and pathology thanadiologists. They argue that they are more likely thanadiologists to understand the management implicationsf various cardiac imaging findings. They claim that theyre likely to know more than radiologists about patients’linical conditions, because they are often the physiciansho refer patients for cardiac imaging studies. Likewise,

he results of imaging studies are more readily available toreating physicians when the diagnostic and therapeuticoles are combined in cardiologists. Finally, they claimetter preparation than radiologists to cope with rare butotentially life-threatening cardiac complications of suchmaging procedures.

Of course, there are also disadvantages when imagingtudies are performed by the same physician who is di-ectly managing a patient. There is a possibility that thelinical picture may inappropriately influence image in-erpretation, leading to interpretations that the imageshemselves do not warrant. Moreover, if each diagnosticest generates additional income for a referring physician,here is a possibility that this financial incentive mayncrease marginal or inappropriate utilization, therebyncreasing waste and driving up health care costs. Fur-hermore, cardiologists attempting to establish high-vol-me cardiac CT and MR imaging services will necessarily

mage many patients who are not their own. These wouldnclude referrals from family physicians, internists, car-iac surgeons, and surgeons in other specialties perform-

ng preoperative workups. In these cases, the cardiologistould probably not know the patient, nor would the

esults of imaging studies be more readily available to thereating physician.

he Case for Radiologists

hat rationales support the performance of cardiac CTnd MR imaging by radiologists? Radiologists generallynderstand better than cardiologists the physics andechnology of CT and MR imaging, as well as the arti-acts they can generate. Radiologists are often morekilled at workstation postprocessing as well. Radiolo-ists are better trained than cardiologists to pick up ex-racardiac diseases, some of which may clinically mimicardiac disease, such as aortic dissection, pulmonary em-oli, pericardial and pleural effusions, and masses in theediastinum and lungs. Another argument in favor of

aving radiologists perform coronary artery imaging ishe fact that radiologists currently perform CT and MR

maging of the vasculature of every other organ in the

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Gunderman et al/2006 ACR Forum 27

uman body, and it is difficult to argue that a specialence should be drawn around the heart.

To address the concern that cardiologists are not qual-fied to interpret chest imaging outside the heart, a majorquipment vendor recently proposed to market a com-uted tomographic scanner that would produce imagesf only the heart. Although the entire chest would bexposed to ionizing radiation, and thus imaging data forll the extracardiac structures of the chest would be ateast potentially available, the scanner would display theeart and great vessels alone. The situation would benalogous to a physician performing a complete physicalxamination on a patient but only recording and actingn the cardiac portion of the examination. After intenseiscussions, the vendor in question has decided not toroceed with marketing this scanner. However, this ex-mple illustrates the more general principle that equip-ent vendors feel little loyalty to any particular medical

pecialty and are generally prepared to sell their devices tony physicians.

he Case for Both

nother model that has been proposed for cardiac CTnd MR is the so-called “split interpretation,” in which aardiologist interprets the heart and a radiologist inter-rets the remainder of the thoracic structures [8]. As longs the total charge for interpreting such studies does notxceed that of a single physician interpreter, payers mayot object to such arrangements. Some might argue thatplitting examinations offers patients the best of bothorlds, with a heart specialist interpreting the cardiac

tructures and a chest specialist interpreting the remain-er of the thorax.In fact, however, split interpretation is fraught with

eril. For one thing, radiologists who enter such arrange-ents will be seen as ceding cardiac expertise to cardiol-

gists. Insofar as such studies are labeled cardiac anderformed primarily for cardiac evaluation, radiologistsill be relegated to the status of second-order interpret-

rs. Moreover, split interpretation may set the precedentor the development of similar arrangements by otherpecialties; for example, gastroenterologists may arguehat they should interpret the colonic portion of com-uted tomographic colonography, leaving the rest of thebdominal and pelvic structures for radiologists to read.

Depending on how split interpretation is configured,here are other potential pitfalls, including false-claimiability, antikickback violations, and increased malprac-ice risk. On the other hand, proponents of split inter-retation argue that failing to accept such arrangementsould disadvantage patients and implicitly undervalue

he work of radiologists by encouraging nonradiologists,

ho possess less training and experience, to assume re- r

ponsibility for evaluating domains of anatomy that theyre poorly equipped to handle.

TRATEGIES

hat strategies would most effectively promote radiolo-ists’ contributions to the future of cardiac CT and MR?roadly speaking, the strategic focuses include educa-

ion, research, clinical practice, economics, and policy.

ducation

n considering how to improve education in cardiac im-ging for radiologists, it is important to recognize thatany radiologists and radiology residents regard cardiac

maging, including cardiac CT and MR, as lost. In manyrograms, no radiology residents even consider careers inhe field, perhaps in part because they lack faculty cardiacadiologists to serve as role models. Although a virtualardiac section is now part of the American Board ofadiology’s oral examination, many residents seem to

egard cardiac imaging merely as a hurdle they must clearo pass their board examinations. Given the great preva-ence of heart disease, it might be reasonable for residentso spend less time learning about obscure genetic condi-ions and rare tumors they are likely to see only once inheir careers and more time on the anatomy and pathol-gy of the coronary arteries. If radiology is to play arominent role in the future of cardiac imaging, it is vitalhat today’s radiology residents be trained in cardiac im-ging, with the hope that some will choose careers in theeld.This raises the broader issue of what it means to be a

adiologist. To secure the future of the specialty, it maye necessary to devote less training time to becoming aeneral radiologist and more time to specialization. Re-ent proposals have suggested that residents spend only 2ears studying general radiology, then devote a year toesearch and 2 more years to clinical training in a specificeld, such as breast imaging, neuroradiology, or cardiac

maging [9]. In cardiac imaging, proponents argue thatost generalist radiologists lack the necessary depth of

nderstanding to provide greater value than cardiologistsho pursue cardiac imaging fellowships. To contribute

ubstantially to the diagnosis and management of heartisease will require a cadre of radiologists who focus

ntensively on both clinical and imaging aspects of car-iac disease.

esearch

he adage that the specialty that drives the research di-ects clinical care requires modification. Virtually all ofhe fundamental research that led to routine coronaryngiography was performed by radiologists, yet today

adiologists perform only a small percentage of coronary

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28 Journal of the American College of Radiology/Vol. 4 No. 1 January 2007

ngiograms. However, it is probably accurate to say thathose specialties that do not drive the research agendaave little or no chance at playing a substantial role in theorresponding clinical arena. Hence, it is vital for radiol-gists to participate more substantively in cardiac re-earch. Until recently, most research publications in car-iac MR were authored by radiologists, but the balanceas shifted, and the majority of publications now ema-ate from teams of cardiologists and radiologists. Theumber of cardiac MR publications by radiologists hasattened out, while cardiologist-only publications are

ncreasing (A. Stillman, personal communication).In terms of funding for cardiac research, it is probably

mistake to look for large commitments from vendors.he fact that results from any industry-funded clinical

esearch would likely benefit all vendors means that noingle vendor has a sufficient incentive to invest in suchnvestigation. Insurers generally regard the beneficiariesf research to be the specialists who use the technologieslinically and are reimbursed for their use, and insurersave largely abstained from supporting research. Theajor source of funding for imaging development and

ssessment remains the federal government, and the Na-ional Institutes of Health has a mandate to foster moreffective prevention and management of heart disease.hat being said, it is vital that radiologists create and

ultivate new sources of funding for clinical research inardiac imaging. At least one source might be radiologistshemselves, who can contribute at greater levels to aca-emic radiology departments and the research funds ofational radiology organizations.

linical Practice

n terms of clinical practice, radiologists need to define aiche for cardiac imaging in each large department orractice. Specialist radiologists are more likely to addalue in the eyes of referring specialists than general ra-iologists. To add value to cardiac specialists will requireadiologists to specialize in cardiac imaging. A person inach large group needs to be designated the cardiac radi-logist, and that individual must be competent to fulfillhat role. Ideally, the cardiac radiologist would be ac-ively engaged in research in the field (which is probablyore difficult for radiologists in nonacademic settings)

nd in collaborating with clinicians who routinely referatients for cardiac imaging.A complicating factor in this equation is the shortage

f radiologists. On one hand, it might seem desirable thatadiologists assume responsibility for all cardiac imaging,ncluding perhaps even echocardiography and coronaryngiography, as well as cardiac CT and MR. On the otherand, there are simply not enough radiologists in practiceo assume this additional workload. Such a move would

e disastrous to an already understaffed field. In fact, s

any radiologists are so busy with the work they alreadyo that they have little interest in taking on additionalesponsibilities for cardiac imaging.

A related danger is the contentment of many radiolo-ists with the status quo. Many feel that they are alreadyeaping sufficient professional and financial rewards fromheir practice and have no interest in investing the timend energy to develop new skills in cardiac imaging. Andage states, “A fat cat never hunts.” New domains oflinical imaging are likely to be won not by the mostontented specialists but by the hungriest ones and thoseith the most vision. In this sense, radiologists risk be-

oming the victims of their own success. To respond tohis challenge, radiology needs to relieve the currenthortage and create opportunities and incentives for ra-iologists to pursue new clinical service lines.Another clinical pitfall for radiologists is the tendency

o organize their thinking in terms of modalities. If radi-logy is to play an important role in cardiac imaging,adiologists need to think less in terms of modalities andore in terms of the anatomy, physiology, and pathology

f the organ system. The most important question is notWhat can we do with this CT scanner?” but ratherWhat approaches can best contribute the most value toatient care?” Ultimately, the clinical focus is more im-ortant than the technologic focus, and radiologists needo begin with the fundamental questions to which theirlinical colleagues need answers. Referring physicians doot care what modality is used. They do care about howo provide better care to patients.

If cardiologists are seen as the only heart doctors, thenadiology’s prospects in the area of cardiac imaging seemim. Radiologists should consider ways to enhance their

mage with patients. One possible approach is to meetith patients to discuss the results of their examinations.ace-to-face contact with patients is one of radiology’sost valuable untapped resources. Promoting cardiac

maging in public forums such as community groups canlso prove highly effective. It would be helpful for radi-logists to visit primary care practices to promote cardiacmaging services. To succeed, radiology needs to pro-

ote the presence of passionate cardiac radiologists inach health care market, giving cardiac imaging in-ser-ices and grand rounds and serving as active partners inhe care of patients undergoing evaluation for cardiacisease.

conomics

conomics also plays an important role. Radiologistseed to cease thinking of themselves as toll collectors whoxact a payment every time a patient crosses the imagingridge. Instead, radiologists need to recognize their dis-inctive economic contribution, which is that of large-

cale imaging production [10]. Radiology is the best spe-

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Gunderman et al/2006 ACR Forum 29

ialty to keep expensive pieces of equipment such as CTcanners and MR scanners busy all day long. Cardiolo-ists preparing a business case for purchasing a scannerould either need to find noncardiac uses for the equip-ent or team up with other cardiologists to fill up the

aily schedule. Moreover, the infrastructure to supportigh-quality imaging is expensive, and economies of scale

n centralizing that infrastructure tend to support anngoing role for radiologists.

Without forsaking this large-scale niche, radiologistshould seek out additional ways to add value, for exam-le, by developing better personal relationships with pa-ients and referring physicians. Image quality and patientafety are crucial, but service and marketing may repre-ent the greatest economic opportunities [11]. To attractatients, radiologists need to build business models thatppeal to primary care physicians.

Radiologists also need to stop thinking of themselvess combatants in a winner-take-all match [12]. Theyeed to give up the counterproductive attitude that theest of medicine is pitted against them, as some oppo-ents of “self-referral” have come to think. Protectionisteasures that seem to promote economic and profes-

ional security in the short term actually represent long-erm suicide. Radiologists should not devote their ener-ies to establishing an exclusive domain but insteadooperate with other physicians to improve patient care.adiologists need not control all cardiac imaging to doell for patients, referring physicians, and themselves.nly part of a whole can still be a great deal.Another way radiology can win its share of the cardiac

maging market is by helping others, especially patientsnd referring physicians. Radiologists need to changexisting referral patterns and cultivate new referralources. Other specialties, such as family medicine, gen-ral internal medicine, and surgery, may prefer to sendheir patients to radiology, knowing that radiologistsose no threat of capturing them. It is unlikely thatadiologists stand to gain much by marketing to cardiol-gists, but there is great potential in marketing directly tohysicians who do not see radiologists as such a threat.atients and primary care physicians are likely to repre-ent far more fruitful referral sources for cardiac imaginghan cardiologists.

olicy

adiologists need to recognize that policymakers haveittle or no interest in medicine’s turf battles. They are,owever, happy to secure higher-quality and safer care,specially if it results in lower overall costs. Radiologistsay be wasting their breath decrying self-referral, but

here is much they can accomplish by emphasizing op-ortunities to keep costs low. In fact, continuing to harp

n self-referral may prove counterproductive by making m

adiologists seem more and more like outliers, radicallyifferent from all other physicians. There is nothing to beained by portraying radiologists as the only kids in theandbox who cannot play with everyone else. Ultimately,uch attitudes undermine radiologists’ credibility as ad-ocates for quality, affordable imaging, and the best in-erests of patients and society. Instead of battling otherpecialties, radiologists might do better to seek out ave-ues of agreement and forge alliances with them.Legislative remedies are not necessarily long-term so-

utions. Instead of pursuing regulatory relief for whatome radiologists deem the unfair competition of self-eferral, radiologists can respond to changing forces inhe health care marketplace. As one example, certificate-f-need laws seemed the bane of radiologists when radi-logists were the only physicians seeking approval tonstall new imaging equipment. Now that other special-ies are seeking approval to purchase their own equip-ent, radiologists have come to see certificate-of-need

aws as quite congenial. It is important that radiologistselp create credible standards for credentialing that pro-ote adequate training and experience to perform and

nterpret particular imaging examinations.There are important differences between national and

ocal efforts. At the national level, there is relatively littlehe ACR can do to promote cardiac imaging by radiolo-ists beyond developing training standards and appropri-teness criteria [13,14]. Every radiologist does not neces-arily exhibit a measurable quality advantage over everyonradiologist. At the local level, however, real victoriesan be won through hard work in research, education,nd forging strong clinical relationships with otherealth professionals.In sum, radiologists might see themselves less as “prey”

han as “predators.” They can operate not in a defensiveode but in a creative mode, seeking to develop new

trategies by which to add value to both patients andeferring physicians. Moreover, they can cultivate rela-ionships with benefits managers and health care payers,ith whom they share a common interest in reducingnnecessary imaging utilization. Radiology’s case forlaying an important role in any health care domainhould ultimately rest on radiologists’ genuine advan-ages in terms of quality, safety, service, and cost.

ECOMMENDATIONS

he Forum concluded with participants’ recommenda-ions for actions that could be taken by the ACR, otherational radiology organizations, local radiology prac-ices, and individual radiologists to promote the perfor-

ance of cardiac imaging by radiologists.

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30 Journal of the American College of Radiology/Vol. 4 No. 1 January 2007

ducation

Promote curricula for cardiac imaging education anddevelop and disseminate cardiac educational modules.Recommend to the American Board of Radiology thatthe prominence of cardiac imaging on the board exam-ination be enhanced, in part by transforming the vir-tual cardiac section into a full-fledged, independentcardiac section.Develop opportunities for further radiologist subspe-cialization in areas such as cardiac imaging, throughgreater flexibility in how the American Board of Radi-ology and the Radiology Residency Review Commit-tee define a radiologist.Develop a permanent educational facility for thehands-on training of radiologists in emerging technol-ogies such as cardiac CT and MR.Expand residency and fellowship curricula to empha-size more of the basic sciences of radiology, includingsuch disciplines as anatomy, physiology, and pharma-cology.Develop programs that encourage radiology depart-ments to develop local experts in cardiac imaging andother emerging technologies.Increase the number of cardiac fellowship trainingslots.Develop programs that educate residents and practic-ing physicians in improving patient contact andsatisfaction.

esearch

Expand resources for cardiac imaging research by radi-ologists, including both the basic and clinical sciences.Expand the scope of the ACR Imaging Network®

beyond cancer to include clinical trials of diseases ofthe cardiovascular system.Support outcomes research for cardiac imaging, in-cluding the establishment and maintenance of dataregistries.Develop more effective collaborations with industryfor clinical trials in cardiac imaging and other emerg-ing technologies.

ractice

Encourage radiology departments to establish a sectionof cardiac radiology or designate cardiac radiologists.Promote the vitality of subspecialty societies dedicatedto the development of radiologists as cardiac imagers.Develop models of imaging care that place greateremphasis on patient contact.Assist radiologists in identifying new referral sourcesand changing referral patterns, as well as service models

that reflect these changes in the marketplace.

Identify market segments in cardiac imaging in whichradiologists are most likely to be successful.Encourage increased emphasis on the outpatient sectorto address new competitive demands and opportuni-ties.Develop new practice models that address the needs ofpatients and referring physicians.Market cardiac imaging and other underfilled practiceniches to trainees.Develop more effective radiology marketing andbranding models for patients and referring physicians.Emphasize radiology’s strengths compared with otherspecialties such as cardiology.

olicy

Address certificate-of-need issues with state govern-ments.Promote radiology credentialing and privileging mod-els with institutions and payers.Develop and disseminate a statement on split interpre-tations involving radiologists and other specialists.Renew the focus on quality and standards, especiallyby enhancing efforts to promote legislation restrictingreimbursement to designated providers of medical im-aging.Promote dialogue over common interests between ra-diology and benefits managers.Improve relationships with other specialty organiza-tions and hospital associations.Continue an aggressive advocacy program with gov-ernment and private payers.Promote the adoption of the ACR’s practice guidelinesas minimum qualifications for the performance andinterpretation of imaging examinations

CKNOWLEDGMENTS

e wish to thank all the participants for their valuableontributions to this article and the discussions thatpawned it. The Forum chair was Jeffrey Weinreb, and theochairs were James Borgstede, Bruce Hillman, and Harveyeiman. Additional participants included Nick Bryan,avid Dowe, Reed Dunnick, Mickey Guiberteau, Richardunderman, David C. Levin, Van Moore, Cindy Moran,

ohn Patti, David Robbins, Geoffrey Rubin, Arthur Still-an, Jonathan Sunshine, James Thrall, and Kay Vydareny.

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