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Turf Wars in Radiology: EmergencyDepartment Ultrasound and

RadiographyDavid C. Levin, MDab, Vijay M. Rao, MDa

In recent years, emergency medicine physicians have made strenuous efforts to take over responsibility forinterpreting and billing for ultrasound and conventional x-ray studies performed in emergency departments.This is a battle that radiologists have largely won. The authors explore some of the history of this controversyand the reasons why radiologists still control emergency department imaging.

Key Words: Medical economics, diagnostic radiology, radiology, radiologists, department management,socioeconomic issues

J Am Coll Radiol 2005;2:271-273. Copyright © 2005 American College of Radiology

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ditor’s note: This article is part of a series by these authorsxpounding on the phenomenon of self-referral and its ef-ects. The initial article appeared in the January 2004 issuef JACR; subsequent articles have appeared approximatelyimonthly.

For two decades, emergency medicine physiciansEPs) have made efforts to perform and bill for imagingtudies (principally ultrasound and conventional radiog-aphy) done on emergency department (ED) patients.everal years ago, our health policy research group in theepartment of Radiology at Thomas Jefferson Univer-

ity Hospital conducted studies of how often EPs arectually the physicians of record who bill and are reim-ursed for ultrasound and conventional radiography inD patients [1,2]. We used nationwide Medicare data

or 1997. Among all ultrasound studies performed onedicare patients in EDs that year, EPs did only 0.6%

1]. Among all x-ray studies on Medicare patients inDs, EPs did only 2.3% [2]. It was apparent from these

tudies that although EPs might often informally reviewlain x-rays or attempt to conduct focused ultrasoundtudies looking for specific abnormalities (such as bloodithin the peritoneum), the responsibility for the official

nterpretation in the vast majority of cases resided withadiologists (or cardiologists in the case of echocardiog-aphy). We recently conducted a follow-up study on the

Department of Radiology, Thomas Jefferson University Hospital and Jeffersonedical College, Philadelphia, Pennsylvania.

HealthHelp, LLC, Houston, Texas.

Corresponding author and reprints: David C. Levin, MD, Department ofadiology, Gibbon 3390, Thomas Jefferson University Hospital, Philadelphia,

mA 19107; e-mail: david.levin@mail.tju.edu.

2005 American College of Radiology091-2182/05/$30.00 ● DOI 10.1016/j.jacr.2004.09.016

ubject that looked at trends over an extended period ofime [3]. Between 1993 and 2001, the percentage of EDltrasound studies billed by EPs dropped from 0.6% to.3% (excluding the small percentage of cases in whichhe specialty of the physician provider could not be de-ermined). The percentage of conventional x-ray studiesilled by EPs dropped from 5.0% in 1993 to 2.2% in001. Clearly, this is a battle radiologists have won. It isherefore instructive to look at the history of this contro-ersy to try and understand why it turned out the way itas.Our previous publication [1] reviewed the history and

rovided a number of references from the emergencyedicine literature through 1999 that advocated the per-

ormance of ultrasound by EPs. Their justification in997 was that radiologists were frequently not availableuring off hours and that EPs would restrict their en-eavors to only a few targeted examinations for emergent

ndications, such as possible blood within the peritonealavity, abdominal aortic aneurysm, ectopic pregnancy,nd pericardial effusion [4]. However, by 1999, whatight be called “indication creep” set in, and a proposalas made to expand the use of ultrasound by EPs to

nclude possible gallstones and other biliary tract disease,ther obstetrical and gynecologic conditions, appendici-is, renal calculi, pleural effusion, deep vein thrombosis,arotid artery disease, scrotal trauma, and other medicalonditions [5]. Calls were made for EPs to bill for theirltrasound and plain x-ray interpretations [6].There was relatively little in the way of a formal re-

ponse by organized radiology to this challenge. In 1997,he Society of Chairmen of Academic Radiology Depart-

ents and the Association of Program Directors in Ra-

271

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272 Journal of the American College of Radiology/Vol. 2 No. 3 March 2005

iology developed a position paper on it, which wasubsequently endorsed by the Society of Radiologists inltrasound. The essence of this position paper was thatPs should not be doing ultrasound examinations inde-endently on ED patients for several reasons: (1) theyere not adequately trained to do them; (2) there was no

ducational requirement from the American Board ofedical Specialties or the Accreditation Council onraduate Medical Education for EPs to be given such

raining; (3) in most EDs, high-quality ultrasound waslready being provided by radiologists and cardiologists;nd (4) EPs generally do poorly when they try to inter-ret imaging studies. Although this position paper wasriefly mentioned in an ACR publication [7], it wasever published, and the ACR chose not to take a formaltance on the matter. By contrast, the American Collegef Cardiology publicly took strong exception to the no-ion that EPs should be doing echocardiography, point-ng out that official interpretations of echocardiogramshould be rendered only by physicians with sufficientraining and experience and that EPs had neither [8].

In more recent years, there have been continued callsy the EP community for more involvement in imagingone in EDs, particularly ultrasound [9-12]. Despitehat, our data [3] have shown that they have lost groundather than gained it. In 2001, EPs all across the nationere reimbursed by Medicare for a grand total of only160 ultrasound examinations, roughly the number ofltrasound studies done in 2 weeks by the radiologyepartment of a single moderately large general hospital.he number of x-ray examinations done by EPs

167,968) was considerably greater, but it had droppedy almost one-third since 1993, and their share of theotal volume had dropped by more than half. Of course,hese numbers do not reflect the informal or “practice”ltrasound studies conducted by EPs on ED patients orhe plain x-ray cases they may review but not bill for. Inost academic emergency medicine departments that

each ultrasound to their residents, the teaching is pro-ided by EP faculty members [13], a likely example ofthe blind leading the blind.”

Why have radiologists been able to fend off this ag-ressive effort by EPs to encroach on the practice ofonography and x-ray imaging? There are several reasons.irst, aside from patients’ visits to EDs, EPs do not con-rol patients any more than radiologists do. A majoreason why radiologists have lost turf battles to cardiolo-ists over things such as coronary angiography and echo-ardiography—and now in many departments nuclearardiac imaging as well—is control of patients. A special-st who controls a patient can generally direct the workupf that patient and can self-refer the patient for imaging

tudies if the necessary equipment is located in his or her a

wn or group’s office. That situation does not pertain inDs.Second, the training offered to emergency medicine

esidents is far less rigorous than that provided to radiol-gy residents. For example, the current guidelines of themerican College of Emergency Physicians calls for 16ours of classroom instruction and for only 150 super-ised studies to be performed, many of which could be onormal volunteers [9]. The guidelines of the ACR andhe American Institute of Ultrasound in Medicine, byontrast, call for a minimum of 3 months of formalraining and the performance of 500 supervised ultra-ound examinations during that training. An interestingtudy by Hertzberg et al. [14] tested the ability of radiol-gy residents at a respected academic institution to prop-rly perform and interpret ultrasound examinations atarious levels of experience. They found that even afteraving done 200 cases, the residents made significantrrors approximately half the time. Obviously, the Americanollege of Emergency Physicians training guidelines of50 cases are not adequate to ensure competence.Third, radiologists have the expertise in imaging; EPs

on’t. As an example, Eng et al. [15] conducted a study inhich panels of radiology faculty members, radiology

esidents, EP faculty members, and EP residents all in-erpreted the same test set of x-rays, half of which wereormal and half of which had significant abnormalities.eceiver operating characteristic curves were calculated

or the four panels. The mean areas under the curves were.85 for faculty radiologists, 0.78 for radiology residents,.70 for EP faculty members, and 0.65 for EP residents.he accuracy rate for faculty radiologists was 80%, com-ared with 71% for radiology residents, 59% for EPaculty members, and 57% for EP residents. It is appar-nt from these data that radiologists do far better atnterpreting conventional x-rays than do EPs; in fact,ven radiology residents outperform EP faculty membersy a substantial margin. We are not aware of any side-by-ide comparisons of radiologists and EPs in interpretingltrasound examinations, but it seems likely that theiscrepancies would be even greater, because ultrasoundxaminations are more operator dependent and may beore difficult to interpret. It also seems likely that cre-

entials committees in most hospitals understand thatlthough EPs are very good at practicing emergency med-cine, they are not sufficiently trained or experienced toe allowed to render the final interpretations of imagingtudies. Concern for good patient care and the risk foriability have generally kept this responsibility in theands of radiologists.Fourth and finally, most of the advances in the science

nd knowledge of conventional radiography and noncar-iac ultrasound have been made by radiologists. There is

well-known adage that today’s research is tomorrow’s

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Levin, Rao/Turf Wars in Radiology 273

linical practice. The fact that most of the research ononcardiac emergency applications of these two modali-ies has been conducted and published by radiologists is aajor reason why they have been largely able to maintain

ontrol of the field.When it comes to scheduling their work hours, most

Ps are more fortunate than radiologists. Emergencyedicine physicians generally work clearly defined shifts

nd then are free to go home, with no further professionalesponsibilities until their next shifts. Radiologists haveore open-ended work schedules. They must stay until

he work gets done and cover nights and weekends, inddition to their regular weekday work hours. This ob-iously puts a strain on radiology departments, especiallyn this era of highly subspecialized radiology and a serious

anpower shortage. Emergency medicine physicians of-en have unrealistic expectations if they think that sub-pecialized radiologic expertise should be instantaneouslyvailable in EDs around the clock every day of the year. Iftrained radiologist cannot view images immediately at

he time of an urgent situation in an ED, it obviouslyakes sense for an EP (or even a trained ultrasound

echnologist) to try to make an initial and unofficialnterpretation on which treatment can proceed. But ourata [3] demonstrate that the system seems to be workingight and has kept the ultimate responsibility for imagenterpretation in the hands of radiologists, the physiciansho know how to do it best. And by the way, the pro-ram requirements for residency education in emergencyedicine, as spelled out in the American Medical Asso-

iation’s [16] Graduate Medical Education Directory004-2005 (the “green book”), still say absolutely noth-ng about any requirement that residents in that fieldeceive training in ultrasound or conventional radiogra-hy.

EFERENCES

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2. Rao VM, Parker L, Levin DC, Sunshine JH, Bushee GR. Diminishinglevel of participation of emergency medicine physicians in the perfor-mance of conventional radiography done in emergency departments [ab-stract]. Radiology 2000;217(P):434.

3. Maitino AJ, Levin DC, Rao VM, Parker L, Sunshine JH. Do emergencymedicine physicians perform ultrasound and conventional radiography inthe emergency department: recent trends from 1993-2001. J Am CollRadiol 2005;2:274-278.

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9. American College of Emergency Physicians. ACEP ultrasound guide-lines—2001. Ann Emerg Med 2001;38:470-81.

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1. Lanoix R, Leak LV, Gaeta T, Gernsheimer JR. A preliminary evaluationof emergency ultrasound in the setting of an emergency medicine trainingprogram. Am J Emerg Med 2000;18:41-5.

2. Costantino TG, Satz WA, Stahmer SA, Dean AJ. Predictors of success inemergency medicine ultrasound education. Acad Emerg Med 2003;10:180-3.

3. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG.The status of bedside ultrasonography training in emergency medicineresidency programs. Acad Emerg Med 2003;10:37-42.

4. Hertzberg BS, Kliewer MS, Bowie JD, et al. Physician training require-ments in sonography: how many cases are needed for competence? Am JRoentgenol 2000;174:1221-7.

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