AJR 2006; 187:1401-1402.
Di Carli M, Rybicki FJ.
Cardiac CT angiography (CCTA) is ¦ a rapidly emerging technology ¦ that has sparked considerable debate recently on utilization, reimbursement, physician qualifications, and turf. The October issue of AJR included a Policy Brief/Commentary on "How to Win the Coronary CTA Turf War." This month's Policy Brief/ Commentary, coauthored by a radiologist and cardiologist, features a different perspective.
The introduction and acceptance of cardiac CT and MRI as clinical tools have renewed the intensity of discussions over who should perform and interpret cardiovascular imaging studies. Radiologists argue that their training and experience in cross-sectional imaging with CT and MRI make them ideally suited for the task. Cardiologists counter that their knowledge about cardiac anatomy and understanding of the clinical issues provide a better set of skills for performing and interpreting these imaging studies.
While there are examples of cardiovascular imaging programs operated by radiology alone and cardiology alone, those with shared, mul-tidisciplinary input will be poised for long-term success and growth, and most importantly, improved patient care. The noninvasive program at our institution benefits from shared input from both cardiologists and radiologists at all levels, including co-directorship between a cardiologist and a radiologist. Our multidisciplinary sharing of ideas and workload extends to our trainees who come from both radiology and cardiology backgrounds.
The cardiologist who works without radiology may be inexperienced using the technology, and errors in technique can lead to errors in interpretation. The radiologist who works alone may render an interpretation of coronary artery disease without putting the results of the study in the context of other cardiac examinations that have been performed and interpreted by cardiologists. If both
groups develop a shared and well-balanced program, these pitfalls can be avoided.
Having radiologists and cardiologists working side-by-side has several advantages, beginning with choosing the best test for an individual patient. If a radiology practice manages one technique (e.g., CT) and a cardiology practice manages another (e.g., nuclear cardiology), a competing "technique-centric" program could develop. A program in which equipment and services are shared equally among specialists will minimize unhealthy bias. Dialogue focused on image acquisition and interpretation may be spearheaded by a radiologist, but in the very same conversation, placing those imaging findings in the context of a treatment plan may be led by the cardiologist. Radiologists interested in cardiovascular imaging may not understand that care for coronary artery disease differs from other disease processes. In a patient with a cough and a fever, the radiologist reports a pulmonary consolidation and the referring clinician chooses an antibiotic. Using cardiac MRI as an example, even the choice of pulse sequences depends on detailed understanding of the patient's problems and available treatment options, and those options that would be best suited for the individual patient.
There are other lost opportunities from thinking alone. In our experience, the majority of clinical cardiologists strive to surround their patients with the best imaging available. In discussing and negotiating witii interventional cardiologists (after a sincere dialogue is established), both parties can entertain the concept that the negative predictive value of cardiac CTA can benefit each. Radiologists can enjoy the productivity of noninvasive imaging, and interventional cardiologists can focus on the practice that many thrive on, namely interventions.
Cooperation rather than competition also provides for the best training.