Welcome to patients at risk a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book patients at risk the rise of the nurse practitioner and physician assistant in healthcare, and today I'm being joined by two special guests. Dr. Phil Shaffer is a retired radiologist. He is a frequent guest of our podcast and he is a board member with physicians for patient
protection. And I also am joined today by Dr. Sharon D'Souza, who is a practicing radiologist. Thank you both for joining us.
Thanks for having us.
Eveyr field of medicine today involves some type of non physician practitioner whose role was originally created to help physicians see patients more efficiently. And the specialty of radiology is no exception with radiologists working with nurse practitioners, physician assistants, and also a special kind of extender called a radiology assistant. So recently, there's been a increased push to use more of these extenders in radiology. And there's some concern that this may have a negative impact
on patient care. So I want to start out Sharon, why don't you start us out by just explaining to our audience for those who are not radiologist? What is the training of a radiologist? What did you go through? And why is it important that you went through all that training?
So I, I completed my medical school in 2004. Then all radiologists need to undergo a year of something general. I chose general surgery intern year. And after that I did four years of diagnostic and radiology residency. And after that I obtained two additional fellowships in breast imaging and in MRI. And since then, I've been in practice over over 10 years. So
Let me just stop you there. What I heard was, let's say four years of college and what did you do your undergrad?
I did microbiology and chemistry.
Okay, so hardcore undergrad degree, four years of that four years of medical school, one year surgery internship which must have been brutal. I don't know what is asked you to choose that. God bless you. And then four years of Radiology. That's right after the one year of internship for years of Radiology and then another couple of years of extra fellowship. That's right. Holy moly. Yeah. Tell us about. Phil, tell us about your radiology. What was your your background like?
it was undergrad in chemistry. And then medical school at the time of my medical school was three years but through the whole year, so essentially, we got the whole whole four years and then three, and then internship which is rotating internship, but primarily internal medicine. And then at the time, it was three years of radiology residency, and then a year of fellowship.
So radiology is sounds like it's one of the longer and more strenuous residency programs as far as length and then these extra years that you guys do to get your sub specialization to be able to do specific types of Radiology. That's really amazing. So Phil, tell us, why is it so important to have such a long residency? What are the nuances of the field of Radiology?
Well, fun fact about radiology is is kind of a covers the entire expanse of medicine, we go into it, not as some areas not as much depth as, say, a cardiologist would in heart, but we're across the entire spectrum of medicine. And it's kind of fun, because you get to see all of the ways that different disease processes work through all the all the systems.
So, you have to for example, you have to know how particular diseases look on X rays, on ultrasound, then nuclear medicine studies, then CT exams and MRI exams and you have to also know which exam is better for particular aspects of a certain disease, certain diseases. Metastases don't show up very well, a cancer with a CT scan that may be very obvious with a nuclear medicine scan or
an MRI scan. And beyond that, MRI is very interesting because if you tune the machine slightly wrong, you can erase lesions and make them not visible at all.
Wow. So and what you're doing is really a matter of life and death often or at least making the correct diagnosis to figure out what's wrong with patients. So what you're doing is so critically important in the care of patients, you know, almost every disease process nowadays there are some type of radiologic evaluation, right.
And one of my referring physicians told me once when we also do PET imaging, which is positron emission tomography, used primarily look for cancers, as he said, he said, you know, my entire plan is based on the result of the PET scan, that has to be right. And they can be very difficult to read, because one of the things you learn in radiology residency is, how many things can fool you, how many things look like disease that
are not really diseased. And if you're not aware of these false positives, you can send someone off to a surgery that they don't need.
You know, I as a family doctor, I appreciate what radiologists do so very much. And of course, like every physician in training, we spend some time learning some basics of Radiology and some practicing physicians even will do their own little evaluation of basic X rays, and then, of course, usually have a radiologist over read it. And I always found even just chest X ray reads to be really challenging. And that, often, I would look at the x ray, and I would think I would
see something. And I remember in the middle of the night as being on call, especially the pediatric chest X rays, I would go oh, I think there might be a pneumonia. And so I'd go and find the radiologist in his little dark corner. And I would say, Could you take a look, and he'll just look at it for two seconds ago. It's normal. And, you know, it seemed like I would always get it wrong, especially
with pediatrics. And I just think there's a lot of hubris with someone just assuming that with minimal training, even something like what we would consider basic a chest X ray, that you could learn how to read that and just such a small amount of time and I raw,
you're absolutely right. It's it's this huge misconception that that a chest X ray is so easy, and it's I think it's because after this decade of training, and after seeing 1000s and 1000s of chest X rays and seeing them when you're on call and in the hot seat and covering the ER and trauma and all of that, we tend to make it look easy because we have this vast experience this depth of knowledge to fall back on.
So now we have these radiology assistants and as I understand it, this is sort of like an nurse practitioner or a physician assistant. This is a person that is meant to help because in radiology, you're using NPs and PAs but this is a person that specifically trained to just do radiology. Can you tell us your in a little bit more about radiology assistants? How long have they been around and how are they trained?
Sure, sure. So the concept of the radiology assistant was originally born through the threat of collaboration with Weber State University and the US Department of Defense in the early 90s - 1990s. And then it was really put forth as a way to address a shortage of radiologists in the military.
Then about 10 years later in 2003, 2004, the American College of Radiology, the council and the ASRT, the American Society of Radiologic Technologists, they got together had several conversations and meetings about this and recognize the RA under certain stipulations, that there was an absolute ban on image interpretation. No prelim, final reads - that the terminology was specifically chosen assistant that they only work with or for radiologists, and no independent
practice. So back in 2003, the list stuff, what a radiology assistant would cover was maybe a page or so long. In subsequent years that has been gradually expanded. It's a multi page document. In 2019, prior to COVID, their scope of practice was expanded to do some procedures under direct supervision rather than personal supervision. They then I believe they are expanding their education to include a master's degree.
Let me just take you back for just one second. So I'm definitely hearing the slippery slope, which we're gonna definitely get into but first of all, when the radiology assistant first came about, and I believe they had to have a bachelor's degree, and then they did some kind of a preceptorship and got certified through their organization. When they first came out, what were they doing to help radiologists like in the very beginning,
I think they depending on the practice, they were they were a true assistant helping radiologists wherever needed, you know, gathering data, helping assimilate that kind of information and helping with fluoroscopic studies. In, in my personal experience, when I was in training, we had a radiology assistant who was in training herself. So she would shadow us really, she would come and hang out for a couple hours, when we were on the call and watch the readout. She would assist with
Floro. In my current practice, we have two RAs, and they've they've been with our practice for gosh, maybe a decade or more, they're very, they're very well respected. They're, they're highly valued, they do their job very well. And from what I understand, I haven't had just because of the nature of what I do in my areas of specialty, I haven't had a lot of direct personal contact with them from but from what I understand they do a decent amount of flouro studies for us
I mean, what it sounds like, to me is like an extra pair of hands to do these studies, maybe somebody that can help you track down, maybe you need old films from some other place, maybe you need someone to get in touch with a surgeon to get them on the phone for you, you know, that kind of thing. Whereas what it's leaning towards now is actually having them sort of become radiologist light, where supposedly they're
going to be reading films. Now, Phil, have you ever worked with a radiology assistant in your practice?
Actually, no, I never did. And I was rather uncomfortable. When we just described when it was suggested we might because I for for us studies. When you're in there watching the barium move or something like that, it can be gone in a flash and you didn't see it. And having someone describe that to you, you're always going well, did he see it? So we I was always opposed to us having those and so we did not really use those.
Yeah, it's it's so interesting, because you know, the all these parallels, you think about how originally the idea of having physician extenders was sort of like this just to help make it easier for a physician to practice medicine. But now, and the argument is always well, medicine has gotten more
complicated. So we need the physician to do the more complicated and let the assistants do the less complicated, but even the least complicated thing in radiology, which to me, I'm guessing is a chest X ray is not uncomplicated. It's very complicated. It takes a long time to learn how to do that correctly, I would imagine. And so now the idea is to take these radiology assistants and get them to read those types of films with theoretically the radiologist is going to override
them. But then I asked myself, How is that actually saving any time? If you guys still have to overread the film, does that actually help anybody?
I don't think it does. And I need to point out something. When the RA was conceived of as a profession, there was an agreement between the ACR and the ASRT, the American Society of radiology technologists, that that radiology technician, technologists would never, or the RAs would never actually interpret films. And that is being breached now. And that is a serious issue. We've got examples. And I will say this to MPs and PDAs have started going
into interpretation. It's an entirely inappropriate thing. They don't know what they're doing. But they do it anyway. Some of these are in in practices that are not run by radiologists, such as one that I heard of is physical medicine. And the woman who work there said that she had been told she had to read the MRI scans. And she said she learned it in a week or two.
There's so much hubris I mean, you guys had to do four years of residency on top of everything plus fellowship training. That's crazy. So let's talk about how radiology extenders are being used. And it's so interesting, because you mentioned like a
private practice setting. But where we're really seeing a lot of this is in academia, and in fact, I recently listened to the audio of a presentation that was a pro con, the use of radiology extenders and the physician who was advocating for pro or more use was Dr. Jha and he is, I guess, a faculty member at University of Pennsylvania? I believe yes. And he was strongly advocating for the use of these
radiology assistants. Phil, can you talk a little bit about some of his points of why he thought radiology assistance should be used more?
Well, he spoke for half an hour, I'm certainly not going to go through all of it. A lot of his points, I thought were off topic. But it kind of boiled down to, wow, we have so much volume, and we can't keep up. And we really need help. And I don't have a whole lot of sympathy with that. I think that what's happening here is that they get busy. So they try to farm out some of it to a relatively unqualified people to to manage the volume.
But the patients are charged the same as if they had had an expert physician actually reading the study. So my feeling is the ethical way to do this is if you don't want to read the studies, if you're too busy, then don't do it. And don't charge people for it. There was one interesting thing in the paper they wrote that spoke to this, they talked about how they had become overwhelmed because they taken over some practices outside of, of Philadelphia, and because of that , their volume
had gone up. And, you know, the obvious point is, there were radiologists reading those studies before, who were in those hospitals, and they got fired. And what happened was the hospital, University of Pennsylvania Hospital took over these practices, but did not increase the number of people reading them and actually decreased. So you've, you've got a money machine going on here, where you just keep adding on studies and telling the radiologists who are there, you
got to read more now. And yeah, you get burned out. But it's, it's the fault of the institution. And it needs to be pointed out that his tuition has a strong financial interest in this, because especially academics, the main campus has a budget and the clinical faculties are supposed to produce a certain amount of profit for the central campus. And if they don't, there's a problem. So the it is truly
money driven situation. And the more they can do with the fewer faculty, the more profit goes back to the main campus.
It's so interesting, because when I listened to his argument, he almost made it sound like it's people other than radiologists that are driving all of this volume saying, Well, you know, everybody gets imaged for every single thing. And a lot of what we're doing is just saying, 'the endotracheal tube is two centimeters above the carina. The NG tube is in proper place.' And you know, he's acting like that is why they're so busy because everybody's like, kind
of over ordering x rays. And then he also says that, you know, doing a chest X ray really doesn't even make any sense, which because most of what you need to read, looking at lungs is on a chest CT scan. So let's have these radiology assistants read the chest X rays while the the radiologist read the CAT scans. Sharon, I mean, what do you think about those points?
I don't think a chest X ray is easy. I don't think anything that that we do is easy. There are - it's a minefield, there's always something that you have to keep your eye out for. There's always something incidental that you
pick up. We're not just we're not just looking for an ET tube, we're looking for the the myriad of other things that are just in the back of your mind that you've seen throughout our years of training that you can't you can't teach in a in a short course in a truncated education. And I do agree, I feel I think all of us radiologists have have our feeling that volumes have
increased. If you truly look at utilization and numbers of studies ordered, they have increased and actually the number of images that we're looking at have increased, like lower extremity runoff is like 5000 images. It's a lot of information that we are interpreting. And we're we're very cognizant of the fact that we're responsible for everything on that image. We look pretty darn closely. And I you know, when we look at this overutilization, partly it is incorrect ordering of studies by
by non physicians. We're seeing that, you know, just a few weeks ago I had to Make a call and say, 'Why'd you order this study this person had a had a CT just last week?' Oh for it was for an ASIC, anomalous venous, something or other. And it was basically a normal finding that a radiologist put in the report. And I had to call in, it took more time out of my day to deal with that.
But, you know, if you had just read the report or done it, you could have gotten paid
and I would have irradiated the patient and got another it was just completely unnecessary. But his solution to having too many studies ordered by people who are not qualified to order them is not to hire more people who weren't qualified to read them. It just it's that's not the it's the opposite of high value care. It just makes no real sense.
Yeah, I mean, as he was talking, I was thinking to myself, Well, one option would be to create a policy, you know, he said, you know, people will order x rays just to see if the NG Tube - nasogastric tube - is in the right position. And you know, we never had to do that before you can tell if it's in the right position, generally, clinically.
So I was thinking, Well, why not create a policy where you say, these are the circumstances in which we will do it or, or if you think that if a doctor orders a chest X ray, and you think a CAT scan is going to be better than create a policy so that that information is shared with me, he's in an academic center. So I think he's talking a lot about hospitalized
patients. But it seems like it might be more efficient to actually just create work with your teams in the hospital and create a policy so that the radiologists mean you guys aren't there just to do our bidding as a non radiologists like do this test, do that test. We're supposed to be working together to do the right thing for the patient. So it seems like that would be the right answer.
Yes, it would seem that way. But I need to point one thing out, the institutions have no incentive to decrease imaging, none. Every study that's done is a profit. With a few exceptions. There are a few facilities like Kaiser where, you know, patients pay up front in almost taken out, but in the fee for service realm, which is almost all of medicine right now. If there's more studies done, that makes more profit.
Absolutely. The The other thing that struck me when I was listening to Dr. Jha talk is sort of this cognitive dissonance because he talked about the simplicity of some of the things that he that his, his team is doing. And he said, he kept saying this mantra, 'blood pus, water, better, worse, 80 to two centimeters above the carina.' You know, he's kind of like rattling it off. Like, that's all they have to do. I mean, number one as Sharon pointed
out, that ain't easy. But then after he says, blah, blah, blah, and rattles is off. Then someone asked, Well, what about radiology, radiology assistants, then wanting to read more advanced films? And he said, Oh, that's not possible because radiology is extremely complex, and that it is not scalable. And of course, I thought, wow, what, what an interesting contrast and saying, Oh, it's so simple, but it's way too hard. I mean, talk about your thoughts on that,
well, he's wrong. How's that? I mean, experience with anesthesia. And ER, tells you that that's not true. I mean, CRNAs started out. And the idea was that they would be helpers to anesthesiologists, they're taking over the field, I have to add one more thing he's going on about how simple the portal chests are. And he put pneumothorax in there. And for lay people in the in the audience, pneumothorax is air between the lung and the chest
wall. And I gotta tell you, that is not easy to see, in a lot of cases. And the findings can be very subtle, particularly when the people are lying flat on their back as they are in the ICU, and all the air goes to the front of the chest. So all you may see is finding that that's very subtle, such as the heart border is a little too sharp. And, you know, Whoa, that's a little weird. And that can that can hide a very significant pneumothorax. So he was being very cavalier about something is
not easy. And one of the someone who was in that facility, I had a discussion with they pointed out they were appalled because the they said, these are our sickest patients, including heart transplants and lung transplants, and they don't have physicians, looking primarily at their chest films.
Yeah, one of the things that doctor Jha said he kind of used this what I thought was a bit of a straw man arguments where he said, Well, how would you Do you feel if your mother was in the hospital? And there were not enough radiologists to read their film her films? Because all the radiologists are overworked and burned out? And of course, the argument is, well, how would you feel if your mom's X rays are being read by someone with minimal training and skill and
something gets missed? Sure. And what are your thoughts on that?
Yeah, I wouldn't want that either. You will always want that that gold standard. You want the imaging expert, to be to be at that at that workstation and reading those films.
And then there's also the transparency issue. What about that? How are patients going to know who's reading their X rays?
They don't and they have no choice. It's imposed upon them.
So one or the other. So it was kind of interesting doctor, I don't want to make this all about Doctor Jha. But he since he was the pro voice, he talked about the myths of radiology extenders. And he said lots and lots of things.
But one of the things that he said is that it's a myth that having these radiology assistants will have a negative impact on radiologists in training residents and sharing Have you heard about any residents or anyone in training, having concerns about their education being diluted by these assistants?
I have I have heard from several residents in training. Basically, every procedure, every imaging study taken by radiology assistant or NP or PA, that's basically a lost opportunity for our residents and training. And, you know, I in throughout my career, I've basically been, though I am specialized, I have these fellowships, I have functioned as a general radiologist, I'm a radiologist that I can be put in a hospital and solo and cover
everything that they have. And I think we're what I'm hearing from residents and training is when they are getting towards the end of their their training, they're not feeling comfortable enough to do that. They don't have the numbers that I had. They just don't have that experience. And that's that's, that's tragic. That's that's not going to serve them well, in the remainder of their career.
The other myths that Dr. Jha said was that somehow that radiologists have a fear of said it something like existential fear of being replaced, and then it's an ego issue, and that there's nothing to fear and that you shouldn't, why are you so worried and radiologists were worried about teleradiology? And look how that turned out? Fine. So what do you think about that attitude that he has of that it's really an ego issue on the on the end of radiologists?
I don't I don't think it's a fear issue. And I don't think it's an ego issue. I think it's looking around at the state of medicine at an at our colleagues in other specialties. What they have gone through every mid level provider that's ever been created, has eventually wanted to expand their scope of practice, to the point of competing with the very entities that created them in the first place. That's happened in every specialty that we've
we've seen them. And I think it's almost more of an ego to assume that it will not happen in radiology. What makes us think that we're different. It's it's the very definition of insanity of repeating the doing the same thing and expecting a different result. We're seeing some pretty alarming similarities with what's going on with radiology assistants versus NPs and PAs. And again, I truly value our radiology assistants. I think they do great work, and I love having
them. But we can't allow it. We can't predict what's going to happen in 10 years. We, though individual RAs, I believe that when they said when they speak on our engage forums, and they say that they they value the radiologist, they don't want to be independent. I believe that that that's truly what they want. But we cannot speak to the RA for 10 in 10 years, or what their societies will push or in 10 years when there's a leadership turnover in their
societies. But we have seen what's happened with NPs, NPs, and just going by history alone. I don't know why people think radiology would be any different.
Yeah, I mean, I think about the interview, which we did with Dr. Robert McNamara - back in 1994 he was calling out academia saying you know, you guys need to do something about these issues that are happening and it was the same exact response that we're hearing from radio geology leaders now, which is, oh, this is just a myth, this will never happen. So I think if you do look at other specialties, you're right, I don't see how the same thing wouldn't just
happen again. And if you look at the history, for example, nurse practitioner profession was established in 1965. And they were supposed to just work and extend. And then in 24 years, they became eligible for direct reimbursement. Physician Assistants were established in 1965. Same thing we're supposed to not going to build, they were part of the team. And then in 21 years, they became eligible for direct payment. And so now, the radiology assistant profession
was started in 1994. They are not currently reimbursed through the Medicare system. But beginning this year, there, there were organizations lobbying for radiology assistance to be paid directly. So just like NPs just like PAs, and then of course, we know after the direct payment comes, we now would like to do this. Now we would like to be independent. So it's hard not to see that slippery slope coming for radiology because it's following the exact same path.
What happens there is if the radiology assistants are paid directly, that means that the administration can hire them and replace radiologists because they're no longer responsible to the radiologist. And what we have observed with nurse practitioners and PAs is that there is there is an enthusiasm in administrator circles for hiring these people. But there is they don't understand or they don't care perhaps about the loss of quality and they don't
look at that closely. One of the real differences in radiology is we have the on the horizon is artificial intelligence as an interpreter of X ray films. And I've been watching this fairly closely for the last 10 years. And there are some systems that have been touted as being as good as radiologists. You read the papers closely, and they're horrible. They they're they're awful. But still the media picks it up. And they promoted as as good as radiologists, they are not at all
It sounds very familiar. And we are going to get into that in part two because we have a few more things that we need to unpack when it comes to studies and when it comes to radiology assistance. So I hope you'll join us for part two. And of course, if you would like to learn more about this topic, I encourage you to get the book patients at risk. It's available at Amazon and at Barnes and Noble. And if you're a physician, please join our organization physicians for
patient protection. You can find us at our website, physicians for patient protection.org Thanks so much and we'll see you on part two.