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Centennial Sounding Board |
1 Department of Radiology, Columbia University, Milstein Hospital 2-131, 622 W. 168th St., New York, NY 10032.
Received January 26, 2000;
accepted after revision February 15, 2000.
Introduction
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Subspecialization in radiology began to appear in major academic centers in the late 1920s [2, 3] as the scope of the new discipline broadened. Subspecialization provided the expertise needed to support the development of radiology. In fact, subspecialization became so popular that many organ-based and technique-based subdivisions in the field became distinct subspecialties over succeeding decades. As we move into the 21st century, however, the degree of subspecialization is such that fragmentation of the field is a growing threat. As the technologic and medical horizons of the discipline expand in the years ahead, how can radiologists possibly stay current? Physicians other than radiologists are involved with imaging in growing numbers and will suggest that they can provide an important part of the answer by relating their particular clinical areas of expertise to radiology. Alternatively, such physicians might attempt to hire subspecialty radiologists away from radiology groups into a subspecialty medical or surgical environment. A more balanced approach to radiologic subspecialization with increased communication between dis-similar practice environments may forestall such developments.
In the future, neither subspecialty-focused (organ-based or technique-based) practice nor immersion in general radiology will guarantee success in a practice environment that has evolved beyond these orientations. A strategy of balanced expertise will be more successful. To a certain degree such approaches are pursued currently by many large private radiology practices. Fellowship-trained radiologists practice focused areas of expertise part of the time, while at other times they cross-cover one another's subspecialty focus and general radiology. On the other hand, many academic diagnostic radiologists become virtually isolated in a particular area of expertise. This focus often is necessary for them to stay at the leading edge of research in their area [4] and may be needed to serve the demands of subspecialized referring physicians, but does not strengthen the overall balance of radiology. If subspecialty radiologists are unable to address the broad integrative challenges facing the discipline, then the threat of administrative and clinical fragmentation will increase. A proposed alternative is a flexible interdisciplinary approach that incorporates the perspectives of both the general radiologist and the subspecialized academic radiologist and fuses them with newer managerial and scientific orientations [5].
What influences exist that are likely to support a broader, more integrative view of radiology in the future? Educational strategies ranging from revised resident curricula to continuing medical education (CME) for the practicing radiologist [6] will play an important role. Today's model of periodic regional CME symposia will be buttressed by much more frequent use of focused interactive CME sessions [7]. Such symposia will be particularly valuable for the private practice radiologist who wishes to enhance skills in one or two specific areas of practice. Such symposia will be increasingly supplemented by readily accessible electronic educational media. It is not as clear what new approaches will stimulate academicians to broaden their educational experience and practice base. Perhaps some of the impetus will come from the recertification and continuing competence programs that are now being developed for physicians (which will be discussed later in this article). Organizations such as the American Roentgen Ray Society will play an important role in developing improved educational approaches that foster these new directions.
It is likely that more effective use of technology will facilitate better integration of newer practice models in diagnostic radiology. Electronic connection of radiologists at various sites by teleradiology or linked picture archiving communication systems would provide the opportunity for on-line access to expertise of the highest level. Such consultative services have not developed as rapidly as predicted; they have been impeded by various technologic, psychologic, and financial factors. If the academic and private practice radiology environments remain functionally remote from one another, the current disparate models of subspecialty expertise and practice organization are likely to continue. Therefore, the challenge and opportunity may lie in the development of technologically facilitated productive relationships or alliances among previously isolated private practice and academic radiology groups.
Periodic recertification may promote a more balanced approach to radiology in the future. Time-limited certificates are already being issued in some subspecialties by the American Board of Radiology and will be issued soon in general diagnostic radiology. Voluntary recertification of radiologists probably also will occur to some degree in the years ahead. Accordingly, educational organizations and people who develop recertification programs will be in position to influence the CME and practice patterns of radiologists. For example, a recertification examination might be quite broad in scope. Alternatively, the applicant might be allowed to select recertification in one or more focus areas along with general radiologic knowledge. Examinations in general radiology could be tailored to test image knowledge, knowledge of appropriateness criteria in consultative settings, or other aspects. Without such profiling, it may be extremely difficult to develop ways to fairly assess the ongoing expertise of practitioners in different working environments.
Balanced approaches to subspecialization will preserve expertise while also providing a degree of versatility. In large academic groups, radiologist staffing would be more cost-effective. Radiologists would be able to meet the challenges of special-interest referring physicians without over-fragmenting the specialty. Such a model of balanced subspecialization assumes that the primary mode of interaction in the next century will continue to be person to person and doctor to patient. If technology triumphs too greatly and radiologic diagnostics begin to be performed by remote teleradiologists who do not have personal contact with the patients and physicians they serve, the field will change even more dramatically. If there were to be many remote teleradiologists, then issues of specialization might be moot. Under such circumstances, theoretically a radiologist would be available at the other end of the computer connection with the expertise needed for any referring physician or patient issue. This would eliminate many aspects of the local physician-to-physician consultative role for radiologists, however, and is an unhappy prospect at best. A more positive prospect is technologically enabled availability of special radiologic expertise to be called on as needed in both the academic and private practice communities.
Balanced subspecialization tailored to specific practice environments and potentially enhanced by electronic communications between community-based and academic environments will help radiologists adjust to the challenges of the expanding scope of radiology and the technologic progress expected in the years ahead. Parallel efforts to profile continuing education for practicing radiologists in dissimilar practice environments and to develop similarly profiled recertification programs will be needed to help radiology minimize fragmentation of the discipline in the increasingly complex medical environment of the 21st century.
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