Data That Support Removing the Mysticism for Radiologist’s Performance of Cardiac CT and MRI

See also the article by Goldfarb and Weber in this issue.

Andrew J. Bierhals, MD, MPH, is vice chair of quality and safety and associate professor of radiology and pediatrics at Mallinckrodt Institute of Radiology, Washington University School of Medicine. His interests include improving medical communication and optimization of imaging workflows to improve and standardize patient care. He is PI on two foundation grants focusing on improving communication. Last, he is co-PI on multiple grants dedicated to cardiac and transplant imaging.

Goldfarb and Weber’s analysis on physician provider and payment data from Medicare Part B services to examine the utilization of cardiovascular CT and MRI gives insight into predicating the needs for both academic and/or multisubspeciality radiology and private practice groups (1). Investigating the utilization trends as newer modalities become established is necessary to plan for future training and staffing to address the needs of patients and referring providers. This understanding has implications beyond subspecialty radiologists to general radiologists who will be tasked to provide this care, unlike in European countries where such imaging is only available at academic institutions. Performance of cardiac CT and/or MRI by private practice general radiology is essential to ensure access.

Clearly, use of cardiac CT and MRI increased from 2012 to 2017, by 97% and 75%, respectively (1). Not only is there increasing utilization, but there is clearly an increase in the number of radiologists performing these types of examinations to a greater degree than cardiologists. Such an increase shows the need for radiologists to be prepared, regardless of subspecialty training, to perform and interpret these studies in academic centers and in community practices.

Let’s step back for a second. We as radiologists need to understand what these data are telling us about the future of cardiac CT and MRI—there will be continued growth, and radiologists will be expected to provide these services. How does this impact the radiology profession? First and foremost, there will need to be enough radiologists to ensure timely care as these services are increasingly being demanded from referring physicians. Second, radiologists, including those in a general practice, will need understanding and training in cardiac CT and MRI. This is not to say training at the level of a fellowship-trained individual, but enough training to effectively interpret the common studies seen in the community setting or emergency department.

Radiologists must be trained in cardiac imaging to address this growth. For radiology as a profession, this is going to require dedicated time in training programs for all residents as part of the general education in cardiovascular CT and MRI. I would encourage all training programs to ensure residents have the opportunity to achieve “level 1” training (2), akin to the mammography requirements mandated for residency programs. Aside from this basic rotation, additional educational opportunities and continuing education practice need to be available to general diagnostic radiologists. We are accomplishing this through the Radiological Society of North America, American College of Radiology, Society of Thoracic Radiology, and North American Society for Cardiovascular Imaging; however, I would challenge those societies to offer level I certificates and have a process for those in low-volume areas to maintain their proficiency.

Seeing this growth of utilization of cardiac CT and MRI with a concomitant greater percentage of radiologists providing interpretations shows us insight as to where we are going. Looking back, this trend is reminiscent of the evolution of pulmonary embolism CT. From the early 1990s up through the landmark article of PIOPED II (Prospective Investigation of Pulmonary Embolism Diagnosis II) (3), CT was not considered the reference standard for the evaluation of pulmonary embolism nor were general radiologists initially interpreting this examination (4). However, as this protocol became accepted and more pervasive, the expectation of training programs evolved in that residents were required to learn and interpret these studies. Concomitantly, radiologists out of training (regardless of fellowship) were expected to provide interpretations to ensure patients received the most up-to-date care regardless of being seen at an academic or community hospital. The same should be said as we move forward with cardiac CT and MRI. It is necessary for general radiologists to interpret these studies because patients do not just have heart disease at academic centers—the majority of the care in the United States is provided in the community. The heart is not a magical organ despite what some in radiology seem to imply. As technology evolves, I envision a similar evolution as we saw with pulmonary embolism CT—cardiac imaging for radiologists to become commonplace in the general radiology world. As cardiac CT has been shown to be a triage tool in the emergency department (5), cardiac MRI will become more commonplace in the community as it is being utilized for functional monitoring as the field of cardio-oncology begins to evolve. The community will need to be able to provide imaging care for the onslaught of oncology patients who will need to be monitored. Even on noncardiac studies, with advancements in technology, coronary and cardiac anatomy is routinely visible. The same can be said for general thoracic MRI, that the heart is in the center and must be addressed.

These data provided by Goldfarb and Weber reinforce this position that the imaging studies are increasing and are being performed at all levels of care, community and academic. Radiologists need to be familiar with basic cardiac concepts. In addition, it is inherent upon training programs to integrate basic cardiac anatomy both from a CT, as well as MRI perspective and make it seem less magical. The data show with increasing utilization of cardiac CT and MRI, there is going to be an increasing need for radiologists to interpret them. That having been said, all radiologists need to be familiar with basic cardiac CT and MRI. Not only will this help the general radiology groups but will improve patient care and accessibility at all locations not just limited to academic centers. Radiologists have been expected to and do an excellent job interpreting other vascular studies, whether pulmonary embolism CT or peripheral vascular imaging; there is no difference with cardiac imaging. Understanding basic concepts of cardiac MRI and CT as well as cardiac physiology is not mystical. We were able to slay the dragon of the pulmonary embolism CT, this will be no different.

As a profession, radiology needs to look forward at these types of studies that evaluate utilization as well as performing physicians. This will better help us direct our educational needs in the future, as well as assist groups in determining practice needs as time evolves.