Radiology scans are often critical to treatment and diagnosis, yet patients who receive many scans over their lifetime may face health risks from the cumulative dose of radiation. As the use of CT scans has increased, government agencies have recognized that guidelines are needed to balance radiology’s benefits with its risks. But because so few radiologists are trained in public health research, they are generally unprepared to participate in this important health policy debate, advises Christoph Lee, M.D., a radiologist and 2010-2012 Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of California at Los Angeles.
Lee and his co-author Howard Forman, M.D., highlight the need for health services research training among radiologists and call for more collaboration between radiologists and clinicians on the front lines of patient care in their article, “Radiology Health Services Research: From Imperative to Legislative Mandate,” published in the May 2011 issue of the American Journal of Roentgenology. Health services research examines how social issues, personality, financial issues, organizational policies and technologies affect the quality and cost of health care.
“We need to create more opportunities for training, provide resources and incentives for the brightest candidates to enter this field and cultivate enriching environments for health services research in all academic radiology departments,” Lee and Forman concluded. They pointed out that other medical specialties, such as emergency medicine, surgery and obstetrics/gynecology have placed a greater emphasis on health services research training. Forman, who was also an RWJF Clinical Scholar in 1994-1996 and an RWJF Health Policy Fellow in 2001-2002 and Lee, noted that even among the 1,100 alums of the RWJF Clinical Scholars program, which specializes in health services research training, only one percent of the participants were radiologists.
A Tradition in Need of Change
Often tucked away in their departments, radiologists have limited involvement in the patient care decisions that arise from imaging tests. “One of my biggest motivations for writing this piece is that the time for radiologists to serve as consultants and only report imaging findings is over,” Lee says. “This is a new era where radiologists have to be able to provide recommendations on imaging findings and be critical players in patient diagnosis and management.”
Lee cites a recent story told in the New York Times as an example of the need for radiologists to have a greater voice. The article was about stroke patients who were overexposed to radiation from CT scans. Part of the reason for problems like this, Lee explains, is that radiologists are not in a position to influence the Food and Drug Administration and other monitoring agencies that can prevent situations where patients are unnecessarily radiated.
Another recent issue was the United States Preventive Services Taskforce formulating new recommendations for mammography without input from radiologists. “Experts in breast imagery were not involved in these discussions and recommendations and I think that is largely because there are no radiologists with the expertise in health services research methodology that is required to be appointed to these panels,” Lee adds. “Radiologists have a certain insight into how medical imaging affects populations that physicians who order the studies do not.”
Even before attending Yale Medical School, Lee was interested in policy and worked at the health policy research firm, the Lewin Group. Once at Yale, he began working with Forman to study awareness of radiation dosages from CT scans among patients, emergency medicine physicians and radiologists. Surprisingly, Lee and Forman found that none of these groups were aware of many of the potential risks of the procedures.
During his clinical rotations, Lee was drawn to radiology as a specialty. “My generation of physicians was trained to order imaging studies for better or worse, but radiology is at the crux of health care today,” he says. Lee continued to study the clinical impact of radiology and medical imaging with Alan Garber, M.D., Ph.D., director for the Center of Health Policy at Stanford and Geoffrey Rubin, M. D., now the chair of Radiology at Duke University. In their work, they examined the cost and clinical impact of incidental findings on CT scans.
In his ongoing work, Lee has found that as physicians increasingly rely on detailed imaging technology, the technology can outpace physicians’ understanding of what they see. “You find these ‘incidentalomas,’” Lee says, blips on imaging films that might represent a health problem. “The clinicians and radiologists don’t know what to do with it—they don’t know if it’s clinically significant. So what happens is that an ‘incidentaloma’ continues to be followed by through more imaging or possibly by an invasive procedure such as a biopsy,” he says. “Sometimes, we do see things that are clinically significant. But what we’ve found in our research is that the majority of findings end up being completely benign and [these tests] just cause more patient anxiety and more utilization of precious medical resources.”
As an RWJF Clinical Scholar, Lee is also working with Joann Elmore, M. D., M.P.H., at the University of Washington, to develop an online primer for physicians on radiation risks from medical imaging. Because emergency physicians order a large proportion of CT scans,
Lee and colleagues are developing guidelines about radiation dose specifically for that part of the medical community. The medical imaging community is also increasingly concerned about the number of biopsies done on breast lesions that are likely benign, so Lee is doing a cost minimization analysis of these procedures as well.
Recently, Lee was awarded a 2011 fellowship from the American College of Radiology, a program that will allow him to spend time looking at issues such as the criteria physicians should use to order imaging studies and the development of a national radiation dose registry. “I hope my new methodological skills will translate into innovative research that will allow radiologists to improve patient care,” he says.
The Robert Wood Johnson Foundation Clinical Scholars program advances the development of physicians who are leaders in transforming health care through positions in academic medicine, public health and other roles. The program trains clinicians in the program development and research methods that will enable them to find solutions to the many challenges posed by the health care system, community health and health services research.