Subspecialty radiology and surgery

Baltimore, USA

Subspecialty radiology and surgery

Steven C Cunningham and Saleem Farooqui

Baltimore, USA

The Master said: "Yu! Shall I teach you the meaning of knowledge? When you know a thing to recognize that you know it; and when you do not, to know that you do not know, -- that is knowledge."—— Confucius (The Analects, Vol I, Book II, Chapter XVII)[1]

Do subspecialist surgeons need subspecialist radiologists?

Although surgeons in general often pride themselves on being their own radiologists, in subspecialist surgeons this pride may run deeper. Yet ironically it may well be the subspecialist surgeons who rely most on subspecialist radiologists, and for good reason: one need not practice subspecialty surgery long to begin to see a disturbing pattern repeat. It goes like this: a patient is referred with a surgical subspecialty problem; outside general radiologist reads the CT or MRI as consistent with differential diagnosis X, Y, or Z, with X being most likely; the case is reviewed in a multidisciplinary conference with subspecialty radiologist; the most likely diagnosis goes from X to Z, and management recommendations change from those that would have been made based on diagnosis X. Case in point: a young, healthy female on oral contraceptive pills was recently referred with a liver mass centrally in segment IV. An MRI was performed and an appropriate differential diagnosis was provided by the outside general radiologist, including hepatocellular adenoma (HCA), focal nodular hyperplasia (FNH), and fi brolammelar hepatocelluar carcinoma (HCC), with HCA being the most likely radiographically (not to mention quite likelyclinically), and core biopsy was discussed. After review by a subspeciality radiologist, however, FNH became the most likely diagnosis, and a potentially risky biopsy was averted. Although FNH was later conf i rmed by liverprotocol MRI using the hepatically excreted contrast agent gadoxetic acid (Eovist®), the diagnosis was already fairly clearly FNH on the original outside MRI, but only after review by a subspecialty radiologist.

Why did the interpretation change? The differential diagnosis given by the general radiologist was appropriate in content, but not only was it so broad as to provide little guidance, but the "most likely" diagnosis was different from the "most likely" diagnosis of the subspecialist radiologist. The reason that the interpretation changed, in our opinion, is what may be characterized as an appropriate (or at least acceptable) lack of knowledge. In this particular case, it may have been that the subtle but reliable diagnostic features identifying FNH as opposed to HCA were overlooked by the general radiologist, who was content with giving a broad differential diagnosis despite the potential risks of percutaneous biopsy. Perhaps the radiologist was not equipped (or specif i cally trained) to describe, for example, the uniform arterial-phase enhancement with portal-phase return to isointensity, not to "washout", relative to surrounding liver, a difference that until recently was not reliably captured by earlier-generation MRI protocols. This, in combination with the typical "cloud-like" peripheral contour of the lesion, lack of intracellular lipid or hemorrhage on dual-echo T1 images, and uniform T2 isointensity, were features noted on the second review, all highly typical descriptors of FNH. Clearly here the subspecialist surgeon (and the patient) needed a subspecialty radiologist.

General radiologists (and general surgeons, for that matter) cannot know everything about a subspecialty — not even a subspecialist can. What is inappropriate in such cases, is not any lack of specif i c knowledge, but a lack of referral to — or consultation with — a subspecialist, recognizing that recent advances in liver imaging (in particular MRI) have introduced subtleties unbeknownst to many well trained generalradiologists. Like the Confucius epigraph reminds us, one need not know everything; rather, one should recognize the limits of his or her knowledge and refer appropriately, lest, in such cases, a general practitioner recommends the wrong plan based on the generalist interpretation, thereby exposing the patient to unnecessary and potentially signif i cant risk. Whether it's mistaking an FNH for an HCA, thereby leading to an unnecessary biopsy, or mistaking an adrenal myelolioma for an adrenal adenoma, thereby leading to an unnecessary operation by failing to perform or correctly interpret the fat-saturation sequences of the MRI, the resultant potential consequences (viz., an unnecessary liver biopsy and adrenalectomy, respectively) are similarly grave and preventable.

Anecdote or broader phenomenon?

But before suggesting that general radiologists should not interpret subspecialty studies,[2-4]and before dealing with all of the diff i cult questions — not the least of which are the actual def i nitions of "subspecialized" and "general" radiologist[3]— that such a policy would require, let's fi rst look at data to see if the above cases are simply anecdotal or whether there are any data suggesting a broader phenomenon.

One of the commonest places for consultation with a subspecialty radiologist to occur, as in the above livermass example, is the multidisciplinary case conference. In 2011, Brook et al[5]studied this forum, and found that of 383 patients, signif i cant new information was added for nearly half of cases and major changes in management occurred in 37% of patients (and minor changes in 15%). When other groups compared generalradiologist with subspecialist-radiologist interpretations of images in subspecialty areas, signif i cant discrepancy rates were found in areas such as neuroradiology (8%-33%),[6,7]and pancreatic carcinoma (32%).[8]In a study of the preoperative staging of gastric cancer, the sensitivity of T, N, and M stage was 64%, 65%, and 25% respectively when CT images were interpreted by a subspecialty radiologist in a multidisciplinary setting versus a paltry 34%, 24%, and 5% when images were interpreted by a general radiologist.[9]In a study of endorectal MRI in the detection of extracapsular extension of prostate cancer from Memorial Sloan Kettering, MRI interpretation was a signif i cant predictor for detection of extracapsular spread of disease only when images were interpreted by genitourinary subspecialist radiologists experienced with MRI of the prostate.[10]Similarly, a study of 250 patients who underwent direct MRI arthrography interpreted by either community-based general radiologists or hospital-based musculoskeletal radiologists, the latter were signif i cantly more likely to correctly identify and characterize labral, rotator cuff, and biceps pathology, as conf i rmed by operative arthroscopy.[11]As subspecialized imaging technology is increasingly available in community hospitals and imaging centers, subspecialty radiologists should be increasingly called upon to realize the benef i ts of this technology.

Which radiologists, for which studies, for which surgeons?

Should policy dictate that only fellowship-trained subspecialist radiologists interpret subspecialty which studies? Clearly not, since many general radiologists may have developed an adequate skill set to do so. However, a gradual shift in a culture of isolationism may well be appropriate: viz, a change towards a lower threshold for requesting consultation from radiologists with subspecialized expertise for second opinions. Just as some radiologists have called for caution in overspecializing radiology into isolated silos of "superspecialized knowledge",[12]so too should general radiologists be wary of interpreting studies in dangerous isolation from subtle or specif i c knowledge outside their area of expertise that may heavily impact patient care.

Do subspecialist surgeons need general radiologists?

Although subspecialist radiologists have a key role in the practice of the subspecialist surgeon, such surgeons share with general surgeons the need for accurate and timely general diagnostic radiology in the pre- and postoperative setting. Furthermore, subspecialist surgeons depend on general radiologists to recognize situations that warrant referral to a subspecialist radiologist, either locally or via teleradiology, as Dr. Borgstede[13]and others[12,14-16]have called for. Indeed, the general radiologist is strategically positioned and well equipped to identify fi ndings outside the area of expertise of the subspecialist surgeon, and could help direct patient care towards the most appropriate clinical service. Due to the inherent fl exibility in their scope of practice, general radiologists are ideally positioned to serve the large number of smaller American communities. It is within this scenario where the generalist will truly succeed or fail at "knowing what they do not know", reading the right studies right but also referring the right studies to subspecialists.

Do general surgeons need subspecialist radiologists?

The need of a general surgeon for a subspecialized interpretation and consultation may be even greater than the need of a subspecialist surgeon for the subspecialist radiologist; conceivably, the general surgeon has less potential to recognize and question an inappropriate or inaccurate interpretation, such as mistaking an FNH for an HCA, than a liver surgeon experienced at dealing with such lesions. Therefore, the general surgeon, once equipped with a high level of diagnostic conf i dence instilled by the subspecialty radiologist, is less likely to put a patient through additional testing or unnecessary risk such as a liver biopsy.

Current and future trends

Clearly, collaborative partnership between specialists and generalists is increasingly necessesary, and indeed is happening, especially in the setting of multidisciplinary conferences. However, whatever the opinion of current surgeons and radiologists of both ilks, radiologists-intraining have decided that subspecialization is the way to go, as evidenced by the increase in those pursuing fellowships from 37% in 1990 to 50% in 1995 to 87% in 2005 to 92% in 2009.[17,18]Sensing the winds of change, the American Board of Radiology has changed the format of the certifying examination, which will take place 15 months after completion of residency training beginning in 2014, and limited to four selected disciplines within Radiology, further emphasizing the subspecialist pathway.[19]

It is becoming clear in this era of personalized (i.e., subspecialized) medicine that subspecialty imaging has an increasing role. The subspecialist has an appreciation of the subtle nuances associated with radiologic manifestations of diseases. A failure to subspecialize, or to recognize when to call upon such a subspecialist, will constitute a general failure to provide personalized care.

Given the increasingly important shift in the healthcare landscape from focus on volume to clinical outcomes as the determinants of compensation by payers, perhaps in addition to outcomes such as rates of infection and rates of readmission, another outcome measure could be rates of correct referral to subspecialty radiologists.

Acknowledgement:We thank Dr. Jesus Esquivel for critical reading of the manuscript.

Contributors:CSC proposed the study. CSC and FS performed work and wrote the fi rst draft. CSC is the guarantor.

Funding:None.

Ethical approval:Not needed.

Competing interest:No benef i ts in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Received November 17, 2012

Accepted after revision December 21, 2012

AuthorAff i liations:Departments of Surgery and Radiology, Saint Agnes Hospital MB 207, Baltimore, MD, 21229, USA (Cunningham SC and Farooqui S)

Steven C Cunningham, MD, FACS, Co-Director of Pancreatic and Hepatobiliary Surgery, Saint Agnes Hospital, 900 Caton Avenue, MB 207, Baltimore, MD, 21229, USA (Tel: 410-368-8815; Fax: 410-719-0094; Email: Steven.Cunningham@stagnes.org)

© 2013, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(13)60020-X