AJA:159,

November

payment

CAPITAL

1992

of Medicare

the difficulty.

inpatient

However,

never been adequately Invariably,

costs will only add to

needs

met through

of hospitals

depreciation

offset by the amount

schedules.

determined

on depreciation

schedules.

Moreover, the Medicare capital pass-through has been discounted. Hospitals must increasingly look beyond the funds

cally generated to generate will

have

replacement of buildings or equipment is far more than the original acquisition cost and therefore not

expensive

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capital

the capital

PLANNING

through

capital become

simply

had a separate

depreciation

always

graphic

systems

will also become

natural

candidates

to be interfaced

Institutions

can evaluate

of plant and equipment

for their capital expenditures.

more common with

their needs for PACS by assessing

for PACS.

Computer-based equipment provides an opportunity to perform dynamic imaging and to extract quantitative physiologic and biochemical information, in addition to anatomic and pathologic information, from images. The increasing computerization of radiology will have a capital implication in the

In manufacturing and other industries, the capital expenditure is simply part of the overall business plan. It is driven by programmatic or product line and business development needs. The key to success will be better management of capital assets and more efficient use of capital equipment.

purchase of either the imaging equipment tions for processing the data. However,

With

to pay-

entist.

The traditional

institu-

become

a computer

the

ments tions

stronger

linkage

for capital

will be penalized

ductive

of patient

equipment

care

productivity

vs cost reimbursement,

for acquiring

unnecessary

continued

capital costs, new computer personnel will be necessary to run the equipment and perform the analyses. The traditional radiologic physicist will increasingly become a computer sci-

radiology

film librarian

will increasingly

operator.

or unpro-

practice

in health care of isolating

the capital proc-

ess from the overall reimbursement and business process. In some sense, this should unshackle the hospital planning process and may be more realistic from a business practice perspective than the old system.

New Capital

Needs

The major have notfaced

capital expenditure in the 1990s that in the past is the acquisition of picture

and communication referred

for the

1990s

systems

to as image

(PACS).

management

hospitals archiving

The systems

are also

and communications

sys-

tems. The success of radiology has overburdened the historical manual-based methods for handling images. The pace of modern

hospitals

and efficiently

and the need to take care of patients

has put departments

of radiology

quickly

in a defensive

posture. The expense for acquiring PACS for large institutions will be in the multimillions of dollars, more expensive than any

single imaging institutions,

device currently the

proportionately

expense

in clinical operation.

will

still

less. A reasonable

be

specific needs or transmission

although

to the acquisition

through

the modular

of partial PACS or “mini PACS’ that address such as multimodality viewing of digital images of images

department,

to the

or operating

intensive

rooms.

care

Conclusions

Radiology

is one of the most capital-intensive

specialties

in

medicine. Hospitals have been pressed to maintain an appropriate capital replacement program for conventional radiographic equipment at the same time they have had to spend unprecedented capital dollars to acquire equipment for new digital cross-sectional modalities. The aging base of

conventional

radiographic

equipment

is a financial

time bomb

ticking away in the hospital industry. Historical depreciation schedules grossly underestimate capital requirements for replacement of equipment and do not take into account new technology or increases in the number of studies performed. Therefore, a comprehensive capital plan must include a re-

placement program based on today’s dollars, must take into account the hurdle of deferred purchases, and should address both increases in the number of procedures and changes in practice patterns. Hospital administrators will suffer sticker shock as they see their radiology capital expenditure needs for the 1990s. They must overcome this shock because imaging is increasingly central to patients’ treatment. Exploratory surgery is far less desirable than “nondestructive testing” through

medical

imaging.

In smaller

substantial

approach

is to build out to a full system

implementation

gency

itself or workstain addition to the

equipment.

In the long run, it is quite possible that the capital DRGs and the DRGs for inpatient care will be merged. This should not be looked on with alarm or negatively in and of itself. The overall level of reimbursement is far more important than the

of PACS

and are

PACS.

how well their current film handling and reporting systems are working. For example, if loss or nonavailability of studies is considered a problem, PACS can provide a solution. Radiology departments with several geographically separate loca-

tions are also prime candidates specifi-

funding. When this view is taken, hospitals more like other businesses that have not

reimbursement

1111

IN RADIOLOGY

units,

Computed

emer-

radio-

REFERENCES 1 . Kay T. Volume

and intensity of Medicare physician Health Care Financing Rev 1990:2:1 33-1 46 2. Berenson A, Holahan J. Sources of the growth

services:

an overview.

in Medicare physician expenditures. JAMA 1992:267:687-691 3. American Hospital Association. Estimated useful lines of depreciable haspital assets. Chicago: American Hospital Association, 1988

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1112

American Roentgen Ray Society: Committees, and Membership Information

Officers,

Officers

National

President:

A. Everette

President-elect: 1st Vice-president: 2nd

James,

Andrew

R. Leopold

Ralph

Joseph

1. Ferrucci,

Treasurer:

Beverly

P. Wood

Jr.

R. J. Alfidi, Davis, N. R. A. E. James, Jr., J. A. Kirkpatrick, Leopold, J. E. Madewell, T. C. Poznanski, R. J. Stanley, J. H Executive

Council:

D. 0.

J. Casarella,

Wood,

K. H. Vydareny,

R. N. Berk, M. P. Capp, W. Dunnick, J. T. Ferrucci, Jr., Jr., A. M. Landry, Jr., G. R. McLoud, A. A. Moss, A. K. Thrall, N. 0. Whitley, B. P.

chair

Policy:

P. C. Freeny,

R. N.

Berk,

A. G. Levitt,

E. Buonocore,

M.

C. R. B. Merritt,

M.

Figley,

W. J. Casarella,

and

Research:

B. Higgins,

R. J. Stanley,

G. M.

R. R. Hattery,

Glazer,

W. M. Thompson,

N. 0.

C.

McClees,

D. J. Anderson,

R.

J. E. Madewell,

A. A. Moss,

J. H. Thrall,

chair

M.

C.

Rohrmann,

Jr.,

Nominating:

Budget:

P. Capp,

Madewell,

chair

Publication:

E. Buonocore, W. J. Casarella,

B. Merritt, Membership:

A. Moss,

D. 0.

Davis,

American patrick, American

R. G. Levitt,

Board

E.

C. R.

T. C. McLoud,

J. E. Madewell,

A.

Organizations

W. J. Casarella,

of Radiology:

College

of

B. L. McClennan, Medical

J. A. Kirk-

Evens,

Radiology:

R.

N. H. Messinger,

Association:

alternate;

A.

T.

Gagliardi,

National

Standards

Measure-

Meetings: San Francisco, New Orleans,

Annual

Goergen,

Institute:

of Pathology:

J. E. Madewell

Meeting

R. R. Lukin,

A. M. Landry, Instructional

April

25-30,

CA; LA

April

Committee:

1993,

Marriott

24-29,

1 994,

J. K. Crowe,

N. H. Messinger,

San New

FranOrleans

N. R. Dunnick,

R. J. Stanley,

R. D. Steele,

Jr.,

Jr., chair Courses:

B. L. McClennan,

associate

chair,

chair

Scientific Program: P. H. Arger, W. R. Brody, G. D. Fullerton, R. M. Gore, D. C. Kushner, D. L. Resnick, W. M. Thompson, J. H. Thrall, C. J. Zylak, A. K. Poznanski, chair D.

Schlesinger,

Exhibits: F. S. Chew, J. M. Destouet, S. Hartman, L. A. Mack, R. G. Ramsey, T. J. Welch,

N. R. Dunnick,

J.

R.

A.

E.

chair

E.

Membership

Application forms may be obtained from the ARRS offices in Reston, VA. Qualified applicants will be admitted quarterly. Send completed forms to American Roentgen Ray Society, 1891 Preston White Dr., Reston, VA 22091 . Active members

are graduates

of an approved

medical

or osteopathic

school

or hold an advanced degree in an allied science. They must practice radiology or work in an associated science in the United States or Canada and be certified by the American Board of Radiology, American Osteopathic Board of Radiology, or Royal College of Physicians of Canada or otherwise adequately document training and credentials. International members are foreign radiologists or scientists who are

active

in radiology

or an allied

are residents or fellows dents in an allied science.

science.

in radiology

Members-in-training or

postgraduate

stu-

R. J. Stanley

R. A. Gagliardi,

G.

J.

CPT

delegate;

Advisory

Committee American

J.

Jr., L. F. Rogers

Madewell,

G.

P. C Freeny, chair

to Other

American

R.

A.

K. Gedgaudas-

chair

Representatives

and

Arrangements

cisco, Hilton,

ARRS and

Protection

Whitley,

chair Finance

Radiation E. L. Saenger

Institute

Annual

Scientific Haaga,

chair Education

Forces

R. J. Stanley,

Committees Editoral

Armed

Meeting

J. Alfidi

Secretary:

on

F. D. Miraldi,

Jr.

K. Poznanski

George

Vice-president:

Council

ments:

M. E. Haskin

Business

Office

Paul R. Fullagar, Executive Director, American Ray Society, 1891 Preston White Dr., Reston, (703) 648-8992; 1 -800-438-2777.

Roentgen VA 22091;

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1113

Perspective

Subspecialization Alexander

and Certification

R. Margulis1

The trustees of the American Board of Radiology agreed at their January 1992 meeting to seek approval from the American Board of Medical Specialties to issue added certificates of qualification in neuroradiology, pediatric radiology,

and vascular and interventional radiology coming almost 6 years after the American ogy Council adopted in 1 986 further subspecialty certification, policy. The change recognizes

slowly

and inexorably

subspecialties

that

a policy reflects the fact

transformed exist

[1]. This decision, College of Radiolstatement against a dramatic shift in that radiology has

itself into a multitude

alongside

the

general

practice

of of

radiology [2-5]. This transformation was caused by the veritable explosion of new techniques in medicine, which greatly increased the value of radiologic diagnostic contributions to the clinical management of patients [6]. The fact that turf battles have started in almost every radiologic subspecialty also has emphasized the need for certification. Radiologists,

like all physicians,

to their patients’ welfare. whether subspecialization

owe their primary

allegiance

It is important, therefore, to consider in radiology is needed, whether

subspecialties of qualification

other than the three designated for certification will be needed, and whether subspecialization along lines of technology also is needed. Finally, one must ask whether subspecialization, prevalent in academic centers,

can be applied to community hospitals and outpatient private practice. Is radiologic subspecialization needed? The knowledge data base in medicine has expanded so rapidly and massively in the last 20 years

that it is virtually

impossible

for a radiolo-

gist or any other physician to keep up with the advances in the whole field and also keep up with the galloping technologic progress. Today, this knowledge gap is even more critical as 1

Magnetic

in Radiology

Resonance

Science

Center,

University

of Califomia,

San Francisco,

radiologists

are increasingly

November

1992 0361 -803X/92/1

595-1

1 13 © American

not only

to contribute

therapy. These added responsibilities, along with new opportunities, are forcing the advent of the subspecialists, of those who know the intricacies of and modern developments in

medicine

in the given field and can use this expertise

the appropriate

imaging

study

and interpret

sectional anatomic

techniques, relationships

become and

radiologic

in performing images

radiologic in their

fields.

in a

the patient. the cross-

generally depict lesions and more clearly, clinician specialists

very interested

interpreting

to select

the images

meaningful way to help the clinician in managing As the new approaches to imaging, particularly

their have

procedures Their

pro-

fessed reason for doing this is that they can perform these functions better than the general radiologist can. Another argument is that imaging techniques can be learned in a relatively medicine

cialists,

short time, whereas it takes years to learn clinical and much effort to stay current in it. Imaging subspe-

however,

can enhance

their superior

technical

exper-

tise fairly easily by acquiring the clinical qualifications of their specialty through additional training and practice. Will further radiologic subspecialties be needed? The three subspecialties designated by the American Board of Radiology for approval are obviously only the beginning of recognizing the legitimacy of other subspecialties, such as cardiac, chest, genitourinary, gastrointestinal, and musculoskeletal radiology, and, finally, mammography. To propose all of them for approval initially would probably be unwise, as the medical

bureaucracy,

as with all bureaucracies,

needs time to digest

and be comfortable with any changes, no matter how logical and even how de facto established they are. The question of 500 Pamassus

Ave. (MU 322w), San Francisco, CA 941 43-0292. Address reprint

requests to A. A. Margulis. AJR 159:1113-1114,

expected

significantly to making diagnoses but also to help stage diseases, guide biopsies, and even participate in or administer

Roentgen Ray Society

MARGULIS

1114

November

1992

for totally technology-oriented subspecialties also will undoubtedly arise. Subspecialists in sonography will probably question organ subspecialization first. However, unless

offices, it would in larger groups

organ-oriented

subspecialty. The chest radiologist and the cardiac radiologist could form a team that also incorporates the interventional radiologist. The neuroradiologist and the musculoskeletal radiologist could join forces and the gastrointestinal and gen-

the need

subspecialists

in radiology

adopt

sonography,

will be taken over by other clinicians, as has already occurred with echocardiography, endorectal sonography for examination of the prostate, and even obstetric sonography. Where radiologists subspecialize in these areas of sonography, they have generally had the advantage in keeping them the field

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AJA:159,

in radiology,

and

their

clinical

specialty

colleagues

happily

depend on the subspecialized, highly skilled radiologist. In the long run, CT and MR imaging subspecialists are probably not needed. As the imaging method matures and techniques develop, organ-oriented subspecialists routinely take over the examinations in these cross-sectional techniques. Radiologic

subspecialties

are

already

a

reality

in

large

teaching centers. In many of them, radiologic subspecialists have formed teams with their clinical specialty colleagues, which has resulted in joint teaching and research programs. The question economically

patient

arises, however, whether subspecialties can be feasible in community hospitals and in the out-

private

practice

As diagnostic

reflect

radiology

the outside

world is highly radiology must

radiology

of radiology. is a consultative

worid

of the practice

specialty,

to medicine

and to the patients

That

because

it must and can ensure continued efforts in advancing the field of imaging. In the private practice of radiology and in

academic

centers,

all radiologists

must also be general

radi-

ologists, as that keeps the field together and is the foundation on which the subspecialties are built. In private practice,

whether

in community

hospitals

or in outpatient

itourinary

of the group

radiologists

could

can have a major and a minor

work

together,

help

out the chest

radiologist, and also do mammography. These are just some of the possibilities, and undoubtedly others will emerge.

Will subspecialty certification eventually lead radiology to a tower of Babel, where no one understands anyone else? The danger is obvious, and that is where knowledge become

and some

practice

of general

radiology

for every

subspecialist

can serve as the binding collagenous substance. Subspecialization in radiology must overcome all obstacles if radiology is to survive.

Let us not forget

that in this world

litigation, ever stricter committees, and state

of seemingly

licensing boards, hospital and federal bureaucracies,

eventually be classified and restricted to a type that is determined by the certificate on the wall.

endless

credential one may of practice

it must

of medicine.

specialized and even subspecialized, and adapt in order to survive. The existence of

is important

ogy, members

be advantageous for radiologists to practice to ensure that besides doing general radiol-

centers

and

REFERENCES 1 . ACR Bull. 1992:48(3): 1 , 4. 2. Margulis AR. Subspecialities in diagnostic radiology: the road to glory or disaster. Radiology 1981:140:837-838 3. Hampton AO. Subspecialization in radiology: response to a need. AJR 1987:148:465-469 4. Redman HC. The route to subspecialty accreditation. Radiology

1989;172:893-894 5. Capp MP. Subspecialization 6. Miller JD, Starr 1989;39:33-36

L. Information

in radiology. AJR 1990:155:451-454 explosion in radiology. Can Assoc

Radiol

J

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1115

Memo

Impediments

to Clarity:

Rhetorical Robert

N. Berk1

Pratfalls and Elizabeth

An Annotated

complex, expertise

with

these

linguistic

is extremely limited, and expensive journal pages,

with these writing problems will begin to write better as they eliminate them from their writing. Third, when authors receive their edited manuscripts back from the publisher, they may be more likely to understand the reasons behind many of the

kling

clean-not

Stille

expression

to be well focused clear,

opaque

and concise.

their efforts

with

had a similar that renders

verbal

fog

idea [3]:

the ideas

the best. The style should

If authors

are wasted

fail

because

most

Nearly

1 50 years

simplest

form

[2].

“The

visible

have transparent

of

is undoubtedly

simplicity,

that the reader scarcely feels a barrier between the author’s.’ Medical writing is replete with opportunities

such

or has studied

linguistic

Grammarians

any type

pratfalls

of writing

and pitfalls

and language

experts

knows

seems

changes

that

Acronyms,

Overuse

Adverbs,

Meaningless

to be endless.

have devised

a whole

lexicon of seemingly mysterious terms to describe rhetorical transgressions and faux pas. A glossary of some of these terms is presented here. We do not mean to indicate that knowing the definitions has importance in itself; rather, we

indicated,

of (see

but

add

nothing

to the

Notes-Conciseness project,

so the

November

1992 0361-803X/92/1595-1

1 15 C American

given

serves

no useful

often

deleted

are

Collegiate are culled

adjectives,

sense

of the

verbs,

or other

sentence.

is a major goal of any medical writing

writer

must

function.

by medical

strive

Writers editors

to delete

any word

that

may note that “very’ because

the

is

adjective

it

describes carries the connotation of “very’ (e.g., “very many’ does not say much more than “many’). Williams [5] gives a helpful

list of other

add nothing to the meaning kind of, really, basically, definitely, practically, actually, virtually, generally. Also, the good writer will avoid using adverbs to modify

the author

adverbs

is trying

that

to convey:

words that, in view of their meanings,

Editor-in-Chief, American Journal of Roentgenology, 2223 Avenida de Ia Playa, Ste. 103. La Jolla, CA 92037. Address Contributing editor, American Journal of Roentgenology, 2223 Avenida de Ia Playa, Ste. 103, La Jolla, CA 92037. 159:1115-1119,

the definitions

“Jargon’)

that modify

Definition-Words

pitfalls

the number

by the editor.

as otherwise

derived from definitions in Webster’s Ninth New Dictionary [4], and some of the examples cited from manuscripts submitted to the AJR. Abbreviations, Overuse of (see “Jargon”)

adverbs

for

made

Except

his mind and

(mistakes that may lead to misunderstandings) and pratfalls (language errors that may cause the reader to chuckle in the middle of a serious article). Anyone who has ever tried to

AJR

acquaintance

time for reading journals who must be frugal with

ago,

1

an

examples, authors may begin to notice these or similar problems in their own work. Second, authors who become familiar

the importance of their work will be lost somewhere in the huge, ever-rising pile of unread or misunderstood research. Stanley Siegelman, editor of Radiology, aptly compares manuscripts to window panes; the manuscript must be spar-

2

having

with various degrees of and easily. Radiologists,

to make their message

of such

that

pratfalls and pitfalls of medical writing can help the author in several ways. First, after reading the following definitions and

readers quickly

require articles

write

of

Whalen2

believe

whose editors,

Glossary

and Pitfalls

Authors of manuscripts written for publication in radiology journals are faced with a daunting challenge [1 ]. They must present a large amount of information, much of which is

in a way that will understand

to Authors

Roentgen

Ray Society

cannot be qualified;

reprint requests to R. N. Berk.

the

Capital planning in radiology.

AJA:159, November payment CAPITAL 1992 of Medicare the difficulty. inpatient However, never been adequately Invariably, costs will only add...
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