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675
Meeting ,H,
#{149}
Radiology Synectics Bruce
.
.;
Summit
-
.:.
H..
Solutions
Through
L. McClennan1
Synectics-A theory or system of problemstating and problem-solution based on creative thinking that involves free use of metaphor and analogy in informalinterchange within a carefully selected small group of individuals of diverse personality and areas of specialization. Webster’s
Unabridged
evolution
of radiologists as researchers in academic departments. and opinions of representatives from all sectors within our specialty were well represented in vigorous debate and thoughtful, articulate interchange as the issues of practice assessment, credentialing, recertification, radiology research, scarce resources, and more were explored. Academic radiologists and those in private The interests
Dictionary
community
cepts
The Radiology Summit Meeting was held in August 199i , at the Park Inn again, in Asheville, NC. The summit meeting is held annually under the auspices of the Intersociety Commission of the American College of Radiology (ACR) chaired by Dr. Bruce L. McClennan. Seventy-eight leaders from 40 member societies and 14 staff members from these organizations (see Table 1) gathered for 3
Grove
days to discuss important
issues confronting
theme for this year was “Solutions two
#{149}:.H
.
Meeting--1991:
News
round-table
work
groups
Through
developed
our discipline. The
Synectics,” a white
and each of
paper
that
was
to the Board of Chancellors and the Council of the ACR in September 1991 in Minneapolis, MN. Resource speakers set the stage for the discussion groups with stimulating reviews of material presented
practice
expressed
opinions
voiced
in the white
ACR Leadership
and helped
to shape
Report
Dr. James B. Moorefield, Jr., from Sacramento, CA, chairman of the Board of Chancellors of the ACR, addressed the summit
during
the weekend,
first thanking
the federal
govern-
ment for providing him such good “material” for his speech. He then reviewed how the rules of the reimbursement game had suddenly changed again on June 5, 1991 With the notice in the Federal Register of the proposal by the Health Care .
Financing
Administration
(HCFA)
for further
cuts
in the fee
Dr. Gerald Dodd of the M.D. Anderson Cancer Center, Houston, TX, and Dr. Lawrence Coia from Fox-Chase Cancer Center in Philadelphia, PA, laid the groundwork for the SBSSIOfl on practe assessment and credentialing. Dr. Cole, along with Dr. Tearle Meyer, vice president of the ACR and head of
schedule to radiology came two new terms-behavioral and transitional offset-that would become anathema
the Committee on Practice Assessment and the Mammography Accreditation Program, assisted Dr. Hywel Madoc-Jones from Tufts University Medical Center in moderating the deliberations on this topic. Dr. Bruce J. Hillman from the University of Virginia was ably assisted by Dr. Charles J. Putman, Duke University, with his discussion session on fostering research by radiologists [1 ]. Dr. Putman presented background material describing the traditional role and
reimbursement
pertinent
I
to the topics
Chairman, Intersociety
for discussion.
Commission
S. Kingshighway Blvd., St. Louis, MO AJR
of the American College of Radiology,
diologists.
C American
Proposed
was
payments
on top ofthe
endured,
portending
Moorefield
an additional
campaigns,
key contacts
Institute of Aadiology,
Roentgen Ray Society
to ra-
cut in radiology
had already in Medicare As was the case in 1988, Dr.
cut overall
out (tongue
state chapter president before key congressional Mallinckrodt
offset
1 8% cut that our specialty a 50%
to radiologists.
pointed
32%
in cheek)
by 1996
that HCFA
our help yet again.” An action plan consisting
63110.
158:675-678, March 1992 0361-803X/92/i583-0675
the con-
papers.
with legislators,
“needed
of letter writing
town
meetings,
and
briefings culminated with testimony committees by ACR officers in the Washington
University School
of Medicine, 510
MEETING
676
Downloaded from www.ajronline.org by 117.255.239.95 on 11/09/15 from IP address 117.255.239.95. Copyright ARRS. For personal use only; all rights reserved
TABLE
1: Radiology
American American American American American American American American
Summit
1991: Organizations
Association Assodaon
of Academic of Physicists
Association
of Women
Residents in Medkne
Chief
in Radiology
Radiologists
Board of Nuclear Mediane Board of Radiology College of MediCal Physics College of Nuclear Physicians College of Radiology
Institute of litrasound
American
Medical
American
Osteopathic College of Radiology Radium Society Roentgen Society Society
Association,
in
actually
AJA:158,
prosecute
violators
under
the antikickback
March 1992
provisions
of Medicare law. Dr. Moorefield reminded summit attendees that ourjob is far from over, and pressure must be maintained on HCFA and Congress to carry out the letter and intent of the law regarding physician payment reform. He further emphasized that these critical issues affect subspecialty societies as well as individual
American
American American American American
in Attendance
NEWS
radiologists
in private
practice.
Medicine
Section
Council
on Radiology
Inc., Report
(RCI),
and Oncology
Society of Head and Neck Radiology Society of Neuroradiology Association of Residents in Radiation Oncology Association of University Radiologists Canadian Association of Radiologists Council on Cardiovascular Radiology of the American
Centennial,
Dr. John Tarnpas, president of Radiology Centennial, Inc. convened the annual meeting of RCI during the 1991 summit meeting. Because RCI grew out of the Intersociety Commission, all member societies are part of the Board of Directors of RCI. Dr. Tampas reported to the directors and others present on the progress made by the organization,
Ray Society for Therapeutic Radiology of Clinic Radiologists
Radiology
American American
particularly Heart Associ-
ation College of Radiology International Skeletal Society National Medical Association, Section on Radiology North American Society for Cardiac Imaging Radiological Society of North America Interamerican
the outstanding
proposed
Residency Review Committee Society for Magnetic Resonance Imaging Society for Pediatric Radiology Society of Breast Imaging Society of Cardiovascular and Interventional
Radiology Society of Chairmen of Academic Radiation Oncology Departments Society of Chairmen of Academic Radiology Departments Society of Body Computed Tomography Society of Gastrointestinal Radiologists Society of Magnetic Resonance in Medicine, Inc. Society of Nuclear Medicine Society of Radiologists in (Jtrasound Society of Thoracic Radiology Society of Uroradiology Veterans Administration Chiefs of Radiology
success
in fundraising
to date.
With unrestricted pledges of $250,000 each from the four major radiological societies-American Roentgen Ray Society, American Society for Therapeutic Radiology and Oncology, ACR, and Radiological Society of North America-RCI has already raised or received pledges for over half of its $3 million
budget
for our 1 995 centennial
celebra-
tion. Additional donations or pledges have been received from the American Association of Physicists in Medicine, American College of Medical Physics, American Society of Neuroradiology, Society of Radiologists in Ultrasound, Society of Chairmen of Academic Radiology Departments, and California Radiological Society. ongoing projects, were all presented.
The committee structure (1 1 committees), and budget projections for each committee Over 200 people are currently participating
in RCI committee functions, and others were invited by Dr. Tampas to participate. Societies that were new to the Intersociety become
Commission
summit
meeting
were
also
invited
to
members of the Board of Directors of RCI. One hundred years of achievement in radiology (1 895-1 995) is a story worthy of great celebration, and RCI is off to a grand start.
summer of 1991 In all, 44,000 pieces of mail from radiologists and supporters were sent to Congress, the President, and key governmental officials. To date, HCFA has backed down
Practice
somewhat but not completely from a transition/behavior offset, but predictions for retention of a 3-6% reduction by early I 992 persistently come from HCFA officials. There was some good news, however, in that global billing with CPT-4 codes
ing, moderated by Dr. Hywel have two excellent speakers
has given
for interventional procedures. Expectations are for more uniform payments across Medicare carriers in the future. Also, Congress appears to actually be on our side in regard to physician payment reform. Representative Pete Stark has held hearings on selfreferral and joint ventures based in part on data collected by the Florida Health Care Commission showing an extremely high percentage (>90%) of physician ownership of imaging centers in the state of Florida. Furthermore, the safe harbor
assessment
regulations were finally released by the inspector general, Mr. Kusserow, and they placed radiologists in a rather favorable light. Recent rulings (e.g., the Hanlester case) have encour-
and no direct linkage to reimbursement. Recent ACR efforts to develop standards for practice assessment and credentialing have rekindled interest in the process. Dr. Dodd acknowledged that the American Board of Radiology is contin-
.
way to split billing,
particularly
aged the inspector general to pursue questionable
cases and
Assessment
and Credentialing
The Work Group on Practice
sions. Dr. Gerald the efforts
Assessment
Madoc-Jones,
and Credentialwas fortunate
to
pave the way for their discusDodd gave a historical perspective on the
of continuing
of the American
clinical
competence,
Board of Medical
beginning
with
Specialties
to
institute voluntary recertification in the early 1970s. ACR Council Resolution No. 27 in 1975 set up guidelines for recertification promulgated by the American Board of Radiology and outlined various pathways to achieve recertification
should it prove necessary. However, active recertification initiatives have not been initiated owing to lack of grassroots support,
no true consensus
on the best
(preferred)
methods,
AJA:158, Marth
MEETING
1992
uing to consider
alternatives,
including
personal
and videodisk programs. Any realistic recertification must be practical, nonpunitive, and allow for remedial
actions,
Dr. Dodd explained.
Joint
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recertification
computer program
Commission
He further
for Accreditation
cautioned
that the
of Healthcare
Organiza-
tions is pushing
its own form of standards
focusing
in the care of patients while actually the need for board certification. Dr. Dodd success of the ACR mammography accredi-
on outcomes
deemphasizing noted tation
and credentialing,
the great program and the important
role of the American Cancer Society in this effort, a role that he personally supported in his position as president of the American Cancer Society. He found the results of, and response to, the mammography accreditation program very encouraging. Dr.
Larry
Coia,
a radiation
oncologist
from
Philadelphia,
in their deliberations on practice assessment and competence. This program within radiation oncol-
ogy was designed
to correlate
and combine
structure
and
process with outcome. Further goals were to assess compliance and bring about improvement in patients’ care. Dr. Coia outlined five steps within the PCS: (1) document facilities, patient demographics, and current practice patterns; (2) de-
velop a consensus cancer
site (e.g.,
expert
panels
gists,
of best current breast,
testis,
comprising
and surgeons;
management
bladder,
academicians,
(3) conduct
for a specific
and larynx)
by using
physicists,
process
surveys
oncolo-
that include
large numbers of patients so as to determine national averages and trends in patient evaluation and management; (4) develop
outcome
surveys
to assess
results
of treatment;
and
(5) develop accreditation programs based on the above. Evaluation and management decision trees are developed and facilities are stratified and statistics compiled, then compliance is assessed on site reviews. If a variance is identified, remedial action is suggested. The PCS is developing national benchmarks
and
stressed
correlating
processes
that the success
stimulus
to diagnostic
with
outcomes.
of this program
radiologists
Dr. Coia
could serve as a
to perform
analogous
stud-
ies, although it was noted that outcome measurement in oncology is easier than in diagnostic processes. Dr. Hywel Madoc-Jones was assisted by Drs. Coia and Meyer in moderating his session and in developing the white paper
that
was
submitted
to the ACR 1 991 Their
Board report
and Council in September a time when momentum for health care reform States was rising. Senator John 0. Rockefeller .
ginia, upon
of Chancellors was written at
in the United of West Vir-
head of the Pepper Commission, had recently called physicians to get involved in the process of improving
health care and access to care with a specific
agreed that it was not necessary to obtain certification via an actual examination. There was serious concern about many
disenfranchising general radiologists with such an examination. Radiation oncologists felt no specific urge for subspecialty certification at this time. Other discussion centered on
self-referral, physician ownership, and the necessity of a 4year training program for radiation oncology similar to what currently exists for diagnostic radiology. There was general agreement that over time, the ACR should urge no physician ownership
of imaging
focus on cost-
centers
or radiation
Research
Dr. Charles
Putman
gave a stimulating
paid only to think.
displayed
This eccentric
initial
own
group
recertification
participants
program
endorsed
in 1 992.
A majority
subspecialty
of the work-
certification,
but
be
himself
by
and universities were slow slower to develop strong
the realities of the budget deficit took hold, but the National Science Foundation budget still increased 13%, and the National Institutes of Health (NIH) budget increased 1 8%. How-
ever, 25 major medical centers get 60% or more of all the research funds budgeted by these two organizations. “It is time to join the party,” Dr. Putman exclaimed. We [radiologists] need to define ourselves, use our collective wisdom,
cultivate interdisciplinary ness. Indeed, we need
avenues, and improve public awareto take the tarnish off the image of
our eccentric uncles. We bring our best and brightest Credible, fundable research Through the efforts of Dr. laboratory now exists at the
must be the interface and must potential researchers to the party. must be our goal. Putman and others, an intramural NIH. Radiology research budgets
at NIH have grown
from $3.2 million
million
oncology
for
radiation
$1 08 million
for diagnostic
in 1 982 to over $100
research
radiology
Hillman.
The
for change
that research by
improving and patients.
the privileges
to perform
sound brightest
research. young
nearly
medicine 50% of all some time
laid by Dr. Putman paid dividends in the work group moderated by Dr. Bruce J.
importance
ing a blueprint
and
noted that have spent
.
The groundwork carefully organized
in 1 991
and nuclear
research in 1 991 Dr. Putman further people who received RO1 NIH grants at the NIH.
ologists physicians
gives
periodically
research programs before the 1970s. Deans of institutions wanted strong research in all departments, including radiology, but they also wanted the films to be found. In the 1980s,
which
(AOBR),
would
that he supports
research alone. Medical schools and most radiology departments
knowledged
of Radiology
uncle
for all to see, noting
and the American
Board
“the eccentric
uncle,” for the radiologist researcher, someone who has traditionally lived in the catacombs of the department, getting
was that the American Osteopathic
review and his own of research in
perspective on the growth and development radiology departments. He coined the phrase,
viewed as a prelude to making
certification, should also give any recertification that eventually becomes necessary. The AOBR is going ahead with its
centers
stressing
by Radiologists
effectiveness of patient management, cost-containment, and outcomes research. Regarding credentialing and recertification, the consensus
Board of Radiology
oncology
by physicians who refer patients to those centers, the real or perceived potential conflict of interest.
Fostering
outlined the Patterns ofCare Study (PCS)established in 1973, and offered it as a potential template for use by diagnostic radiologists continuing
677
NEWS
Attraction physicians
of research
in radiology
recommendations
and improvement.
pays dividends their New
practice techniques
and provide and in our
was
re-
and designThe group
for practicing
ac-
radi-
for both referring and services and
them have their basis in
retention field
of the
depends
best
and
on our
per-
MEETING
678
formance
of credible
ognition by clinical will all be improved
research.
Our image, respect,
and rec-
colleagues, as well as our reimbursement, by effective radiologic research. In order
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to improve the posture of radiologic research, several vital issues needed to be addressed, according to Dr. Hillman’s work group. These are (1) an agreed upon definition of radiologic research; (2) the lack of sufficient funding sources, which threatens to become more scarce with shrinking clinical reimbursement; (3) the paucity of mentors in academic de-
partments who are well trained in research and are themselves funded; (4) a reluctance among many residents and fellows to choose a career in research; and (5) the conflict that exists between busy clinical radiologists and budding researchers in many departments. Several recommendations were forthcoming from the workshop of Drs. Hillman and Putman, including more and better resident or fellowship training in the science and methodology of technology assessment, increasing awareness by funding agencies of the importance of technology assessment and better scripts
support byjournal
for it, more rigorous assessment of menueditors, and requirements that authors need to be more objective in their interpretation of the validity and
general applicability of results. The broadest-based definition of radiology research was encouraged, with a renewed emphasis on basic science research by radiologists. Rather than mere new
descriptions evolving
molecular economic,
radiology gists
of new
imaging
technologies,
techniques
applications
to fundamental
of the biological
are needed. A consideration of social, and organizational issues related to the field of must also receive attention if research by radioloprocesses
is to be acknowledged,
accepted,
and
funded
in the
NEWS
alike
AJR:158,
must
get
March 1992
involved
by encouraging research, creating providing seed money, and soliciting philanthropic support and endowments. Role models (mentors) can be found both within and outside radiology
time in busy departments,
departments. Closer research arrangements with nonphysician researchers within radiology departments or in other disciplines can be structured to improve training for researchers in radiology. Direct involvement in the intramural research program at NIH should be encouraged for our young investi-
gators.
A clearinghouse
information,
regular
at the ACR for grant publication
of
instructional
and funding materials
about “how to do research,” and grantsmanship workshops and symposia were all listed as specific steps that could be taken to increase the general knowledge base for research opportunities within our specialty. Successful recruitment of researchers will depend on an “up front” identification of qualified candidates and suitable adjustments in our training curriculum for these candidates. This will all take time, but the overall goal should be a gradual cultural change within departments where rewards are commensurate with efforts and excellence in achievements, both for clinical and research missions.
Summary In many ways, standards were back on the table again at this year’s summit: standards for assessment of continuing competence and how to improve the standards of radiology research. For standards to have merit and meaning, they should have the broadest possible base and democratic input in development. Research by radiologists can begin and
19905. Outside funding for research has improved slightly along with the development of an intramural laboratory at the NIH, but awareness offunding sources and better exploitation of traditional sources are needed. Continuation and strengthening of ties to industry and greater contributions by radiologic societies, both large and small, to research and education
improve if many of the recommendations of this year’s summit are embraced. Many problems were addressed within the context of the summit gathering, and synectics can yield
funds
REFERENCE
were specific
However, departmental
recommendations
much radiology sources.
research Department
by Dr. Hillman’s
today is still funded chairs
and
group.
from
radiologists
solutions.
1 . Hillman BJ, Putman CJ. Fostering research press); Invest Radio! 1992 (in press)
by radiologists.
Radiology
(in
675
Meeting ,H,
#{149}
Radiology Synectics Bruce
.
.;
Summit
-
.:.
H..
Solutions
Through
L. McClennan1
Synectics-A theory or system of problemstating and problem-solution based on creative thinking that involves free use of metaphor and analogy in informalinterchange within a carefully selected small group of individuals of diverse personality and areas of specialization. Webster’s
Unabridged
evolution
of radiologists as researchers in academic departments. and opinions of representatives from all sectors within our specialty were well represented in vigorous debate and thoughtful, articulate interchange as the issues of practice assessment, credentialing, recertification, radiology research, scarce resources, and more were explored. Academic radiologists and those in private The interests
Dictionary
community
cepts
The Radiology Summit Meeting was held in August 199i , at the Park Inn again, in Asheville, NC. The summit meeting is held annually under the auspices of the Intersociety Commission of the American College of Radiology (ACR) chaired by Dr. Bruce L. McClennan. Seventy-eight leaders from 40 member societies and 14 staff members from these organizations (see Table 1) gathered for 3
Grove
days to discuss important
issues confronting
theme for this year was “Solutions two
#{149}:.H
.
Meeting--1991:
News
round-table
work
groups
Through
developed
our discipline. The
Synectics,” a white
and each of
paper
that
was
to the Board of Chancellors and the Council of the ACR in September 1991 in Minneapolis, MN. Resource speakers set the stage for the discussion groups with stimulating reviews of material presented
practice
expressed
opinions
voiced
in the white
ACR Leadership
and helped
to shape
Report
Dr. James B. Moorefield, Jr., from Sacramento, CA, chairman of the Board of Chancellors of the ACR, addressed the summit
during
the weekend,
first thanking
the federal
govern-
ment for providing him such good “material” for his speech. He then reviewed how the rules of the reimbursement game had suddenly changed again on June 5, 1991 With the notice in the Federal Register of the proposal by the Health Care .
Financing
Administration
(HCFA)
for further
cuts
in the fee
Dr. Gerald Dodd of the M.D. Anderson Cancer Center, Houston, TX, and Dr. Lawrence Coia from Fox-Chase Cancer Center in Philadelphia, PA, laid the groundwork for the SBSSIOfl on practe assessment and credentialing. Dr. Cole, along with Dr. Tearle Meyer, vice president of the ACR and head of
schedule to radiology came two new terms-behavioral and transitional offset-that would become anathema
the Committee on Practice Assessment and the Mammography Accreditation Program, assisted Dr. Hywel Madoc-Jones from Tufts University Medical Center in moderating the deliberations on this topic. Dr. Bruce J. Hillman from the University of Virginia was ably assisted by Dr. Charles J. Putman, Duke University, with his discussion session on fostering research by radiologists [1 ]. Dr. Putman presented background material describing the traditional role and
reimbursement
pertinent
I
to the topics
Chairman, Intersociety
for discussion.
Commission
S. Kingshighway Blvd., St. Louis, MO AJR
of the American College of Radiology,
diologists.
C American
Proposed
was
payments
on top ofthe
endured,
portending
Moorefield
an additional
campaigns,
key contacts
Institute of Aadiology,
Roentgen Ray Society
to ra-
cut in radiology
had already in Medicare As was the case in 1988, Dr.
cut overall
out (tongue
state chapter president before key congressional Mallinckrodt
offset
1 8% cut that our specialty a 50%
to radiologists.
pointed
32%
in cheek)
by 1996
that HCFA
our help yet again.” An action plan consisting
63110.
158:675-678, March 1992 0361-803X/92/i583-0675
the con-
papers.
with legislators,
“needed
of letter writing
town
meetings,
and
briefings culminated with testimony committees by ACR officers in the Washington
University School
of Medicine, 510
MEETING
676
Downloaded from www.ajronline.org by 117.255.239.95 on 11/09/15 from IP address 117.255.239.95. Copyright ARRS. For personal use only; all rights reserved
TABLE
1: Radiology
American American American American American American American American
Summit
1991: Organizations
Association Assodaon
of Academic of Physicists
Association
of Women
Residents in Medkne
Chief
in Radiology
Radiologists
Board of Nuclear Mediane Board of Radiology College of MediCal Physics College of Nuclear Physicians College of Radiology
Institute of litrasound
American
Medical
American
Osteopathic College of Radiology Radium Society Roentgen Society Society
Association,
in
actually
AJA:158,
prosecute
violators
under
the antikickback
March 1992
provisions
of Medicare law. Dr. Moorefield reminded summit attendees that ourjob is far from over, and pressure must be maintained on HCFA and Congress to carry out the letter and intent of the law regarding physician payment reform. He further emphasized that these critical issues affect subspecialty societies as well as individual
American
American American American American
in Attendance
NEWS
radiologists
in private
practice.
Medicine
Section
Council
on Radiology
Inc., Report
(RCI),
and Oncology
Society of Head and Neck Radiology Society of Neuroradiology Association of Residents in Radiation Oncology Association of University Radiologists Canadian Association of Radiologists Council on Cardiovascular Radiology of the American
Centennial,
Dr. John Tarnpas, president of Radiology Centennial, Inc. convened the annual meeting of RCI during the 1991 summit meeting. Because RCI grew out of the Intersociety Commission, all member societies are part of the Board of Directors of RCI. Dr. Tampas reported to the directors and others present on the progress made by the organization,
Ray Society for Therapeutic Radiology of Clinic Radiologists
Radiology
American American
particularly Heart Associ-
ation College of Radiology International Skeletal Society National Medical Association, Section on Radiology North American Society for Cardiac Imaging Radiological Society of North America Interamerican
the outstanding
proposed
Residency Review Committee Society for Magnetic Resonance Imaging Society for Pediatric Radiology Society of Breast Imaging Society of Cardiovascular and Interventional
Radiology Society of Chairmen of Academic Radiation Oncology Departments Society of Chairmen of Academic Radiology Departments Society of Body Computed Tomography Society of Gastrointestinal Radiologists Society of Magnetic Resonance in Medicine, Inc. Society of Nuclear Medicine Society of Radiologists in (Jtrasound Society of Thoracic Radiology Society of Uroradiology Veterans Administration Chiefs of Radiology
success
in fundraising
to date.
With unrestricted pledges of $250,000 each from the four major radiological societies-American Roentgen Ray Society, American Society for Therapeutic Radiology and Oncology, ACR, and Radiological Society of North America-RCI has already raised or received pledges for over half of its $3 million
budget
for our 1 995 centennial
celebra-
tion. Additional donations or pledges have been received from the American Association of Physicists in Medicine, American College of Medical Physics, American Society of Neuroradiology, Society of Radiologists in Ultrasound, Society of Chairmen of Academic Radiology Departments, and California Radiological Society. ongoing projects, were all presented.
The committee structure (1 1 committees), and budget projections for each committee Over 200 people are currently participating
in RCI committee functions, and others were invited by Dr. Tampas to participate. Societies that were new to the Intersociety become
Commission
summit
meeting
were
also
invited
to
members of the Board of Directors of RCI. One hundred years of achievement in radiology (1 895-1 995) is a story worthy of great celebration, and RCI is off to a grand start.
summer of 1991 In all, 44,000 pieces of mail from radiologists and supporters were sent to Congress, the President, and key governmental officials. To date, HCFA has backed down
Practice
somewhat but not completely from a transition/behavior offset, but predictions for retention of a 3-6% reduction by early I 992 persistently come from HCFA officials. There was some good news, however, in that global billing with CPT-4 codes
ing, moderated by Dr. Hywel have two excellent speakers
has given
for interventional procedures. Expectations are for more uniform payments across Medicare carriers in the future. Also, Congress appears to actually be on our side in regard to physician payment reform. Representative Pete Stark has held hearings on selfreferral and joint ventures based in part on data collected by the Florida Health Care Commission showing an extremely high percentage (>90%) of physician ownership of imaging centers in the state of Florida. Furthermore, the safe harbor
assessment
regulations were finally released by the inspector general, Mr. Kusserow, and they placed radiologists in a rather favorable light. Recent rulings (e.g., the Hanlester case) have encour-
and no direct linkage to reimbursement. Recent ACR efforts to develop standards for practice assessment and credentialing have rekindled interest in the process. Dr. Dodd acknowledged that the American Board of Radiology is contin-
.
way to split billing,
particularly
aged the inspector general to pursue questionable
cases and
Assessment
and Credentialing
The Work Group on Practice
sions. Dr. Gerald the efforts
Assessment
Madoc-Jones,
and Credentialwas fortunate
to
pave the way for their discusDodd gave a historical perspective on the
of continuing
of the American
clinical
competence,
Board of Medical
beginning
with
Specialties
to
institute voluntary recertification in the early 1970s. ACR Council Resolution No. 27 in 1975 set up guidelines for recertification promulgated by the American Board of Radiology and outlined various pathways to achieve recertification
should it prove necessary. However, active recertification initiatives have not been initiated owing to lack of grassroots support,
no true consensus
on the best
(preferred)
methods,
AJA:158, Marth
MEETING
1992
uing to consider
alternatives,
including
personal
and videodisk programs. Any realistic recertification must be practical, nonpunitive, and allow for remedial
actions,
Dr. Dodd explained.
Joint
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recertification
computer program
Commission
He further
for Accreditation
cautioned
that the
of Healthcare
Organiza-
tions is pushing
its own form of standards
focusing
in the care of patients while actually the need for board certification. Dr. Dodd success of the ACR mammography accredi-
on outcomes
deemphasizing noted tation
and credentialing,
the great program and the important
role of the American Cancer Society in this effort, a role that he personally supported in his position as president of the American Cancer Society. He found the results of, and response to, the mammography accreditation program very encouraging. Dr.
Larry
Coia,
a radiation
oncologist
from
Philadelphia,
in their deliberations on practice assessment and competence. This program within radiation oncol-
ogy was designed
to correlate
and combine
structure
and
process with outcome. Further goals were to assess compliance and bring about improvement in patients’ care. Dr. Coia outlined five steps within the PCS: (1) document facilities, patient demographics, and current practice patterns; (2) de-
velop a consensus cancer
site (e.g.,
expert
panels
gists,
of best current breast,
testis,
comprising
and surgeons;
management
bladder,
academicians,
(3) conduct
for a specific
and larynx)
by using
physicists,
process
surveys
oncolo-
that include
large numbers of patients so as to determine national averages and trends in patient evaluation and management; (4) develop
outcome
surveys
to assess
results
of treatment;
and
(5) develop accreditation programs based on the above. Evaluation and management decision trees are developed and facilities are stratified and statistics compiled, then compliance is assessed on site reviews. If a variance is identified, remedial action is suggested. The PCS is developing national benchmarks
and
stressed
correlating
processes
that the success
stimulus
to diagnostic
with
outcomes.
of this program
radiologists
Dr. Coia
could serve as a
to perform
analogous
stud-
ies, although it was noted that outcome measurement in oncology is easier than in diagnostic processes. Dr. Hywel Madoc-Jones was assisted by Drs. Coia and Meyer in moderating his session and in developing the white paper
that
was
submitted
to the ACR 1 991 Their
Board report
and Council in September a time when momentum for health care reform States was rising. Senator John 0. Rockefeller .
ginia, upon
of Chancellors was written at
in the United of West Vir-
head of the Pepper Commission, had recently called physicians to get involved in the process of improving
health care and access to care with a specific
agreed that it was not necessary to obtain certification via an actual examination. There was serious concern about many
disenfranchising general radiologists with such an examination. Radiation oncologists felt no specific urge for subspecialty certification at this time. Other discussion centered on
self-referral, physician ownership, and the necessity of a 4year training program for radiation oncology similar to what currently exists for diagnostic radiology. There was general agreement that over time, the ACR should urge no physician ownership
of imaging
focus on cost-
centers
or radiation
Research
Dr. Charles
Putman
gave a stimulating
paid only to think.
displayed
This eccentric
initial
own
group
recertification
participants
program
endorsed
in 1 992.
A majority
subspecialty
of the work-
certification,
but
be
himself
by
and universities were slow slower to develop strong
the realities of the budget deficit took hold, but the National Science Foundation budget still increased 13%, and the National Institutes of Health (NIH) budget increased 1 8%. How-
ever, 25 major medical centers get 60% or more of all the research funds budgeted by these two organizations. “It is time to join the party,” Dr. Putman exclaimed. We [radiologists] need to define ourselves, use our collective wisdom,
cultivate interdisciplinary ness. Indeed, we need
avenues, and improve public awareto take the tarnish off the image of
our eccentric uncles. We bring our best and brightest Credible, fundable research Through the efforts of Dr. laboratory now exists at the
must be the interface and must potential researchers to the party. must be our goal. Putman and others, an intramural NIH. Radiology research budgets
at NIH have grown
from $3.2 million
million
oncology
for
radiation
$1 08 million
for diagnostic
in 1 982 to over $100
research
radiology
Hillman.
The
for change
that research by
improving and patients.
the privileges
to perform
sound brightest
research. young
nearly
medicine 50% of all some time
laid by Dr. Putman paid dividends in the work group moderated by Dr. Bruce J.
importance
ing a blueprint
and
noted that have spent
.
The groundwork carefully organized
in 1 991
and nuclear
research in 1 991 Dr. Putman further people who received RO1 NIH grants at the NIH.
ologists physicians
gives
periodically
research programs before the 1970s. Deans of institutions wanted strong research in all departments, including radiology, but they also wanted the films to be found. In the 1980s,
which
(AOBR),
would
that he supports
research alone. Medical schools and most radiology departments
knowledged
of Radiology
uncle
for all to see, noting
and the American
Board
“the eccentric
uncle,” for the radiologist researcher, someone who has traditionally lived in the catacombs of the department, getting
was that the American Osteopathic
review and his own of research in
perspective on the growth and development radiology departments. He coined the phrase,
viewed as a prelude to making
certification, should also give any recertification that eventually becomes necessary. The AOBR is going ahead with its
centers
stressing
by Radiologists
effectiveness of patient management, cost-containment, and outcomes research. Regarding credentialing and recertification, the consensus
Board of Radiology
oncology
by physicians who refer patients to those centers, the real or perceived potential conflict of interest.
Fostering
outlined the Patterns ofCare Study (PCS)established in 1973, and offered it as a potential template for use by diagnostic radiologists continuing
677
NEWS
Attraction physicians
of research
in radiology
recommendations
and improvement.
pays dividends their New
practice techniques
and provide and in our
was
re-
and designThe group
for practicing
ac-
radi-
for both referring and services and
them have their basis in
retention field
of the
depends
best
and
on our
per-
MEETING
678
formance
of credible
ognition by clinical will all be improved
research.
Our image, respect,
and rec-
colleagues, as well as our reimbursement, by effective radiologic research. In order
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to improve the posture of radiologic research, several vital issues needed to be addressed, according to Dr. Hillman’s work group. These are (1) an agreed upon definition of radiologic research; (2) the lack of sufficient funding sources, which threatens to become more scarce with shrinking clinical reimbursement; (3) the paucity of mentors in academic de-
partments who are well trained in research and are themselves funded; (4) a reluctance among many residents and fellows to choose a career in research; and (5) the conflict that exists between busy clinical radiologists and budding researchers in many departments. Several recommendations were forthcoming from the workshop of Drs. Hillman and Putman, including more and better resident or fellowship training in the science and methodology of technology assessment, increasing awareness by funding agencies of the importance of technology assessment and better scripts
support byjournal
for it, more rigorous assessment of menueditors, and requirements that authors need to be more objective in their interpretation of the validity and
general applicability of results. The broadest-based definition of radiology research was encouraged, with a renewed emphasis on basic science research by radiologists. Rather than mere new
descriptions evolving
molecular economic,
radiology gists
of new
imaging
technologies,
techniques
applications
to fundamental
of the biological
are needed. A consideration of social, and organizational issues related to the field of must also receive attention if research by radioloprocesses
is to be acknowledged,
accepted,
and
funded
in the
NEWS
alike
AJR:158,
must
get
March 1992
involved
by encouraging research, creating providing seed money, and soliciting philanthropic support and endowments. Role models (mentors) can be found both within and outside radiology
time in busy departments,
departments. Closer research arrangements with nonphysician researchers within radiology departments or in other disciplines can be structured to improve training for researchers in radiology. Direct involvement in the intramural research program at NIH should be encouraged for our young investi-
gators.
A clearinghouse
information,
regular
at the ACR for grant publication
of
instructional
and funding materials
about “how to do research,” and grantsmanship workshops and symposia were all listed as specific steps that could be taken to increase the general knowledge base for research opportunities within our specialty. Successful recruitment of researchers will depend on an “up front” identification of qualified candidates and suitable adjustments in our training curriculum for these candidates. This will all take time, but the overall goal should be a gradual cultural change within departments where rewards are commensurate with efforts and excellence in achievements, both for clinical and research missions.
Summary In many ways, standards were back on the table again at this year’s summit: standards for assessment of continuing competence and how to improve the standards of radiology research. For standards to have merit and meaning, they should have the broadest possible base and democratic input in development. Research by radiologists can begin and
19905. Outside funding for research has improved slightly along with the development of an intramural laboratory at the NIH, but awareness offunding sources and better exploitation of traditional sources are needed. Continuation and strengthening of ties to industry and greater contributions by radiologic societies, both large and small, to research and education
improve if many of the recommendations of this year’s summit are embraced. Many problems were addressed within the context of the summit gathering, and synectics can yield
funds
REFERENCE
were specific
However, departmental
recommendations
much radiology sources.
research Department
by Dr. Hillman’s
today is still funded chairs
and
group.
from
radiologists
solutions.
1 . Hillman BJ, Putman CJ. Fostering research press); Invest Radio! 1992 (in press)
by radiologists.
Radiology
(in
