THE ROLE AND VALUE OF THE CLINICAL
RADIOLOGIST - POSITION PAPER
FACULTY OF CLINICAL RADIOLOGY
THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS®
Role and Value of the Clinical Radiologist: Recognising
the Value and Responding to the Challenges
Clinical Radiology
Position Statement
Name of document and version:
The Role and Value of the Clinical Radiologist, Version 1.0
Approved by:
Faculty of Clinical Radiology
Date of approval:
5 November 2014
ABN 37 000 029 863
Copyright for this publication rests with The Royal Australian and New Zealand College of
Radiologists ®
The Royal Australian and New Zealand College of Radiologists
Level 9, 51 Druitt Street
Sydney NSW 2000 Australia
Email: [email protected]
Website: www.ranzcr.edu.au
Telephone: +61 2 9268 9777
Facsimile: +61 2 9268 9799
Disclaimer: The information provided in this document is of a general nature only and is not intended as a
substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between a
patient and his/her doctor.
TABLE OF CONTENTS
1.
Executive Summary
4
2.
Introduction
6
3.
Evolution of Clinical Radiology
7
4.
Practice of Clinical Radiology
8
5.
Training of Clinical Radiology
9
6.
Value of Radiologists in Healthcare
10
7.
Challenges for the Future of Radiology and Radiologists
14
8.
Responding to the Challenges
18
9.
Appendices
18
10. Acknowledgements
18
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 2 of 19
About the College
The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit
association of members who deliver skills, knowledge, insight, time and commitments to promote the
science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and
radiation oncology in Australia and New Zealand.
The Faculty of Clinical Radiology, RANZCR, is the peak bi-national body for setting, promoting and
continuously improving the standards of training and practice in diagnostic and interventional
radiology for the betterment of the people of Australia and New Zealand.
Our Vision
RANZCR as the peak group driving best practice in clinical radiology and radiation oncology for the
benefit of our patients.
Our Mission
To drive the appropriate, proper and safe use of radiological and radiation oncological medical
services for optimum health outcomes by leading, training and sustaining our professionals.
Our Values
Commitment to Best Practice
Exemplified through an evidence-based culture, a focus on patient outcomes and equity of access to
high quality care; an attitude of compassion and empathy.
Acting with Integrity
Exemplified through an ethical approach: doing what is right, not what is expedient; a forward thinking
and collaborative attitude and patient-centric focus.
Accountability
Exemplified through strong leadership that is accountable to members; patient engagement at
professional and organisational levels.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 3 of 19
1. EXECUTIVE SUMMARY
1.1
The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit
association of members who deliver skills, knowledge, insight, time and commitment to
promote the science and practice of the medical specialties of clinical radiology (diagnostic
and interventional) and radiation oncology in Australia and New Zealand. RANZCR has an
international reputation for producing highly competent radiologists with a wide range of expert
diagnostic and procedural skills.
1.2
The specialty of radiology is broad, encompassing an increasing range of imaging technologies
and imaging-guided treatments including X-ray, computed tomography (CT), ultrasound,
mammography and magnetic resonance imaging (MRI). With technological innovation
continuing, imaging techniques are becoming ever more sophisticated and complex.
1.3
Radiologists are medical practitioners who have undertaken broad medical training as well as
comprehensive specialist training in performing and interpreting diagnostic imaging tests and
imaging-guided procedures or treatments that involve the use of a range of imaging
modalities.
1.4
However radiologists are trained to add value beyond just image interpretation. Working
alongside other doctors and healthcare practitioners, radiologists are integral to the care of
patients by making accurate diagnoses, monitoring response to treatment, performing
imaging-guided treatments and advising on how best to use imaging in the care of patients.
1.5
This paper establishes RANZCR’s position on the role and value of the clinical radiologist,
which is that contemporary patient-centred care requires a new and more collaborative
radiology practice model – with radiologists, as key members of multi-disciplinary teams,
taking a greater role in clinical decision-making and patient management, while maintaining
the focus on optimising patient outcomes through higher quality, appropriate and timely
imaging-based care.
1.6
The purpose of the paper is to inform patients, health professionals, health administrators, the
public and interested individuals about the value radiologists bring to healthcare.
1.7
The paper summaries the evolution of the specialty, the practice of radiology, the training of
radiologists, and the value of radiologists in healthcare - particularly in ensuring the quality of
imaging care. The paper also outlines some challenges facing the specialty and RANZCR’s
responses to those challenges.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 4 of 19
1.8
Definitions
In this Position Paper:
Member means a member of the College.
Radiologist means clinical radiologist.
Radiology means clinical radiology.
RANZCR means The Royal Australian and New Zealand College of Radiologists.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 5 of 19
2. INTRODUCTION
2.1
Since its beginnings in 1895, radiology has been at the evolutionary forefront of
technological advances that have revolutionized the practice of diagnostic and procedural
clinical medicine. As imaging technologies and clinical procedures have become more
varied, complex and sophisticated, radiologists have adopted new technologies and
modalities of care that benefit patients and support the entire healthcare system. As such,
the expertise of radiologists is central to safe, effective, timely and cost-effective care.
2.2
The core competence of radiologists is their integrated clinical knowledge and radiological
expertise which is critical in ensuring that patients receive quality imaging and appropriate
imaging-guided treatments that actively contribute to the diagnosis and management of their
illness.
2.3
The full clinical role of radiologists encompasses, but is not limited to, providing important
positive observations and pertinent negative observations in a relevant summary with a
concise differential diagnosis. Radiologists oversee the clinical journey of a patient from
access to appropriate imaging modalities, patient interaction before and after imaging, to
communicating the knowledge gained. Radiologists are also involved in directly providing
care to patients through clinical procedures, often referred to as interventional radiology.
2.4
Although the effectiveness of the radiologist requires teamwork with other healthcare
practitioners sharing responsibility for a patient’s care, radiologists are responsible for the
oversight of all components of medical imaging, and overall medical and legal (or medicolegal) care of their patients.
2.5
While radiology is long accustomed to adopting new technologies and modalities of care
that benefit patients and support the entire healthcare system, there are major challenges
currently facing radiologists. These challenges include how to:
2.6

Acquire new knowledge in the field of radiology at an ever increasing pace

Deliver more patient-centered and personalised healthcare

Demonstrate the value of imaging and radiologists to all stakeholders

Ensure more radiologists can participate in research and innovation

Respond to new policy initiatives and changing funding arrangements.
RANZCR will continue to support all clinical radiologists through training, professional
development and advocacy, which will enable radiology to emerge stronger for the future.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 6 of 19
3. EVOLUTION OF CLINICAL RADIOLOGY
3.1
Wilhelm Roentgen’s discovery of X-rays in 1895 heralded the arrival of a new method of
medical diagnosis and the birth of the specialty of clinical radiology.
3.2
Since that time, radiology has been at the forefront of technological advances that have
revolutionized the practice of clinical medicine. Radiologists have in large part introduced
these techniques to medicine and worked with other clinicians to establish the value of their
clinical application.
3.3
The past century has seen rapid dissemination and an increasing sophistication in the
utilisation of X-rays, along with other energy sources such as radio-isotopes, ultrasound,
magnetic resonance and positron emission techniques (PET). These advances have
enabled very detailed and accurate displays of human anatomy, pathology and physiology
to be used in the diagnosis of diseases as well as having an important role in monitoring the
response to treatment and predicting clinical outcome.
3.4
Furthermore, advances in minimally invasive techniques using sophisticated imagingguidance have enabled safer, easier and less costly treatment of conditions that previously
required extensive invasive surgery or were deemed untreatable.
3.5
Many of the major breakthroughs in medical care in the last 40 years have followed
innovations and advancements in radiology. The use of radiology has increased
dramatically in this time and other healthcare professionals have come to rely on radiology
to care for their patients.
3.6
Radiology has, and continues to be, essential to healthcare. With the rapidly developing and
expanding field of radiology, the role and value of the radiologist is continuing to evolve and
contribute to best practice patient care. Ongoing developments in patient care will mean an
increasing role in the future for radiologists in:

screening for disease

early detection of disease at a more easily-treatable stage

monitoring the response to treatment and

treating patients and providing continuity of care
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 7 of 19
4. PRACTICE OF CLINICAL RADIOLOGY
4.1
Despite pressure in the early 1990s to define radiology as a technical service, it was quickly
apparent that radiographic interpretation and reporting required medically-trained
specialists.
4.2
Today, radiologists have broad medical training as well as specialist training in clinical
radiology. They combine their comprehensive knowledge of anatomy, pathology, physiology
and clinical medicine with their expertise in image capture technology, advances in physics
and engineering, and the application of information technology to healthcare.
4.3
This extensive training uniquely qualifies radiologists to be experts in image interpretation
and imaging-guided treatment. Understanding how to interpret images requires a sound
knowledge of complex physics principles as well as an understanding of the advanced
computer systems used for the processing and display of data as images or in other
formats. Radiologists’ training in medical physics and technology enables them to ensure
optimal image acquisition for each clinical condition and ensures that the images reflect the
patient’s clinical presentation rather than abnormalities in the technique.1
4.4
As specialists in image acquisition, interpretation and the application of imaging information
to clinical care, radiologists are crucial to using imaging to improve the clinical management
of patients in both health maintenance and disease prevention. This role is central to the
health and well-being of patients.
4.5
Radiologists are responsible for the management of patients as well as supervision of the
work performed by other members of the radiology team under their guidance. With their
foundation of core clinical medical training, together with their specialist radiology training,
radiologists understand the significance of a patient’s medical history, examination findings
and the results of investigations.
4.6
The contemporary specialty of clinical radiology, including the professional care of patients
by radiologists, is a process that starts at the point of referral – the commencement of
handover of care to the radiologist – and continues until the care is handed back to the
referrer, usually with the communication of results or upon completion of treatment. For
patients being treated by radiologists, the responsibility for care may rest with the radiologist
for much longer, potentially in partnership with the referring practitioner, as patients return
for review or further treatment.
1
Krestin GP. Maintaining identity in a changing environment: the professional and organizational future of radiology.
Radiology. 2009 March;250(3):612-7.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 8 of 19
4.7
The major steps in clinical radiology are:

pre-examination evaluation for necessity and appropriateness

determining how best to examine or treat the patient

monitoring and/or performance of examinations or treatments for proper
performance, radiation safety and image quality

interpretation of examination findings and/or treating the patient

post-examination communication of treatment and/or imaging results to the referring
healthcare practitioner and the patient.2,3
4.8
The integrated knowledge and expertise of the radiologist are critical to ensure that patients
receive quality imaging and appropriate imaging-guided treatments that actively contribute
to the diagnosis and management of their illness.4
5. TRAINING OF CLINICAL RADIOLOGY
5.1
RANZCR provides among the highest standard educational, training and assessment
programs in the world which equip Fellows, trainees and members of RANZCR with the
knowledge and skills to practice radiology and radiation oncology at the highest standards
throughout their working life. RANZCR has an international reputation for producing highly
competent radiologists with a wide range of expert diagnostic and procedural skills.
5.2
As medical professionals, Fellows of RANZCR are able to participate in management,
collaborative research, team-based medical care and new developments in imaging for the
benefit of patients in Australia and New Zealand. The Radiodiagnosis Training Program
Curriculum5 is informed by the CanMEDS Framework6 that stipulates the medical expert
and six non-medical expert roles. Appendix A provides examples of their application to
clinical radiology.
5.3
Radiologists are required to complete at least two years of general medical training, in other
areas of medicine and under supervision in a hospital, before they can enter the five-year
specialist training program for clinical radiology. This core clinical medical training is the
foundation upon which radiologists base their comprehensive specialty training in radiology.
2 Patti
JA, Berlin JW, Blumberg AL, Bryan RN, Gaschen F, Izzi BM, Larson PA, Lewin JS, Liebscher LA. ACR white paper:
the value added that radiologists provide to the healthcare enterprise. J Am Coll Rad. 2008 October;5(10):1041-53.
3
Borgstede JP. Radiology: commodity or specialty. Radiology. 2008 June;247(3):613-16.
4
The Royal Australian and New Zealand College of Radiologists. Role evolution in diagnostic imaging RANZCR response to
QUDI QS3 discussion paper on role evolution [Internet]. 2006 [Updated 2006 August 30; cited 2014 March 31]. Available from:
http://www.ranzcr.edu.au/component/docman/doc_download/399-343-22-college-response
5
The Royal Australian and New Zealand College of Radiologists. Curriculum [Internet]. [Cited 2014 June 20]. Available from:
http://ranzcr.edu.au/training/radiology/current-training-program/curriculum
6
Royal College of Physicians and Surgeons of Canada. Royal College: The CanMEDS Framework [Internet]. [Cited 2014 June
20]. Available from: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 9 of 19
5.4
The five year full-time post-graduate specialist training is based on a robust and transparent
curriculum and a series of thorough assessments and examinations. Following the
successful completion of this comprehensive program, radiologists may undertake additional
post-specialty training to concentrate on one area of radiology, such as breast imaging,
interventional radiology, nuclear medicine, musculoskeletal radiology and paediatric
imaging. Moreover, radiologists will acquire the skills and training essential to their particular
practice environment.
5.5
This comprehensive training provides the foundation of knowledge required to practise as a
radiologist.
5.6
As with other medical specialists, there is a need for lifelong learning, maintenance of
professional skills and ongoing professional development in order to maintain core
competence and learn new skills and techniques as these develop.
6. VALUE OF RADIOLOGISTS IN HEALTHCARE
6.1
Radiologists represent one of medicine’s least acknowledged but most important medical
specialties in terms of the value they are able to add to patient care and health outcomes.
Radiologists are often the ‘behind the scenes’ doctors who have a pivotal role in patient
care, utilising their general clinical and specialist radiological knowledge and skills in order to
provide expert care for patients referred to them, whether it is for diagnostic tests or
treatment.
6.2
This expertise is used to determine:

which imaging techniques, if any, are most appropriate to investigate and/or treat
clinical problems

how best to use the selected imaging technique or perform a selected treatment
including ensuring image quality is clinically acceptable

the interpretation of the acquired images

the writing of the report and

the communication of the findings to the referrer in a time-appropriate manner and
follow-up as appropriate.
6.3
Radiologists are also aware of the pitfalls of imaging and are well-trained in determining
whether an imaging finding is real, significant or due to an unexpected cause.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 10 of 19
6.4
Radiology and radiologists are central to patient care. Quality of care has been defined by
Hillman7 as “the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge. Specifically with regard to diagnostic imaging and image-guided treatment,
quality is the extent to which the right procedure is done in the right way, at the right time,
and the correct interpretation is accurately and quickly communicated to the patient and
referring practitioner. The goals are to maximise the likelihood of best health outcomes and
to satisfy the patient”.
6.5
The provision of quality care by radiologists is manifest by the safe provision of appropriate
imaging and imaging-guided treatment in a timely manner, accompanied by a report
succinctly and accurately explaining the findings and/or treatment provided.
Evaluating a referral for appropriateness and urgency
6.6
Selecting the most appropriate examination modality and technique to answer a specific
clinical question has become more challenging as imaging has become more complex.
Radiologists are the best-trained clinicians to ensure the correct procedure is performed, in
the best way, and at the most appropriate time to answer the clinical question or treat a
patient. To achieve these optimal patient outcomes there is a need for coordinated care,
communication, and sharing of expertise. Radiologists must have an active role in
determining whether a patient requires imaging and if so, what imaging is most appropriate.
To facilitate this, the referral must include information about the patient’s presentation and
the clinical problem to be addressed.
6.7
Radiologists understand the strengths and weaknesses of the range of examinations and
procedures available and are the best-trained specialists to effectively guide referring
practitioners in the use of imaging in the care of their patients. Close working relationships
between referring practitioners and radiologists help to ensure the most effective imaging
plans for patients.
Monitoring for proper performance, radiation safety and image quality
6.8
Responsibility for the quality of imaging services is an essential component of the
radiologist’s role. Radiologists have responsibilities across all aspects of the imaging
process: equipment selection and maintenance; proper training and supervision of allied
health staff; the design of imaging protocols; policies and procedures for patient
management and safety; and reporting standardisation and techniques. Maintaining and
continuously improving protocols and workflow efficiency often requires close cooperation
between radiologists and radiographers, nurses, physicists, IT professionals, clerical staff
and other members of the imaging team.
7
Hillman BJ, Amis ES, Neiman HL on behalf of the FORUM Participants. The future of quality and safety of medical imaging:
proceedings of the third annual ACR FORUM. J AM Coll Radiol. 2004 Januaray;1(1)33-9.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 11 of 19
6.9
The performance of any test or procedure entails risks. Radiologists have the knowledge to
mitigate risks and enhance the quality and safety of all imaging procedures for patients.
They are also experts in the appropriate and safe use of ionising radiation. The risks
radiologists seek to mitigate include: performing unnecessary or inappropriate tests;
unnecessary/excessive radiation exposure; incorrect interpretation and report; and risks
associated with communication of the imaging findings.8
6.10
The commitment of radiologists to the provision of high quality diagnostic and procedural
radiology to the Australian and New Zealand communities is reflected in the development
over the past ten years of a set of minimum standards of practice to support all public and
private practices in their delivery of high quality service. In addition, these standards provide
a framework to assist practices in continuous quality improvement.
6.11
The RANZCR Standards of Practice for Diagnostic and Interventional Radiology9, which
comprise the practice of clinical radiology, are reviewed on a planned, regular basis in order
to maintain currency. Each revision has incorporated innovations in practice and adapted to
changes in regulations with a focus on continually striving for best practice and optimal
patient outcomes. These standards are intended to be applicable to all medical imaging
practices in Australia and New Zealand.
Providing objective consultations and discussing imaging results
6.12
The radiologist’s formal written report of the results of the imaging examination is an
important medical document that covers a number of essential areas.10 It not only forms part
of a patient’s medical record but it encompasses all components of the imaging and/or
procedure for which the radiologist is responsible. Their medico-legal responsibility includes:

assessment of the indication

determining the best way to acquire images and/or perform a procedure

ensuring that appropriate and sufficient imaging has been performed

determining that images are of diagnostic quality

interpreting the images in the context of the patient’s clinical presentation and past
medical history, including imaging and other investigations where appropriate

carrying out imaging-guided procedures or treatments and effectively
communicating the results to the referring practitioner in a timely manner.
8
Hannaford N, Mandel C, Crock C, Buckley K, Magrabi F, Ong M, Allen S, Schultz T. Learning from incident reports in the
Australian medical imaging setting: handover and communication errors. Br J Radiol. 2013 February; 86:20120336
9
The Royal Australian and New Zealand College of Radiologists. Standards of practice for diagnostic and interventional
radiology- version 10. 2014 [Updated 2014 July, 14; cited 2014 July 18]. Available from: http://ranzcr.edu.au/quality-asafety/radiology/standards-of-practice
10
The Royal Australian and New Zealand College of Radiologists. RANZCR Written Radiology Report Guideline [Internet]. 2011
[Updated 2011 November 4; cited 2014 June 20]. Available from: http://www.ranzcr.edu.au/quality-a-safety/program/written-reportguidelines
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 12 of 19
6.13
The radiologist’s primary duty of care and legal responsibility is to the patient. Although the
results of clinical radiology are generally communicated to referring practitioners through a
written report, the radiologist must ensure that the information is provided in a way and time
that enables the patient to receive appropriate care and treatment. When clinically
appropriate, this may include urgent referral by the radiologist to a hospital when emergency
medical care is required for the patient.
6.14
The clinical effectiveness of the radiologist is optimised when the radiologist understands
the clinical problem and when there is a strong professional relationship between the
referring practitioner and the radiologist.
6.15
Such relationships add value to patient care through better communication and
understanding between referring practitioners and radiologists and should form part of the
referral and feedback process. A discussion of the clinical concerns, questions and findings
from a properly selected and performed imaging examination is a very powerful tool in
providing optimum care and added value for the patient.
6.16
Whilst the traditional model in Australia and New Zealand is one of radiologists
communicating patients’ results to their referring practitioners, radiologists who treat patients
and/or who practise paediatric radiology, ultrasound, angiography and nuclear medicine
typically consult directly with patients and communicate the imaging results. Radiologists
may discuss imaging results with the patient immediately after a scan – for example, where
a subsequent imaging investigation is indicated – to provide follow-up recommendations or
to advise of the need for urgent care. Increasingly, patients prefer to know the outcome of a
radiological examination from the reporting radiologist.11
Advancing imaging and image-guided procedures to improve patient care
6.17
The anatomical detail and sensitivity of imaging modalities is now of a high order and the
use of imaging in new areas of technological development such as functional and
quantitative diagnostics and molecular imaging is increasing. Radiologists have been central
to these developments and have been responsible for much of the evaluation of the
strengths and weaknesses of different investigations and procedures.
11
Consumers Health Forum of Australia. Quality use of diagnostic imaging consumer consultation project final report, Canberra:
2010 Aug, 6p.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 13 of 19
6.18
Radiologists have expert knowledge of the appropriate integrated imaging algorithms,
including procedures, to maximise clinical and cost effectiveness and have been responsible
for the implementation of these developments into the clinical setting. Pressure on health
budgets is requiring more rigorous assessment of the clinical efficacy and cost effectiveness
of new procedures and treatments.12
7. CHALLENGES FOR THE FUTURE OF RADIOLOGY AND RADIOLOGISTS
7.1
Radiology is now, more than ever, essential to healthcare. However major challenges facing
radiologists are recognised. Radiologists must preserve and enhance their value by
continuing to proactively respond to the evolving trends including:

technological advances in healthcare

telecommunications and IT assuming an increasing role

demand for healthcare increases due to the ageing population, more chronic
disease, more treatable diseases

new developments in imaging resulting in greater sensitivity in detecting earlystage disease

patients taking an increasing role in directing their own healthcare

requirements to prove the value of interventions through outcomes research.13
A shift in practice and training will position the profession and RANZCR to embrace the
future.
Increases in health care expenditure
7.2
The Grattan Institute recently reported that increases in health expenditure in Australia over
the past ten years have been driven by people of all ages seeing doctors more often: having
more tests and operations, and taking more prescription drugs as effective new treatments.
Although this increase in health expenditure has demonstrable benefits - including an
increase in life expectancy, particularly for those aged 65 and over - it has come at a
financial cost.14
7.3
Given rapidly increasing health expenditure, evidence of health outcomes and drivers of
growth are being more closely examined. This pattern has been evident in the field of
12
McCall I on behalf of the European Society of Radiology. The future role of radiology in healthcare. Insights into Imaging. 2010
Jan; 1(1):2-11. doi: 10.1007/s13244-009-0007-x
13
Patti JA, Berlin JW, Blumberg AL, Bryan RN, Gaschen F, Izzi BM, Larson PA, Lewin JS, Liebscher LA. ACR white paper: the
value added that radiologists provide to the healthcare enterprise. J Am Coll Rad. 2008 October;5(10):1041-53. doi:
10.1016/j.jacr.2008.06.003.
14
Daley J, McGannon C, Savage J. Budget pressures on Australian governments: Grattan Institute; 2013 April. 94 p. Report
No.:2013-4.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 14 of 19
radiology. For example, in Australia over the past five years, the average growth rates in per
capita utilisation of Medicare funded diagnostic imaging services for patients 75 years of age
and over have been much higher than those of younger age groups, particularly amongst
both males and females aged 75-84: 5.3% and 6.0% per annum respectively and males 85
and over: 12.3% per annum; compared to an average growth of 3.7% across other age
groups.15
Rapid knowledge acquisition in the field of radiology
7.4
The traditional model of general radiologists, as consultants to referring practitioners, has
provided essential care and served patients very well for a long time. However, as clinical
care has become more complex, a portion of imaging is now performed by sub-specialist
radiologists, who concentrate on one area of radiology, such as interventional radiology,
nuclear medicine or paediatric imaging. In some areas, such as tertiary and quaternary
referral hospitals, there has been a gradual increase in the degree of sub-specialisation of
radiologists along clinical specialties, in line with greater sub-specialisation of other medical
specialties.
7.5
There are good reasons put forward to support the need for both sub-specialist radiologists
and generalist radiologists, with or without a special interest. Broad, general imaging training
is essential as it provides a solid foundation for all radiologists and allows for a natural
progression of generalist radiologists to sub-specialists. Notwithstanding the continuing
need for the broad perspective and knowledge base of the radiologist, especially in rural and
remote practices and acute care settings, further sub-specialisation of radiologists will likely
be necessary for a number of reasons including the immensity of both general clinical and
radiological knowledge and the rate at which these are growing.
7.6
The growing array of radiological tools means that radiologists need to make fundamental
decisions about how to focus and balance their areas of expertise. Radiologists need to subspecialise to a greater or lesser extent according to the needs of their patients and referring
practitioners.
7.7
At the same time, it is difficult to assess what impact changes occurring in the healthcare
systems in Australia and New Zealand will have on clinical practice for imaging services and
to determine how this should be structured to provide integrated imaging to patients and
their referring practitioners. Although not referring to radiology directly, the Australian
Department of Health’s Independent Review of Health Workforce Program Report 16 made
the following comments in respect of overarching themes that emerged in the review:
15
Medicare. Medicare Group Reports [Internet]. [Updated 2014 August 22; cited 2014 August 23]. Available from:
https://www.medicareaustralia.gov.au/statistics/mbs_group.shtml
16
Mason J. Review of Australian Government Health Workforce Programs. Canberra: Australian Department of Health; 2013
May. 450 p.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 15 of 19
“The current system, despite reforms, continues to be focused heavily around increasingly
expensive and specialised acute care in major metropolitan centres, rather than on
measures to redirect resources to the provision of high quality primary care, population
health initiatives and preventative care. This is both unaffordable in terms of escalating
future cost, and inimical to optimum patient care, particularly of chronic conditions. It is
imperative both economically and for population health to move beyond a focus on specialist
medicine and acute care beds, to appropriate generalist skills, team based community care”.
Trend to more patient-centred healthcare delivery
7.8
Radiologists have become less visible and as a consequence the value of radiologists in
patient care is not widely recognised by the general public, patients or referring practitioners.
7.9
A shortcoming of the role of the radiologist is the lack of interaction with both patients and
other medical practitioners. This has worsened in the digital imaging environment: the
volume and complexity of examinations has increased and referrers are able to view images
online, sometimes before a radiologist has had time to report them.
7.10
RANZCR believes that public recognition of the value of radiologists is essential and this will
be dependent on having greater contact with patients.
7.11
Optimal patient care requires teamwork, coordination, sharing of expertise and
communication of information. The requirements of a more patient-centred model of
healthcare delivery necessitates a new and more collaborative radiology practice model that
more effectively combines the technological, organisational and image interpretation skills of
the radiologist with the patient insight and clinical skills common to all medical practitioners.
Radiologists are already key members of multi-disciplinary teams focused on optimal patient
outcomes. They need to have a greater, more recognised, role in clinical decision-making
and patient management.
7.12
More direct communication between radiologists and their patients and referring
practitioners will not only require a new radiology practice model but a culture shift –entailing
a change in the role of the radiologist to one that combines the ability to provide costeffective, additional value to patient care. An example of this is working with referring
practitioners to more effectively manage patients and ensure imaging is appropriate and
necessary, thereby reducing the need for follow-up studies.
7.13
An associated challenge will be changing the culture of certain referring practitioners who
see radiologists as technicians providing a service to the referring practitioner. Radiologists
need to be recognised as medical specialists whose knowledge and expertise is essential,
in the same way that a referral from a medical practitioner to a surgeon or other medical
specialist is viewed. There needs to be a change in nomenclature from ‘ordering’ or
‘requesting’ imaging to ‘referral to a radiologist’.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 16 of 19
7.14
A radiologist who is visible to both patients and their referring practitioners is the key to
patient-centred radiology.
Demonstrating the value of imaging and radiologists
7.15
There has been insufficient research into the benefits of appropriate medical imaging and
personalised care. A role for minimising radiation exposure by only performing tests and
treatments that are likely to benefit the individual patient clearly exists. Studies from other
countries where self-referral for imaging is common show that medical practitioners who
own medical imaging equipment refer their patients for imaging more often and that the
quality of these tests, including reports, is inferior.1718 Often, a set of images, a stand-alone
report, or both, is not generated, retained or accessible to others - thus the potential benefit
of the imaging is not available for the patient when being treated by other practitioners.
Policy changes and forward-looking funding arrangements
7.16
Policy changes and new funding arrangements will be necessary to ensure greater value
from available imaging techniques and imaging-guide procedures.
7.17
A more strategic approach to horizon scanning for new imaging technologies, applications
and procedures is required that can identify and prioritise assessments to make them
available to patients. This must be underpinned by a strong evidence base that
demonstrates their cost-effectiveness and benefits to patient health outcomes. This new
approach should be coupled with timely applications for public funding in Australia to the
Medical Services Advisory Committee (MSAC) and in New Zealand to the National Health
Committee at the Ministry of Health.
7.18
Further advances in information management systems – enabling integrated storage of
imaging data alongside clinical, demographic, histological, and genomic data – will enable
clinicians and epidemiologists to analyse relationships within the data. This will help inform
healthcare providers and policy-makers about which imaging tests and procedures provide
the greatest value to patients, including when and under what circumstances they should be
used.
17
Levin DC, Rao VM. Turf wars in radiology: updated evidence on the relationship between self-referral and the overutilization
of imaging. J Am Coll Radiol. 2008 Jul. 5(7):806-10. Doi:10.1016/j.jacr.2008.01.025.
18
Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: review of the empirical literature. AJR Am J
Roentgenol. 2002 Oct, 179(4):843- 50.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 17 of 19
8. RESPONDING TO THE CHALLENGES
8.1
RANZCR has a strategy and program of initiatives that aim to respond to these challenges
and achieve the following:

Enable radiologists to have a greater role in clinical decision-making and patient
management in line with best practice clinical guidelines

Changes will be required in Australia to the Medicare regulatory framework to remove
existing barriers to radiologists having a more collaborative role in imaging decisions

Advocate to ensure patients in Australia and New Zealand have access to appropriate
and affordable imaging care

Determine how optimal clinical radiology practice models should be structured within
the evolving healthcare system to provide integrated radiology for patients and their
referring practitioners

Identify and prioritise new technologies and applications with an evidence base that
demonstrates their cost-effectiveness and health outcomes, and submit an application
to the relevant assessment authorities for public funding

Determine strategies to mitigate and migrate from the current service delivery model
to more patient-centred radiology

Address and tangibly improve public awareness of radiologists

Determine how the imaging referral process should be managed in order to provide
integrated imaging care to patients and their referring practitioners

Determine the optimal balance in sub-specialisation for patient care

Further research on the clinical effectiveness of new and existing imaging techniques
and treatments.
RANZCR will support radiologists through this transition in practice and patient care
through training, professional development and advocacy, which will enable radiology to
emerge stronger for the future.
9. APPENDICES
A. CanMeds Key Competencies and Clinical Radiology
10. ACKNOWLEDGEMENTS
RANZCR is grateful for the input provided by the Faculty of Clinical Radiology, in particular Dr Sanjay
Jeganathan, Dr Catherine Mandel and Dr Greg Slater.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 18 of 19
Appendix A
CanMEDS Key Competencies and Radiology
The RANZCR curriculum consists of seven roles which encompasses the competencies of the
specialty. These roles are based on the CanMEDS model19, which stipulates the medical expert and
six non-medical expert roles as they pertain to radiology: team work; communication skills; patient
support and advocacy; professionalism; management and administrative skills; research and
education. The CanMEDS20 roles, as adapted to radiology in the RANZCR context, are illustrated
below:
Skill Set
Competency
Medical expert
Expert radiology knowledge
Clinical decision-making skills
Interventional expertise and judgment
Team work
Multi-disciplinary care
Communication skills
Report writing expertise
Presentation skills
Patient communication
Consent-taking
Patient support and advocacy
Appropriate use of medical imaging
Radiation and electromagnetic
safety Contrast agent safety
Professionalism
Ethical practice in radiology
Patient confidentiality in imaging
Management and administrative skills
Rostering and rotation planning
Space and resource planning
Purchase of new equipment
Research and education
Continuing professional development
Research skills and ethics
Performing a literature search
Appraisal of imaging literature
Teaching and assessment of radiology
Writing for publication and grant applications
19
Royal College of Physicians and Surgeons of Canada. Royal College: The CanMEDS Framework [Internet]. [Cited 2014 June
20]. Available from: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework
Adapted from the CanMEDS Physician Competency Diagram with permission of the Royal College of Physicians and Surgeons
of Canada copyright © 2009.
20
Frank JR(Ed). The CanMEDS 2005 physician competency framework. Betters Standards Better Physicians. Better Care.
Ottawa (Canada): The Royal College of Physicians and Surgeons of Canada, 2005. 40 p.
The Role and Value of the Clinical Radiologist Version 1.0
© The Royal Australian and New Zealand College of Radiologists®
November 2014
Page 19 of 19
THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS®