Often unknown to the general public, physicians in the U.S. continuously struggle to defend and expand their increasingly overlapping empires. Hospitals, freestanding healthcare centers, and other venues are their battlegrounds and facility planners are often in the crossfire. As medical technology continues to evolve ― and reimbursement diminishes ― the traditional boundary lines separating specialties have become blurred and facility planning can be contentious.
RADIOLOGY DEPARTMENT AT THE FOREFRONT
Although many areas of the healthcare realm are involved, the hospital radiology department is the most frequent zone of conflict. Historically, radiology provided a limited number of modalities focused on diagnostic imaging and it was a physically distinct “department” of the hospital. As technology advanced, radiology evolved beyond the traditional diagnostic role to include a variety of therapeutic and invasive procedures. The interventional radiologist’s stock and trade has been the angiogram (an X-ray of the inside of blood vessels) and the precise placement of catheters in blood vessels. With the development of procedures like coronary angiograms, the placement of stents (small mesh tubes that act as scaffolds inside an artery), and balloon angioplasties to open up blockages, radiologists were in direct competition with cardiologists. Then neurosurgeons co-opted the placement of stents in the brain to prevent strokes while vascular surgeons started to compete for new revenue associated with less invasive treatment for peripheral vascular disease.
At the same time, a number of other specialties developed procedures which rely on the use of technology that used to be only available in the radiology department ― fluoroscopy, computer tomography (CT), and other imaging modalities. Gastroenterologists, neurosurgeons, cardiothoracic surgeons, orthopedists, and cardiologists all wanted access to this advanced technology as well. Simultaneously, with insurers devising bundled payments for patients based on their specific ailments, specialists were forced to share the same diminishing healthcare dollar.
Radiologists viewed the intrusion of other specialists into their traditional turf as an economic as well as professional threat, particularly in the growing outpatient market. As vendors began offering new financing options for costly imaging equipment its acquisition became more practical for group practices. Imaging modalities previously only available in hospitals became more common in outpatient settings. Cardiologists expanded into computer tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Neurology groups bought their own MRI units and obstetricians and gynecologists added ultrasound and mammography capabilities.
COMPETITION IN THE SURGERY SUITE
The trend in surgery has been toward less and less invasive treatment. With the advent of minimally invasive surgery ― sometimes known as laparoscopic or key hole surgery ― surgeons perform procedures through incisions as small as 1/16 of an inch. Though technically demanding, surgeons trained in the art of laparoscopic surgery and minimally invasive techniques can perform many traditionally “open” procedures with the same or better safety and speed while offering the patient a quicker recovery time and reduced risk of complications.
In place of cardiac surgeons performing bypass operations, interventional cardiologists started performing angioplasty and deploying stents to treat coronary-artery disease. Between 2000 and 2010, the number of traditional cardiac bypass surgeries fell more than 30 percent. And then there are interventional radiologists, using catheters and stents to deal with carotid artery disease, in place of vascular surgeons who use a scalpel in the operating room. Technology further melds as neurosurgeons use intraoperative magnetic resonance to view images of the patient’s brain to help them remove tumors without damaging other parts of the brain. The hybrid operating room has permanently installed equipment such as intraoperative computed tomography (CT), magnetic resonance imaging (MRI), and fixed c-arms ― typically used in conjunction with cardiovascular, thoracic, neurosurgery, spinal, and orthopedic procedures ― to enable diagnostic imaging before, during, and after surgical procedures.
Thoracic surgeons and pulmonologists share some of the same territory in diagnosing lung cancer and changing technology is further shifting the balance. CT lung cancer screening picks up more small, early-stage lung cancers that pulmonologists are treating endoscopically without any surgery which is eroding the turf of the thoracic surgeon. The use of robotic surgery, endobronchial ultrasound, and CT lung cancer screening are creating even more conflicts.
MULTIDISCIPLINARY INTERVENTIONAL SUITES
Radiologists, cardiologists, vascular surgeons, and neurosurgeons not only increasingly overlap in the types of diagnostic and interventional procedures that they perform, but the procedure room, support space, and the equipment is essentially the same whether a procedure is performed to assess heart function, brain function, or other vascular issues. Duplicate interventional procedure suites have evolved at large medical centers because each specialty demanded their own turf. The trend is to create a centralized suite that can be shared by all specialties. Even if the actual procedure rooms are dedicated, their co-location will provide optimal future flexibility as specific procedures and techniques evolve over time. The sharing of patient intake, prep, and recovery space provides savings in capital as well as operational dollars. The further co-location of the interventional suite with the surgical suite can provide additional flexibility with the melding of interventional radiology, minimally-invasive, image-guided, and traditional open surgical techniques.
RADIOLOGISTS MARKETING NEW PROCEDURES TO OUTPATIENTS
Radiologists have traditionally focused on the procedure itself rather than pre- and post-procedure patient care and relied upon other specialists for referrals. Radiologists are beginning to market directly to patients and are opening outpatient centers to respond to niche markets. Some specialties whose turf they are now invading include:
- Cardiology. Non-invasive coronary computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are both alternatives to invasive cardiac catheterization in diagnosing heart disease. Both modalities are minimally invasive and less costly than traditional cardiac catheterization. Now that cardiologists have managed to wrestle cardiac angiography from interventional radiologists, the radiology department is striking back.
- Gastroenterology. Using 3-D images from CT or MRI, radiologists are touting the benefits of virtual procedures that compete with procedures traditionally done in an endoscopy suite by the gastroenterologist. For example, colonoscopies to screen for colon cancer have been traditionally performed by a gastroenterologist using a fiber-optical scope but are now being offered in the radiology department. These new virtual colonoscopies are less invasive and need no sedation although the preparation for the patient is the same. Then there is Cologuard that is aggressively marketing a noninvasive at home screening option for colon cancer. These trends could impact the planning of endoscopy suites across the country with an estimated 15 million colonoscopies done annually by gastroenterologists.
- Gynecology. Many gynecologists see patients with uterine fibroids requiring treatment and automatically schedule surgery to remove the fibroids or the entire uterus itself. However, the interventional radiologist may be able to perform an effective yet minimally-invasive uterine fibroid embolization (UFE) procedure that provides the same relief for the patient.
- Vascular surgery. Varicose veins have been traditionally treated in the operating room by the vascular surgeon. However, the interventional radiologist, using endovenous laser treatments or ultrasound-guided sclerotherapy, can provide quick, safe, and relatively painless relief for the patient without invasive surgery.
Unfortunately, turf battles among specialists show no signs of abating. Since healthcare, like politics, is local, turf issues between specialties depend on local leadership, historical relationships, and a culture of competition versus collaboration. Historically, adoption of a new, alternate, or replacement treatment or modality occurs rapidly once Medicare and insurance companies start paying for it. Insurers may also decide on the most cost-effective alternative which will result in patients being directed to one technology or another.
Planning diagnostic and therapeutic imaging facilities, and assessing the need for imaging equipment, can be complicated from many perspectives. Historical workload trends may no longer be an indicator of future workloads. Because of new advances in multi-functional imaging equipment, the challenge is not only how many procedure rooms and what size, but what type of equipment and where should it be located. Facility planners must help their clients create flexible and generic space to the extent possible while avoiding getting hit in the crossfire between competing specialists.
See related article: Vascular Centers Are Addressing an Unmet Demand.
This article is an update of a previous post.