Risky radiology: not so black and white

First, the federal government announced a 3-year cost-saving trial in the 2009–10 Budget. Since 1 November 2010, the trial allows doctors to request certain “image-only” radiological investigations without an accompanying radiologist report.1 The investigations attract a lower rebate to cover only the technical component of image acquisition. The changes should not alter the cost to patients as most imaging studies, which currently include radiologist reports, are bulk billed.

The trial currently involves chest x-rays and certain facial examinations. The government’s presumption is that for these investigations a radiologist’s assessment is not required and referring practitioners will assume full responsibility for the correct identification and interpretation of all primary, secondary and incidental findings. In doing so, referring doctors will also accept all liability for errors. While the incentive for referrers to request these new item numbers is unclear, the increased risk and responsibility borne by them is obvious.

Second, in a measure to mimic the National Health System in the United Kingdom, there is advocacy from some levels of health administration to implement role extension for allied health professionals within diagnostic imaging. This would involve the provision of descriptive reports from non-radiologists with no conclusive interpretation, leaving referring doctors to draw their own clinical conclusions. Error rates for these types of reports are not insignificant when compared with a radiologist’s report.2,3 Disposing of a specialist’s evaluation may delay referral or management, and will again transfer responsibility for errors to the referring doctor.4 The false inference underpinning this model is that general medical and specialist training can be fast-tracked or circumvented without any detriment.

The most concerning ramifications from these proposed changes are those for standards of patient care. Reduced radiologist input will result in higher error rates and inaccurate diagnoses;5 will remove the option of clinical discussion regarding difficult cases; and may compromise elements of patient care. Ironically, such medical errors often increase downstream burdens for health systems, negating any short-term cost savings.

From a medicolegal perspective, undertaking independent interpretation of images and acting on descriptive reports is a high-risk activity and insurance premiums for doctors may ultimately reflect this.