Breast Surgeons Reading Screening Mammograms: Are Radiologists Always Necessary?


I came across an intriguing article on Medscape, which discussed having specially trained breast surgeons read screening mammograms. Justus Apffelstaedt, MD, chief of a breast health center in South Africa, presented his data at the 11th annual meeting of the American Society of Breast Surgeons in Las Vegas. 10,020 screening mammograms were analyzed, and the recall rate, biopsy rate and cancer diagnosis rate were tracked for two patient subdivisions, ages 40-49 and over 50. The conclusion was that specially trained breast surgeons are capable of accurately reading screening mammograms.

I did not see any data directly comparing the readings of breast surgeons with the readings of breast radiologists. That study would be challenging to design, but would be interesting to see.

I am not surprised that surgeons did very well in this study. Most clinicians probably agree that specialists are capable of reading their particular type of imaging with very high accuracy. This should hold true whether it is abdominal surgery, neurosurgery, orthopedics, or even medical specialties.

The issue is not to remove readings from the purview of radiologists, but to address shortage areas, where breast radiologists are unavailable. More broadly though, if radiology were transformed from its current format – where every film is reviewed, into a consultative format – where specialists read their own films, a massive amount of cost may be removed from the system. This would be true if the quality of the readings were acceptable, and if the specialists review of films were not separately billed.

Most physicians would not want to shoulder radiology risks atop their normal concerns, but they would have the option of getting a consultation at any time. For some specialties, it would seldom be asked. Consider hand trauma surgery. In the vast majority of these cases, the patient is seen and the radiographic diagnosis of a finger fracture or similar is fairly obvious. Surgeons here don’t typically wait around for the official reading of the films before they take care of the problem.

An argument against this paradigm is the “tunnel vision and missed significant incidental finding”. In other words, the surgeon looking at the abdominal CT scan focusing on appendicitis misses a tiny lesion in the liver or elsewhere. Although this is possible, it is likely to be rare, and under this system surgeons would have to make sure to first look at the film comprehensively – as is the teaching, to avoid the tunnel vision syndrome.

The lesson here might be that when there is a shortage of a particular service, an opportunity opens for a disruptive solution. (By disruptive, I mean against the normal grain of how things are done). Radiologists can try to avoid coverage gaps through the use of teleradiology, but other disruptions have been seen in the following areas:

-Specially trained non-dentist tooth specialists serving rural areas.
-Breast reconstructions being performed by surgeons other than plastic surgeons.
-Primary care being increasingly delivered by nurse practitioners or physician assistants.

We are likely to see many more examples over time. These are not problems per se, but they can represent opportunities to direct resources to fill service gaps. Careful tracking of clinical outcomes as well as costs will be two important metrics to consider when studying the impact of these developments.

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