La Plus Change . . . Continuing Evolution of the Canadian Association of Radiologists Journal

Article Outline

• The Radiologist: Physician or Gatekeeper?
• Copyright

The universe is change; our life is what our thoughts make it.

Marcus Aurelius Antonius (AD 121–180), philosopher and Roman Emperor (AD 161–180)

As most of you already know, the Canadian Association of Radiologists Journal (CARJ) Editorial Office has moved from McMaster University in Hamilton to the University of British Columbia in Vancouver. An entirely new staff has taken over responsibility for running the journal. A few of you have undoubtedly already noticed some of the changes that have occurred in terms of the format of the journal and its cover. Many more changes not as obvious to readers have occurred behind the scenes as a long process of transitioning has been underway.

Many of you have made inquiries about the Continuing Medical Education (CME) feature of the journal (Insights4Imaging). This feature has not appeared in the journal since early in 2009, and it is being resuscitated with this issue. For a variety of reasons, the previous editorial team thought it was impractical to continue with the online submission of scores for this feature. At present, those of you filling out the questionnaires for CME credit will need to mail in your test sheets to the editorial office here at the Vancouver General Hospital. We have already brought on a computer consultant, Mr Michael Mudri, to help us restore online capacity for this feature, and we hope to have this up and running before the end of 2010. We realize that this CME feature is extremely important for many readers of the journal and hope to have a smoothly functioning mechanism for facilitating this in the near future. The editorial staff asks for your patience and tolerance while this is underway.

The Residents' Corner feature is also being altered. There have been a gradually increasing number of submissions of full-scale articles that necessitated reduction in the number of published Residents' Corner articles. In most instances, these articles will be reduced to 2 per issue. To economize on space, many of you will have also noticed that some of the blank spaces attached to these Residents' Corner features are no longer included. Traditionally, an unknown case has been published in one issue with the answer in the subsequent issue. In the near future both parts will be published in the same issue on nonfacing pages. Because we anticipate that a lower total number of Residents' Corner cases can be published, criteria for publishing these cases will be made somewhat narrower, with more unusual and novel cases being greatly favored for publication. This is also important in preserving the impact factor of the journal, because cases of this type are more likely to be cited in the literature. We would strongly encourage residents to consider publishing pictorial reviews, because these are greatly valued by the readership, are extremely valuable teaching exercises, and form an excellent basis for the awarding of CME credits.

One of the major ongoing challenges for CARJ has been securing the help of reviewers. We would very strongly encourage all of you to participate in this. Reviewers are certainly eligible to have their time credited under category six of the Royal College of Physicians and Surgeons Guidelines for MOCOP. Your help in this regard is appreciated by the editorial staff more than you can possibly imagine!

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The Radiologist: Physician or Gatekeeper? 

I am not young enough to know everything.

Oscar Wilde (1854–1900), Irish playwright and author

The more alternatives, the more difficult the choice.

Abbe Leonor-Jean-Christine Soulas D'Allanival (1700–1754), French playwright

Over the past year, we have all been bombarded with often grim economic news. Marked stock market fluctuations, huge governmental stimulus packages that resulted in significant budgetary deficits, and long-established iconic corporations going down to oblivion have all been part of this complex picture.

From a health care point of view, considerable fallout is being experienced as governments attempt to bring their finances into order, and, certainly, most of us have seen this locally in our own provinces. Certainly, this has been the case in western Canada. In my own province of British Columbia, the health care budget will soon constitute 50% of the total provincial expenditure, creeping up a little bit more with each year. In spite of the increasing outlay, major hospitals often find themselves in a situation where they are running annual deficits that must be brought under control and find themselves in situations where programs must be cut back. In my own institution, this has resulted in significant trimming back of the number of magnetic resonance examinations, as only one of many examples. Not unexpectedly, this has resulted in waiting lists ballooning alarmingly. Colleagues of mine in New Zealand, Ireland, and elsewhere have reported a similar phenomenon.

This continuing expansion of health care costs is caused by a variety of different reasons. Part of the issue is that there is so much more that we can do for patients now than we could 50 or 60 years ago. More diagnostic and therapeutic options exist for the same disease state. Much of this involves sophisticated, often expensive, technology that our predecessors never had the option to use. In addition, as the population grows older and lives longer, a larger segment of the population can benefit from the diagnostic and therapeutic tools that radiology can now offer.

As has often been pointed out in both the professional and lay media, the ongoing expansion of public health care budgets cannot continue increasing without limit. How much of the public dollar do we allow to be spent on health care, and how does one go about limiting it? Where is the line to be drawn in terms of what will or will not be done for patients, and who decides this? These are extremely difficult questions to answer, and a wide range of opinions exist. Some have proposed that it is up to physicians to decide where the line is drawn; in other words, who will or will not get certain diagnostic tests or procedures. This is not so bad if we do it based on clinical judgement as to who will or will not benefit from having a test or procedure done purely on medical grounds. It becomes much more problematic if the decision has to be made on financial grounds.

This raises the issue of whether we should function as gatekeepers? My own philosophy has been that I try to treat patients as if they were a relative or friend in terms of deciding whether or not there is any clinical advantage to doing a test or therapeutic procedure. If there is not a specific question to be answered when ordering a diagnostic test, then it probably should not be done. If there is not a reasonable expectation that an interventional radiologic maneuver will improve a patient's well being, then it should be avoided. I have never been comfortable with the concept that we can only do so many therapeutic interventional procedures in the course of a budget year, and it is up to the physician to decide who does and does not get it. This becomes a serious dilemma when the number of patients presenting who need the procedure exceeds the budget. I will keep doing the procedures until there is no more equipment left in the room, as long as it is clearly indicated that the patient will definitely have a good chance of benefiting from the procedure. Others clearly disagree with this philosophy, but, as a physician having taken the Hippocratic Oath, it is what I feel I must do.

Some would choose to use a battlefield type of philosophy, whereby they only treat the patients who will get the maximum benefit even if other patients could but are less likely to do so. Some would argue that this is the very reason that private health care should be more widely available in Canada to function as a decompression mechanism, preventing public health care budgets from getting out of control and also preventing these difficult “rationing issues” from worsening. This debate has already been engaged in and will undoubtedly intensify over the next few years as continuing pressure on health care budgets throughout the country increases. It is not an issue that will go away, nor is it a simple one. It, without a doubt, will be something that will greatly impact us in the coming years.