Referral to radiologists: the value of expertise and specialty training in the practice of radiology (more than a doc in a dark box).

High-resolution computed tomography (CT) of the lungs was first described in 1978 by Itoh et al (1), and within a decade it was recognized as an important diagnostic tool for the evaluation of the pulmonary parenchyma and small airways (2–8). Initially, high-resolution CT was largely the purview of academic, thoracic radiology specialists. Now, Scatarige et al (9), in a well-designed scientific survey of U.S. pulmonologists published in this issue of Academic Radiology, have demonstrated just how important specialists in lung disease believe this tool to be in the evaluation of their patients. Nearly all practicing pulmonologists make use of highresolution CT in their clinical practice today. Pulmonologists who refer patients to specific facilities for high-resolution CT examinations do so because they have confidence in the radiologists’ interpretations of the images— often the interpretation made by a specific radiologist. Pulmonologists generally trust their own thoracic radiologist(s), not anyone else’s! This is usually the result of trust and referral that are developed over time and is probably similar to relationships built by fellowshiptrained radiologists in all disciplines. It comes through sharing a common interest in and understanding of an organ system and the diseases that are encountered within that organ system, and the role of imaging in diagnosis of those diseases. As both a presenter and an attendee of continuing medical education programs on high-resolution CT and as a faculty person responsible for the oversight of thoracic radiology training in a large residency program and a thoracic radiology fellowship program, I have come to understand that interpretation of high-resolution CT scans is a source of considerable unease for many radiologists and radiology trainees. Continuing medical education presentations on high-resolution CT often draw large, standingroom-only crowds, and this is not because the speaker is better than the one next door. While teaching a protocol for high-resolution CT imaging is fairly straightforward, the interpretation of the images is often filled with nuance and frustration. In an academic medical center with a busy group of pulmonologists interested clinically and academically in diffuse interstitial and obstructive lung diseases, highresolution CT is performed often. We may interpret images from 10 such examinations in one day. In a private practice, by contrast, an entire group may not see that many high-resolution CT images in an entire month, and the images that do come along may get “left over” for others to read. The majority (85%) of pulmonologists regularly reviewed the high-resolution CT images themselves with the written radiologist report (9); however, almost a full third (32%) have interpreted the images themselves without the written radiologist report, implying that in such cases the pulmonologists felt more confident in their own interpretation (9). This may reflect not only their keen interest in the images themselves, but their unease with the interpretations they receive from radiologists. At a time of tremendous staffing shortage in radiology (10,11), many specialty training programs within radiology—including some of the very best and well known in Acad Radiol 2002; 9:1365–1367