ASNR Special Focus Lecture: The Neuroradiologist as a Primary, Secondary, and Referring Physician

I think it is useful to periodically review the current content and practice dynamics of medical specialties and their impli­ cations for the future of neuroradiology. Within the memory of most of you, neuroradiology was viewed as an intellectual specialty, with most procedures­ pneumoencephalography, cerebral angiography, and myelog­ raphy-performed by neurosurgeons and a few neurologists. The superior knowledge of neuroradiologists, along with overburdened practices of neurosurgeons, eventually (but with no little struggle) transformed the specialty into a pro­ cedural/cognitive one, initially by those specifically trained in neuroradiology and later by other "general" radiologists trained by those leaders. This transition was assisted in no small way by the introduction of catheter techniques, which mandated new skills . Training programs in neurosurgery con­ tinued to include neuroradiology, often with the reasoning that many practice locations may not have radiologists trained in neuroradiologic procedures. This changed as more radiol­ ogists were trained , and currently it is rare for neurosurgeons to acquire hands-on experience with procedures. Almost from its inception, the American Board of Radiology examined candidates in "intellectual" neuroradiology; that is, it required knowledge of anatomy and pathology but not actual performance. Over time, the content of the examination changed from emphasis on pneumoencephalography and myelography and plain-film examination of the skull to cerebral angiography, including questions on the "cerebral vein of the day." Then came CT and MR imaging, and emphasis again shifted. These changes were a reflection on what was hap­ pening in the practice of neuroradiology. All this occurred without recognition by certification of the subspecialty of neuroradiology. The process of accreditation of fellowships in neuroradiology is now approved, and invita­ tions are being sent to institutions to apply for accreditation of neuroradiology fellowships . But this success story of the discipline is not likely to continue forever. Already, challenges for the CT and MR turf plague many of you in this Society as well as radiologists practicing neuroradiology. The reasons usually cited are eco­ nomic-too many neurologists and the greater reimburse­ ment rewards for procedures as compared with so-called cognitive practice. However, I am not convinced that econom­ ics is the sole driving force . A contributing factor is a matter of specialty pride. We certainly have it in radiology-defining in our minds what is OURS. Other specialties do likewise. A good example is urology, where intravenous pyelography is considered part of the specialty. Residents are trained in interpretation; and, commonly, practicing urologists perform it in their office. In some military hospitals, urologists perform IVPs on in- and out-patients, and there is no financial incen­ tive . But economics does play a major role. During neuroradiol­ ogy 's shift from an intellectual to a procedural specialty, procedures were favored by reimbursement from the private insurance carriers and , in 197 4, by Medicare. And radiologists were well positioned because skills in catheterization proce­ dures rested almost completely in their domain.