Limits of teleradiology: A radiologist for each hospital

2014 06 16 10 34 49 368 Norbert Hosten 200

Dr. Norbert Hosten is director and professor in the Institute of Diagnostic Radiology and Neuroradiology of the Medical School of Greifswald University, Germany, and until May 2015 he was the president of the German Radiological Society (DRG). He is now its immediate past president. The motto he devised for his time in office was "Interconnectedness of radiology." A topic that concerns him in this context is teleradiology and the role of the radiologist within teleradiological scenarios.

DRG: Professor Hosten, you recently voiced your fears about teleradiology and the vanishing relevance of radiologists within the diagnostic processes. Is the situation really that bad?

Hosten: Let's get straight to the point: We need teleradiology. The question is to what extent and in what form.

Dr. Norbert Hosten, immediate past president of the German Radiological Society (Deutsche Röntgengesellschaft, DRG).Dr. Norbert Hosten, immediate past president of the German Radiological Society (Deutsche Röntgengesellschaft, DRG).
Dr. Norbert Hosten, immediate past president of the German Radiological Society (Deutsche Röntgengesellschaft, DRG).

At present there are two trends in our specialty. The first is a very liberal use of teleradiology in which referrer and appraiser are basically geographically separate from each other, acting in different institutions. With this approach, which is already very widespread in the U.S., in practice the radiologist only sees the patient in the form of radiographic images on his or her monitor, prepares a report, and sends this back to the clinician. There is no in-depth exchange between the radiologist and the referrer, or between the radiologist and the patient. This type of teleradiology is very efficient for radiologists because they can produce a high volume of findings reports very quickly.

The second trend is a more conservative approach. It involves having an in-house radiologist who is integrated into the treatment processes, who can speak to the clinicians and the patients, who explains the findings, and who can also ensure that radiation protection is adhered to. The latter is a very important point as the indication for radiological exposure must be justified. In all good conscience, this can only be done by a doctor who is an expert -- in most cases a radiologist -- who knows the case and the patient. It is precisely the confirmation of this clinical justification that can easily be overlooked in a teleradiological context. This can be critical if an investigation harms a patient, for instance because a pregnant woman is x-rayed. In such cases, the radiologist becomes accountable.

But the staffing situation at university hospitals and major institutions is not the same as in smaller institutions where teleradiology is often the only way of getting specialist expertise...

And in these cases teleradiology can be a blessing. We ourselves offer teleradiological services for hospitals in the surrounding area -- but only at night and at weekends. This is because many hospitals here in this region do not run their radiology service themselves and the providers have no standby services at the weekend.

The first scenario I have described goes a step further, however. Its underlying concept is to have no radiology at all in smaller hospitals, for reasons of cost, and to rely completely on teleradiology instead. In Germany, we are still rather cautious about implementing this approach, and this is certainly attributable to the high awareness of radiation protection. Also, only the radiologist can establish the individual radiation-sparing investigational techniques -- this is the radiologist's guiding function.

Basically, the questions are: How much added value does an on-site radiologist provide and what is the value to us of making this expertise -- whether it be the clinical justification, direct communication, or reporting of findings -- available to all patients equally? I'm not talking here about major institutions or the sort that only treat private patients. Let's be honest: these always provide the radiological service on site.

But what about the medium-sized and small institutions and rural districts? These suffer from great cost pressure and in some circumstances also from a lack of specialist staff.

The question of whether money is available for such a service is actually a social one. At present, there is a consensus: wherever a person has an accident, he or she will get a CT scan -- where and in what conditions this scan will be interpreted is an open question.

If an accident occurs in Munich, there will most probably be a radiologist on site who can communicate directly with the clinician and assess the accident victim personally. If the accident happens somewhere in Western Pomerania, a CT scan will be performed and the images from this might first have to be sent out and interpreted without any further communication. Looking at this quite objectively, there are differences here that have an impact on the level of care.

In my talks I like to use the following example: If you have to take the train from Mannheim to Frankfurt, a direct connection is available to you with the option of a first-class ticket. If you travel by train from Pasewalk to Szczecin, you will unequivocally have quite a different travelling experience in terms of speed and comfort. And now I ask this question: Do we also want to accept these differences in the provision of medical care?

It's easy to say no in this case, but it's not always exactly simple to provide another solution. What do you suggest?

The bottom line is that every hospital should have a radiologist. Society should fund this. But I also appeal to radiologists as a community: They must show that a radiologist's role is indispensable. For instance, we should communicate more with the clinical sectors and further expand -- so to speak -- the concept of service.

Editor's note: This is an edited version of a translation of an article published in German online by the German Radiological Society (DRG, Deutsche Röntgengesellschaft). Translation by Syntacta Translation & Interpreting. To read the German article, visit the DRG website. The original source of this interview was VISUS VIEW Nr. 11, 10/2015,

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