be certified by the American. Board of Radiology,. American. Osteopathic. Board of Radiol- ogy, or Royal. College of Physicians of Canada or otherwise.
AJA:159,
November
payment
CAPITAL
1992
of Medicare
the difficulty.
inpatient
However,
never been adequately Invariably,
capital
the capital
costs will only add to
needs
met through
PLANNING
of hospitals
depreciation
schedules.
replacement of buildings or equipment is far more than the original acquisition cost and therefore not
expensive
offset by the amount
determined
on depreciation
schedules.
Moreover, the Medicare capital pass-through has been discounted. Hospitals must increasingly look beyond the funds
cally generated to generate will
have
through
capital become
simply
had a separate
depreciation
always
graphic
systems
will also become
natural
candidates
to be interfaced
Institutions
can evaluate
of plant and equipment
for their capital expenditures.
more common with
their needs for PACS by assessing
for PACS.
Computer-based equipment provides an opportunity to perform dynamic imaging and to extract quantitative physiologic and biochemical information, in addition to anatomic and pathologic information, from images. The increasing computerization of radiology will have a capital implication in the
In manufacturing and other industries, the capital expenditure is simply part of the overall business plan. It is driven by programmatic or product line and business development needs. The key to success will be better management of capital assets and more efficient use of capital equipment.
purchase of either the imaging equipment tions for processing the data. However,
With
to pay-
entist.
The traditional
institu-
become
a computer
the
ments tions
stronger
linkage
for capital
will be penalized
ductive
of patient
equipment
care
productivity
vs cost reimbursement,
for acquiring
unnecessary
continued
capital costs, new computer personnel will be necessary to run the equipment and perform the analyses. The traditional radiologic physicist will increasingly become a computer sci-
radiology
film librarian
will increasingly
operator.
or unpro-
practice
in health care of isolating
the capital proc-
ess from the overall reimbursement and business process. In some sense, this should unshackle the hospital planning process and may be more realistic from a business practice perspective than the old system.
New Capital
Needs
The major have notfaced
capital expenditure in the 1990s that in the past is the acquisition of picture
and communication referred
for the
1990s
systems
to as image
(PACS).
management
hospitals archiving
The systems
are also
and communications
sys-
tems. The success of radiology has overburdened the historical manual-based methods for handling images. The pace of modern
hospitals
and efficiently
and the need to take care of patients
has put departments
of radiology
quickly
in a defensive
posture. The expense for acquiring PACS for large institutions will be in the multimillions of dollars, more expensive than any
single imaging institutions,
device currently the
proportionately
expense
in clinical operation.
will
still
less. A reasonable
be
specific needs or transmission
although
to the acquisition
through
the modular
of partial PACS or “mini PACS’ that address such as multimodality viewing of digital images of images
department,
to the
or operating
intensive
rooms.
care
Conclusions
Radiology
is one of the most capital-intensive
specialties
in
medicine. Hospitals have been pressed to maintain an appropriate capital replacement program for conventional radiographic equipment at the same time they have had to spend unprecedented capital dollars to acquire equipment for new digital cross-sectional modalities. The aging base of
conventional
radiographic
equipment
is a financial
time bomb
ticking away in the hospital industry. Historical depreciation schedules grossly underestimate capital requirements for replacement of equipment and do not take into account new technology or increases in the number of studies performed. Therefore, a comprehensive capital plan must include a re-
placement program based on today’s dollars, must take into account the hurdle of deferred purchases, and should address both increases in the number of procedures and changes in practice patterns. Hospital administrators will suffer sticker shock as they see their radiology capital expenditure needs for the 1990s. They must overcome this shock because imaging is increasingly central to patients’ treatment. Exploratory surgery is far less desirable than “nondestructive testing” through
medical
imaging.
In smaller
substantial
approach
is to build out to a full system
implementation
gency
itself or workstain addition to the
equipment.
In the long run, it is quite possible that the capital DRGs and the DRGs for inpatient care will be merged. This should not be looked on with alarm or negatively in and of itself. The overall level of reimbursement is far more important than the
of PACS
and are
PACS.
how well their current film handling and reporting systems are working. For example, if loss or nonavailability of studies is considered a problem, PACS can provide a solution. Radiology departments with several geographically separate loca-
tions are also prime candidates specifi-
funding. When this view is taken, hospitals more like other businesses that have not
reimbursement
1111
IN RADIOLOGY
units,
Computed
emer-
radio-
REFERENCES 1 . Kay T. Volume
and intensity of Medicare physician Health Care Financing Rev 1990:2:1 33-1 46 2. Berenson A, Holahan J. Sources of the growth
services:
an overview.
in Medicare physician expenditures. JAMA 1992:267:687-691 3. American Hospital Association. Estimated useful lines of depreciable haspital assets. Chicago: American Hospital Association, 1988
1112
American Roentgen Ray Society: Committees, and Membership Information
Officers,
Officers
National
President:
A. Everette
President-elect: 1st Vice-president: 2nd
James,
Andrew
R. Leopold
Ralph
Joseph
1. Ferrucci,
Treasurer:
Beverly
P. Wood
Jr.
R. J. Alfidi, Davis, N. R. A. E. James, Jr., J. A. Kirkpatrick, Leopold, J. E. Madewell, T. C. Poznanski, R. J. Stanley, J. H Executive
Council:
D. 0.
J. Casarella,
Wood,
K. H. Vydareny,
R. N. Berk, M. P. Capp, W. Dunnick, J. T. Ferrucci, Jr., Jr., A. M. Landry, Jr., G. R. McLoud, A. A. Moss, A. K. Thrall, N. 0. Whitley, B. P.
chair
Policy:
P. C. Freeny,
R. N.
Berk,
A. G. Levitt,
E. Buonocore,
M.
C. R. B. Merritt,
M.
Figley,
W. J. Casarella,
and
Research:
B. Higgins,
R. J. Stanley,
G. M.
R. R. Hattery,
Glazer,
W. M. Thompson,
N. 0.
C.
McClees,
D. J. Anderson,
R.
J. E. Madewell,
A. A. Moss,
J. H. Thrall,
chair
M.
C.
Rohrmann,
Jr.,
Nominating:
Budget:
P. Capp,
Madewell,
chair
Publication:
E. Buonocore, W. J. Casarella,
B. Merritt, Membership:
A. Moss,
D. 0.
Davis,
American patrick, American
R. G. Levitt,
Board
E.
C. R.
T. C. McLoud,
J. E. Madewell,
A.
Organizations
W. J. Casarella,
of Radiology:
College
of
B. L. McClennan, Medical
J. A. Kirk-
Evens,
Radiology:
R.
N. H. Messinger,
Association:
alternate;
A.
T.
Gagliardi,
National
Standards
Measure-
Meetings: San Francisco, New Orleans,
Annual
Goergen,
Institute:
of Pathology:
J. E. Madewell
Meeting
R. R. Lukin,
A. M. Landry, Instructional
April
25-30,
CA; LA
April
Committee:
1993,
Marriott
24-29,
1 994,
J. K. Crowe,
N. H. Messinger,
San New
FranOrleans
N. R. Dunnick,
R. J. Stanley,
R. D. Steele,
Jr.,
Jr., chair Courses:
B. L. McClennan,
associate
chair,
chair
Scientific Program: P. H. Arger, W. R. Brody, G. D. Fullerton, R. M. Gore, D. C. Kushner, D. L. Resnick, W. M. Thompson, J. H. Thrall, C. J. Zylak, A. K. Poznanski, chair D.
Schlesinger,
Exhibits: F. S. Chew, J. M. Destouet, S. Hartman, L. A. Mack, R. G. Ramsey, T. J. Welch,
N. R. Dunnick,
J.
R.
A.
E.
chair
E.
Membership
Application forms may be obtained from the ARRS offices in Reston, VA. Qualified applicants will be admitted quarterly. Send completed forms to American Roentgen Ray Society, 1891 Preston White Dr., Reston, VA 22091 . Active members
are graduates
of an approved
medical
or osteopathic
school
or hold an advanced degree in an allied science. They must practice radiology or work in an associated science in the United States or Canada and be certified by the American Board of Radiology, American Osteopathic Board of Radiology, or Royal College of Physicians of Canada or otherwise adequately document training and credentials. International members are foreign radiologists or scientists who are
active
in radiology
or an allied
are residents or fellows dents in an allied science.
science.
in radiology
Members-in-training or
postgraduate
stu-
R. J. Stanley
R. A. Gagliardi,
G.
J.
CPT
delegate;
Advisory
Committee American
J.
Jr., L. F. Rogers
Madewell,
G.
P. C Freeny, chair
to Other
American
R.
A.
K. Gedgaudas-
chair
Representatives
and
Arrangements
cisco, Hilton,
ARRS and
Protection
Whitley,
chair Finance
Radiation E. L. Saenger
Institute
Annual
Scientific Haaga,
chair Education
Forces
R. J. Stanley,
Committees Editoral
Armed
Meeting
J. Alfidi
Secretary:
on
F. D. Miraldi,
Jr.
K. Poznanski
George
Vice-president:
Council
ments:
M. E. Haskin
Business
Office
Paul R. Fullagar, Executive Director, American Ray Society, 1891 Preston White Dr., Reston, (703) 648-8992; 1 -800-438-2777.
Roentgen VA 22091;
1113
Perspective
Subspecialization Alexander
and Certification
R. Margulis1
The trustees of the American Board of Radiology agreed at their January 1992 meeting to seek approval from the American Board of Medical Specialties to issue added certificates of qualification in neuroradiology, pediatric radiology,
and vascular and interventional radiology coming almost 6 years after the American ogy Council adopted in 1 986 further subspecialty certification, policy. The change recognizes
slowly
and inexorably
subspecialties
that
a policy reflects the fact
transformed exist
[1]. This decision, College of Radiolstatement against a dramatic shift in that radiology has
itself into a multitude
alongside
the
general
practice
of of
radiology [2-5]. This transformation was caused by the veritable explosion of new techniques in medicine, which greatly increased the value of radiologic diagnostic contributions to the clinical management of patients [6]. The fact that turf battles have started in almost every radiologic subspecialty also has emphasized the need for certification. Radiologists,
like all physicians,
to their patients’ welfare. whether subspecialization
owe their primary
allegiance
It is important, therefore, to consider in radiology is needed, whether
subspecialties of qualification
other than the three designated for certification will be needed, and whether subspecialization along lines of technology also is needed. Finally, one must ask whether subspecialization, prevalent in academic centers,
can be applied to community hospitals and outpatient private practice. Is radiologic subspecialization needed? The knowledge data base in medicine has expanded so rapidly and massively in the last 20 years
that it is virtually
impossible
for a radiolo-
gist or any other physician to keep up with the advances in the whole field and also keep up with the galloping technologic progress. Today, this knowledge gap is even more critical as 1
Magnetic
in Radiology
Resonance
Science
Center,
University
of Califomia,
San Francisco,
radiologists
are increasingly
November
1992 0361 -803X/92/1
595-1
1 13 © American
not only
to contribute
therapy. These added responsibilities, along with new opportunities, are forcing the advent of the subspecialists, of those who know the intricacies of and modern developments in
medicine
in the given field and can use this expertise
the appropriate
imaging
study
and interpret
sectional anatomic
techniques, relationships
become and
radiologic
in performing images
radiologic in their
fields.
in a
the patient. the cross-
generally depict lesions and more clearly, clinician specialists
very interested
interpreting
to select
the images
meaningful way to help the clinician in managing As the new approaches to imaging, particularly
their have
procedures Their
pro-
fessed reason for doing this is that they can perform these functions better than the general radiologist can. Another argument is that imaging techniques can be learned in a relatively medicine
cialists,
short time, whereas it takes years to learn clinical and much effort to stay current in it. Imaging subspe-
however,
can enhance
their superior
technical
exper-
tise fairly easily by acquiring the clinical qualifications of their specialty through additional training and practice. Will further radiologic subspecialties be needed? The three subspecialties designated by the American Board of Radiology for approval are obviously only the beginning of recognizing the legitimacy of other subspecialties, such as cardiac, chest, genitourinary, gastrointestinal, and musculoskeletal radiology, and, finally, mammography. To propose all of them for approval initially would probably be unwise, as the medical
bureaucracy,
as with all bureaucracies,
needs time to digest
and be comfortable with any changes, no matter how logical and even how de facto established they are. The question of 500 Pamassus
Ave. (MU 322w), San Francisco, CA 941 43-0292. Address reprint
requests to A. A. Margulis. AJR 159:1113-1114,
expected
significantly to making diagnoses but also to help stage diseases, guide biopsies, and even participate in or administer
Roentgen Ray Society
MARGULIS
1114
AJA:159,
November
1992
for totally technology-oriented subspecialties also will undoubtedly arise. Subspecialists in sonography will probably question organ subspecialization first. However, unless
offices, it would in larger groups
organ-oriented
subspecialty. The chest radiologist and the cardiac radiologist could form a team that also incorporates the interventional radiologist. The neuroradiologist and the musculoskeletal radiologist could join forces and the gastrointestinal and gen-
the need
subspecialists
in radiology
adopt
sonography,
will be taken over by other clinicians, as has already occurred with echocardiography, endorectal sonography for examination of the prostate, and even obstetric sonography. Where radiologists subspecialize in these areas of sonography, they have generally had the advantage in keeping them the field
in radiology,
and
their
clinical
specialty
colleagues
happily
depend on the subspecialized, highly skilled radiologist. In the long run, CT and MR imaging subspecialists are probably not needed. As the imaging method matures and techniques develop, organ-oriented subspecialists routinely take over the examinations in these cross-sectional techniques. Radiologic
subspecialties
are
already
a
reality
in
large
teaching centers. In many of them, radiologic subspecialists have formed teams with their clinical specialty colleagues, which has resulted in joint teaching and research programs. The question economically
patient
arises, however, whether subspecialties can be feasible in community hospitals and in the out-
private
practice
As diagnostic
reflect
radiology
the outside
world is highly radiology must
radiology
of radiology. is a consultative
worid
of the practice
specialty,
to medicine
and to the patients
That
because
it must and can ensure continued efforts in advancing the field of imaging. In the private practice of radiology and in
academic
centers,
all radiologists
must also be general
radi-
ologists, as that keeps the field together and is the foundation on which the subspecialties are built. In private practice,
whether
in community
hospitals
or in outpatient
itourinary
of the group
radiologists
could
can have a major and a minor
work
together,
help
out the chest
radiologist, and also do mammography. These are just some of the possibilities, and undoubtedly others will emerge.
Will subspecialty certification eventually lead radiology to a tower of Babel, where no one understands anyone else? The danger is obvious, and that is where knowledge become
and some
practice
of general
radiology
for every
subspecialist
can serve as the binding collagenous substance. Subspecialization in radiology must overcome all obstacles if radiology is to survive.
Let us not forget
that in this world
litigation, ever stricter committees, and state
of seemingly
licensing boards, hospital and federal bureaucracies,
eventually be classified and restricted to a type that is determined by the certificate on the wall.
endless
credential one may of practice
it must
of medicine.
specialized and even subspecialized, and adapt in order to survive. The existence of
is important
ogy, members
be advantageous for radiologists to practice to ensure that besides doing general radiol-
centers
and
REFERENCES 1 . ACR Bull. 1992:48(3): 1 , 4. 2. Margulis AR. Subspecialities in diagnostic radiology: the road to glory or disaster. Radiology 1981:140:837-838 3. Hampton AO. Subspecialization in radiology: response to a need. AJR 1987:148:465-469 4. Redman HC. The route to subspecialty accreditation. Radiology
1989;172:893-894 5. Capp MP. Subspecialization 6. Miller JD, Starr 1989;39:33-36
L. Information
in radiology. AJR 1990:155:451-454 explosion in radiology. Can Assoc
Radiol
J
1115
Memo
Impediments
to Clarity:
Rhetorical Robert
N. Berk1
Pratfalls and Elizabeth
An Annotated
complex, expertise
with
these
linguistic
is extremely limited, and expensive journal pages,
with these writing problems will begin to write better as they eliminate them from their writing. Third, when authors receive their edited manuscripts back from the publisher, they may be more likely to understand the reasons behind many of the
kling
clean-not
Stille
expression
to be well focused clear,
opaque
and concise.
their efforts
with
had a similar that renders
verbal
fog
idea [3]:
the ideas
the best. The style should
If authors
are wasted
fail
because
most
Nearly
1 50 years
simplest
form
[2].
“The
visible
have transparent
of
is undoubtedly
simplicity,
that the reader scarcely feels a barrier between the author’s.’ Medical writing is replete with opportunities
such
or has studied
linguistic
Grammarians
any type
pratfalls
of writing
and pitfalls
and language
experts
knows
seems
changes
that
Acronyms,
Overuse
Adverbs,
Meaningless
to be endless.
have devised
a whole
lexicon of seemingly mysterious terms to describe rhetorical transgressions and faux pas. A glossary of some of these terms is presented here. We do not mean to indicate that knowing the definitions has importance in itself; rather, we
indicated,
of (see
but
add
nothing
to the
Notes-Conciseness project,
so the
November
1992 0361-803X/92/1595-1
1 15 C American
given
serves
no useful
often
deleted
are
Collegiate are culled
adjectives,
sense
of the
verbs,
or other
sentence.
is a major goal of any medical writing
writer
must
function.
by medical
strive
Writers editors
to delete
any word
that
may note that “very’ because
the
is
adjective
it
describes carries the connotation of “very’ (e.g., “very many’ does not say much more than “many’). Williams [5] gives a helpful
list of other
add nothing to the meaning kind of, really, basically, definitely, practically, actually, virtually, generally. Also, the good writer will avoid using adverbs to modify
the author
adverbs
is trying
that
to convey:
words that, in view of their meanings,
Editor-in-Chief, American Journal of Roentgenology, 2223 Avenida de Ia Playa, Ste. 103. La Jolla, CA 92037. Address Contributing editor, American Journal of Roentgenology, 2223 Avenida de Ia Playa, Ste. 103, La Jolla, CA 92037. 159:1115-1119,
the definitions
“Jargon’)
that modify
Definition-Words
pitfalls
the number
by the editor.
as otherwise
derived from definitions in Webster’s Ninth New Dictionary [4], and some of the examples cited from manuscripts submitted to the AJR. Abbreviations, Overuse of (see “Jargon”)
adverbs
for
made
Except
his mind and
(mistakes that may lead to misunderstandings) and pratfalls (language errors that may cause the reader to chuckle in the middle of a serious article). Anyone who has ever tried to
AJR
acquaintance
time for reading journals who must be frugal with
ago,
1
an
examples, authors may begin to notice these or similar problems in their own work. Second, authors who become familiar
the importance of their work will be lost somewhere in the huge, ever-rising pile of unread or misunderstood research. Stanley Siegelman, editor of Radiology, aptly compares manuscripts to window panes; the manuscript must be spar-
2
having
with various degrees of and easily. Radiologists,
to make their message
of such
that
pratfalls and pitfalls of medical writing can help the author in several ways. First, after reading the following definitions and
readers quickly
require articles
write
of
Whalen2
believe
whose editors,
Glossary
and Pitfalls
Authors of manuscripts written for publication in radiology journals are faced with a daunting challenge [1 ]. They must present a large amount of information, much of which is
in a way that will understand
to Authors
Roentgen
Ray Society
cannot be qualified;
reprint requests to R. N. Berk.
the
