It is one of the many ironies of medicine today that quality has become an issue at the same time that physicians are becoming scarce, none more so than the radiologist, and of radiologists, none harder to find than the mammographer.

That the radiologist shortage is acute is without a doubt. A consultant I know ran a radiology department at a community hospital in New York State for 6 months on locum tenens alone before the administration managed to find a new radiology group that would agree to cover the hospital. This is troubling, not just for medicine and radiology, but for society at large. The hospital no doubt expended extraordinary effort and dollars just to maintain adequate service. Under such circumstances, there is scant likelihood of producing excellence. Physician supply is a complex issue and beyond the scope of this discussion, but the anecdote about the hospital with the locum tenens radiology department suggests that the government may have to resort to conscription. For a variation on that theme, see the Perspective in Health Affairs by Uwe E. Reinhardt, PhD, in the September-October 2002 edition of Health Affairs.

Mammography has become a flash point for quality in radiology, and that is another of medicine's ironies. The modality is based on the x-ray, highly efficacious in imaging bones but not so when it comes to soft tissue. Nonetheless, annual mammograms are a woman's best defense against dying of breast cancer and there are many studies to prove that early detection lowers mortality. Not all tumors, however, are detected by mammography, even when the image is produced with technology that meets the criteria of the Mammography Quality Standards Act, and even when read by an experienced mammographer. The modern version of the Hippocratic oath states, "I will not be ashamed to say I know not&.' " But this probably is not an acceptable defense in a court of law. Considering the popular pastime of suing mammographers for missing tumors that are extremely difficult to see and then pillorying them in the press, it is amazing that there are any radiologists willing to read mammograms.

In the interest of improving the effectiveness of the national screening program,  Senator Barbara A. Mikulski (D-Md) plans to introduce more stringent requirements for radiologists who read these studies. While there is considerable evidence in the literature that subspecialty reading does improve the accuracy of reports, this proposal could further damage access in the short term. And access is key in a national screening program. If there is no one willing to a) take the risk, b) take the heat, and c) underwrite the loss, we have a problem. Adding yet another requirement to the heavily regulated breast cancer screening program will add to its cost. To call for quality and then allow mammography to languish at the same reimbursement level for 8 years from 1992 to 2000 flatly is hypocritical.

Excellence in breast imaging and breast care in general will not be achieved solely through additional funding. Jay R. Parikh, MD, and Cathy Coleman, RN, have written an exhaustive article on what it takes to develop a quality breast care program, and it is a lot more than a well-maintained mammography machine. This is a collaborative effort that involves radiologists, oncologists, surgeons, and technologists (see "Building a Better Breast Program," page 60). It involves software, hardware, and the commitment and dedication of a lot of people. And it involves standards and accountability. Radiology must demonstrate to government and insurers what quality breast imaging entails and how much it costs to run such a program.

It would be a mistake for radiology to abandon the cause of access to quality breast care. Instead, radiology needs to take the lead in this discussion. Quality in medicine is a noble cause, and there are many in radiology who are working toward continuous quality improvement by developing standards, software, and technological improvements. What government and patients are willing to pay for quality is another issue altogether.

Cheryl Proval

cproval@medpubs.com