Ellen B. Mendelson, MD

More than 10 years ago, when we began to develop a women's imaging fellowship in Pittsburgh, there was great enthusiasm for bringing together all the imaging techniques needed for evaluation of women at various ages and stages of life. To support clinical activities, share experiences, and further define the focus of a women's imaging subspecialty and its goals, the Society for the Advancement of Women's Imaging (SAWI) was formed. Breast imaging studies and pelvic ultrasound examinations were to be done at one site, and MRI, bone densitometry, and evaluations of medical problems that largely affect the female population were also offered.

The rationale for the women's imaging approach made good sense clinically and for patient care. Economically, also, women's imaging would seem to have offered an excellent opportunity for practice growth. Taking stock of the last decade, however, it is evident that little progress has been made in large hospital-based outpatient settings or in large academic centers. Breast imaging and other modality-specific sections of radiology are loosely tied, and the women's imaging services are not truly integrated.

High-end private practices dedicated to the major studies and procedures requested by and for women have done very well. These practices, some of which have bypassed the low CMS reimbursements by operating on a cash-only basis with charges that will ensure profit rather than loss, offer breast imaging, ultrasound, and bone densitometry. The equipment is generally state-of-the-art, and patients are well treated.

Why has women's imaging, a very good idea, not taken hold? A number of reasons apply. Unfortunately, there is no easy answer. As part of radiology, women's imaging has essentially been ratcheted down to breast imaging, and several negative forces have prevented expansion into other areas of women's imaging. Mammography's efficacy is periodically attacked in the news media, and women question their annual ritual. Reimbursement for mammography is poor, although for 2003, the proposals for reducing reimbursement have been softened somewhat. Another inhibiting force is medical malpractice. The enormous liability associated with missed or delayed diagnosis of breast cancers has deterred many residents from entering the field of breast or women's imaging. Fellowship training is necessary, and the pool of potential fellows has almost completely dried up; currently, the hot fellowship is musculoskeletal within a body imaging fellowship framework. The stressful work, low reimbursement, high liability, and loose organization of women's imaging services within radiology departments have resulted in a shrinking number of centers and services. Already, radiology departments are looking for ways to subsidize mammography, so that the fiscal responsibility for this public service does not fall upon radiology's shoulders.

In addition, turf issues and possession of the patient by physician colleagues have diminished the scope of women's imaging. Obstetric/gynecologic imaging has been lost to most radiology departments. Without pelvic ultrasound and obstetrical ultrasound studies, often done by sonographers in the OB/GYN's office, a women's imaging fellowship is deprived of an important segment of training. Bone densitometry is more and more a nonradiologic study, occurring in internists' and OB/GYNs' offices. The loss of these and other procedures has had a negative effect.

Is there a ray of hope? Radiology may look for partnering to the few very large, merged imaging companies with well-publicized women's health divisions for marketing, education, and program development. The interactions of these companies with radiologists and radiology departments can help promote women's imaging and stimulate growth in these areas. Corporate support and the networking of these companies for women's imaging within radiology might help.

Ellen B. Mendelson, MD, is professor of radiology and chief, Breast Imaging Section, Northwestern University Medical School, Northwestern Memorial Hospital, Lynn Sage Comprehensive Breast Center, Chicago.