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The 2006 ACR Forum: Cardiovascular Imaging: Learning From the Past, Strategies for the Future

2006; Elsevier BV; Volume: 4; Issue: 1 Linguagem: Inglês

10.1016/j.jacr.2006.08.020

1558-349X

Richard B. Gunderman, Jeffrey C. Weinreb, James P. Borgstede, Bruce J. Hilman, Harvey L. Neiman,

Advanced X-ray and CT Imaging

This paper summarizes the 2006 ACR Forum, which explored the history of the relationship between radiology and cardiovascular imaging and sought to explore strategies by which radiology could cope with similar challenges in the future. Key topics include: competition between radiology and other medical specialties, the importance of cardiac imaging, the relative merits of cardiologists and radiologists as cardiovascular imagers, and specific recommendations for radiology leaders in the areas of education, research, clinical practice, and policy. This paper summarizes the 2006 ACR Forum, which explored the history of the relationship between radiology and cardiovascular imaging and sought to explore strategies by which radiology could cope with similar challenges in the future. Key topics include: competition between radiology and other medical specialties, the importance of cardiac imaging, the relative merits of cardiologists and radiologists as cardiovascular imagers, and specific recommendations for radiology leaders in the areas of education, research, clinical practice, and policy. Herb Abrams, one of the pioneers of cardiac imaging and professor emeritus of radiology at Harvard University and Stanford University, recalls a 2-hour conversation with one of the United States’ most prominent radiologists. This leader was lamenting radiology’s imminent demise. Neuroradiology was being captured by the neurologists and neurosurgeons, gastrointestinal radiology by the gastroenterologists, uroradiology by the urologists, musculoskeletal radiology by the orthopedists, and so on. What was precipitating what he called the “end of radiology?” Key factors included a lack of interest among radiologists, insufficient training and research, and a dearth of role models. As a result, radiology was about to be picked apart by other specialties, and no one seemed inclined to do much to stop it. Although this gloomy forecast sounds familiar, this conversation did not take place earlier this year, but some 46 years ago, in 1961. The more things change, the more they remain the same. The bearer of this dark forecast, Leo Rigler, MD, did not foresee the introduction of completely new imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance (MR), as well as the development of new techniques in angiography and interventional radiology, innovations that would not only revive radiology but endow it with unprecedented strength. And yet his pessimistic forecast was not completely without merit. Radiology would soon largely cede to other specialties a number of these gains, including much of obstetrical ultrasound and most coronary angiography. What happened, and what lessons can be drawn from this experience for radiology’s future? To address these questions, the ACR convened its annual Forum in June 2006, in Reston, Va. The Forum is an annual long-range planning event of the college, which brings together individuals with varied viewpoints and perspectives on a topic considered to be of strategic importance to the specialty. The 2006 Forum was titled “Cardiovascular Imaging: Learning From the Past, Strategies for the Future.” The Forum explored the history of the relationship between radiology and cardiovascular imaging and sought to devise strategies by which radiology could cope with similar challenges in the future. Although cardiovascular imaging served as the focal point of the discussions, the ultimate goal was to look beyond the heart to better understand and respond to the challenges that radiology faces from other specialists across all organ systems and imaging modalities [1Hillman B.J. Neiman H.L. Radiology 2012: radiology and radiologists a decade hence—a strategic analysis for radiology from the Second Annual ACR Forum.Radiology. 2003; 227: 9-14Crossref PubMed Scopus (17) Google Scholar]. What follows is a synthesis of the discussions that took place among the Forum participants. The article concludes with consensus recommendations to the specialty on how radiology can better contribute to cardiac imaging. Radiologic imaging of the heart takes a number of forms, including plain radiography, cardiac catheterization and coronary angiography, nuclear medicine, echocardiography, CT, and MR. Since the 1960s, however, cardiologists have virtually replaced radiologists in performing echocardiography and catheter cardiac imaging, and nuclear cardiac imaging has been slowly migrating from radiologists to cardiologists [2Levin D.C. Rao V.M. Turf wars in radiology: should it be radiologists or cardiologists who do cardiac imaging?.J Am Coll Radiol. 2005; 2: 749-752Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. Forum participants identified a number of reasons for cardiology’s success with these procedures. Most significantly, cardiologists see patients clinically and are able to play the roles of both referring physician and imaging consultant, which is almost never the case for radiologists. In addition, the American Board of Internal Medicine required training in these cardiac imaging modalities to sit for its cardiology examination, whereas the American Board of Radiology’s oral examination had no specific cardiac section. (A “virtual” cardiac section has recently been added to the American Board of Radiology’s oral examination.) Many more cardiologists than radiologists received training in cardiac catheterization and coronary angiography, and cardiology contributed a greater proportion of the research [3Levin D.C. Abrams H.L. Castaneda-Zuniga W.R. et al.Lessons from history: why radiologists lost coronary angiography and what can be done to prevent future similar losses.Invest Radiol. 1994; 29: 480-484Crossref PubMed Scopus (29) Google Scholar]. As of 2003, radiologists were still performing more than 90% of cardiac CT and MR, but cardiologists are showing great interest in these modalities [4Wysong P. Cardiac MRI: use it or lose it—to cardiologists: an expert interview with Vivian Lee, MD, PhD. Available at: http://www.medscape.com/viewarticle/5288322. Accessed July 18, 2006.Google Scholar]. Today, just as in 1961, some radiologists see the specialty as under siege, even using the term turf war to describe the state of affairs [5Kaiser C.P. Cardiac imaging: radiologists move to protect CT and MR turf.Diagn Imaging. 2004; November: 48-61Google Scholar, 6Levin D.C. Rao V.M. Turf wars in radiology: the overutilization of imaging resulting from self-referral.J Am Coll Radiol. 2004; 1: 169-172Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar]. They regard cardiac CT and MR as one such turf war, in which every gain by cardiology is a loss to radiology. One difficulty with this siege mentality is that it usually portrays radiology in the role of the besieged. In fact, however, radiology is not a perpetual loser. Over the past few decades, radiology has acquired much more territory than it has lost. As examples, interventional techniques have supplanted general surgery in areas such as abscess drainage and hemostasis, CT has largely replaced diagnostic peritoneal lavage and exploratory laparotomy in the evaluation of abdominal trauma, and positron emission tomography frequently replaces surgical biopsy and resection. One area in which the role of radiologists has expanded dramatically is neuroradiology. Decades ago, most neuroradiology was performed by neurologists, neurosurgeons, and orthopedists. Over time, however, the new radiologic specialty of neuroradiology was introduced, and now radiologists do most neuroradiology. What happened? First, despite uncertain career prospects, a small number of radiologists dedicated themselves full-time to neuroradiology. Second, the specialty was formalized through fellowships, followed by formal testing by the American Board of Radiology. Third, the National Institutes of Health provided funding for such fellowships, which promoted substantial research in the field by radiologists. Another area in which radiologists have assumed greater responsibility is breast imaging. This includes a substantial role in patient intake through screening mammography; in diagnosis through diagnostic mammography, aspiration, biopsy, and needle localization; and in management through active collaboration with surgery, oncology, and radiation oncology. Keys to this success included aggressive quality assurance measures such as accreditation, stringent continuing medical education requirements, board certification, and maintenance of certification. Organized radiology was highly supportive of the federal Mammography Quality Standards Act, which many believe was responsible for persuading nonradiologists to give up performing low-volume, low-quality mammography. Radiology’s history has been characterized by successive waves of innovation, in which radiologists develop, nurture, and refine new techniques, getting them reimbursed and simplifying them to the point that other specialties begin to move in. As long as radiology remains dependent on referrals from physicians in other fields, this is situation is likely to persist. One means of thriving in such a niche is to keep innovating, thereby ensuring that radiology is always at the front of the next new wave in innovation. What makes cardiac imaging worthy of attention? According to the American Heart Association, approximately 6.5 million US patients visit emergency rooms each year with a chief complaint of chest pain [7American Heart Association. Heart disease and stroke 2006 statistics. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3037327. Accessed July 30, 2006.Google Scholar]. Although in many cases, the cause of the pain turns out to be noncardiac, cardiac disease is usually the most important diagnosis to exclude. Moreover, the American Heart Association estimates that there are 13.2 million patients in the United States with coronary artery disease. Imaging of the anatomy of the heart and coronary arteries and various aspects of cardiac function is crucial in establishing such diagnoses. Ongoing research suggests that cardiac CT and MR may be able to provide imaging of these structures that is quick, noninvasive, very low risk, and substantially less expensive than other diagnostic alternatives. Radiologists have other reasons to take a special interest in cardiac CT and MR. For one thing, if radiologists are willing to cede CT and MR of the heart to cardiologists, other specialists may ask why they should not assume responsibility for cross-sectional imaging of their particular organ systems. For example, neurologists and neurosurgeons may seek to take over responsibility for brain and spinal imaging. Orthopedists may argue that they should control the imaging of joints such as the knee, hip, and shoulder. Gastroenterologists may seek to take over responsibility for such studies as computed tomographic colonography. And urologists may argue that they should be responsible for cross-sectional imaging of the urinary tract. Indeed, these transitions are already under way, propelled in part by decreasing volumes and reimbursements for traditional services in these specialty areas. The appeal of cardiac imaging is likely to vary according to modality. For example, MR of the heart is more time consuming, necessitates more technical knowledge and physician involvement in image acquisition, requires more extensive postprocessing, and offers less potential revenue than routine studies such as brain MR. Because of longer examination and interpretation times and lower levels of reimbursement, an MR scanner might generate one fifth or even one tenth the daily revenue performing cardiac studies that it would produce performing brain studies. For these and other reasons, cardiac MR may remain a “niche player” for the next 5 to 10 years, focused mainly on evaluating parameters such as flow, function, and perfusion. High-speed, multidetector CT, on the other hand, is the first generally applicable noninvasive test for coronary anatomy and pathology, and it is likely to be widely embraced. Cardiac imaging has been perhaps the greatest single driving force behind the development of 64-slice and dual-source computed tomographic scanners, a clear indication that equipment vendors recognize the potential magnitude of the market. Aside from the sheer number of patients undergoing cardiac imaging and the potentially very large revenue associated with it, there are other reasons for interest in cardiac CT and MR. One is the intrinsic interest of the studies themselves. Heart disease is a major cause of death and disability among US adults of all ages, and the ability to image the anatomy and physiology of the heart offers great opportunities for disease prevention and therapeutic intervention. From an economic point of view, the opportunity to put cardiac CT and MR to work in prevention is compromised somewhat by the fact that there are currently no government or private payer policies that provide coverage for imaging asymptomatic patients with risk factors for cardiovascular disease. At present, such patients need to pay for such studies out of pocket. Even more significantly, there still is much research to be done to demonstrate that the application of these technologies to population-based screening actually reduces morbidity and mortality from cardiovascular disease. Currently, no generalizable studies support this contention. Should cardiologists assume responsibility for most cardiac CT and MR? Cardiologists advance a number of arguments to this effect. They claim a better understanding of cardiac anatomy, physiology, and pathology than radiologists. They argue that they are more likely than radiologists to understand the management implications of various cardiac imaging findings. They claim that they are likely to know more than radiologists about patients’ clinical conditions, because they are often the physicians who refer patients for cardiac imaging studies. Likewise, the results of imaging studies are more readily available to treating physicians when the diagnostic and therapeutic roles are combined in cardiologists. Finally, they claim better preparation than radiologists to cope with rare but potentially life-threatening cardiac complications of such imaging procedures. Of course, there are also disadvantages when imaging studies are performed by the same physician who is directly managing a patient. There is a possibility that the clinical picture may inappropriately influence image interpretation, leading to interpretations that the images themselves do not warrant. Moreover, if each diagnostic test generates additional income for a referring physician, there is a possibility that this financial incentive may increase marginal or inappropriate utilization, thereby increasing waste and driving up health care costs. Furthermore, cardiologists attempting to establish high-volume cardiac CT and MR imaging services will necessarily image many patients who are not their own. These would include referrals from family physicians, internists, cardiac surgeons, and surgeons in other specialties performing preoperative workups. In these cases, the cardiologist would probably not know the patient, nor would the results of imaging studies be more readily available to the treating physician. What rationales support the performance of cardiac CT and MR imaging by radiologists? Radiologists generally understand better than cardiologists the physics and technology of CT and MR imaging, as well as the artifacts they can generate. Radiologists are often more skilled at workstation postprocessing as well. Radiologists are better trained than cardiologists to pick up extracardiac diseases, some of which may clinically mimic cardiac disease, such as aortic dissection, pulmonary emboli, pericardial and pleural effusions, and masses in the mediastinum and lungs. Another argument in favor of having radiologists perform coronary artery imaging is the fact that radiologists currently perform CT and MR imaging of the vasculature of every other organ in the human body, and it is difficult to argue that a special fence should be drawn around the heart. To address the concern that cardiologists are not qualified to interpret chest imaging outside the heart, a major equipment vendor recently proposed to market a computed tomographic scanner that would produce images of only the heart. Although the entire chest would be exposed to ionizing radiation, and thus imaging data for all the extracardiac structures of the chest would be at least potentially available, the scanner would display the heart and great vessels alone. The situation would be analogous to a physician performing a complete physical examination on a patient but only recording and acting on the cardiac portion of the examination. After intense discussions, the vendor in question has decided not to proceed with marketing this scanner. However, this example illustrates the more general principle that equipment vendors feel little loyalty to any particular medical specialty and are generally prepared to sell their devices to any physicians. Another model that has been proposed for cardiac CT and MR is the so-called “split interpretation,” in which a cardiologist interprets the heart and a radiologist interprets the remainder of the thoracic structures [8Dakins D.R. Caiser C.P. Specialists discover common ground in cardiovascular CT.Diagn Imaging. 2005; February: 9-11Google Scholar]. As long as the total charge for interpreting such studies does not exceed that of a single physician interpreter, payers may not object to such arrangements. Some might argue that splitting examinations offers patients the best of both worlds, with a heart specialist interpreting the cardiac structures and a chest specialist interpreting the remainder of the thorax. In fact, however, split interpretation is fraught with peril. For one thing, radiologists who enter such arrangements will be seen as ceding cardiac expertise to cardiologists. Insofar as such studies are labeled cardiac and performed primarily for cardiac evaluation, radiologists will be relegated to the status of second-order interpreters. Moreover, split interpretation may set the precedent for the development of similar arrangements by other specialties; for example, gastroenterologists may argue that they should interpret the colonic portion of computed tomographic colonography, leaving the rest of the abdominal and pelvic structures for radiologists to read. Depending on how split interpretation is configured, there are other potential pitfalls, including false-claim liability, antikickback violations, and increased malpractice risk. On the other hand, proponents of split interpretation argue that failing to accept such arrangements would disadvantage patients and implicitly undervalue the work of radiologists by encouraging nonradiologists, who possess less training and experience, to assume responsibility for evaluating domains of anatomy that they are poorly equipped to handle. What strategies would most effectively promote radiologists’ contributions to the future of cardiac CT and MR? Broadly speaking, the strategic focuses include education, research, clinical practice, economics, and policy. In considering how to improve education in cardiac imaging for radiologists, it is important to recognize that many radiologists and radiology residents regard cardiac imaging, including cardiac CT and MR, as lost. In many programs, no radiology residents even consider careers in the field, perhaps in part because they lack faculty cardiac radiologists to serve as role models. Although a virtual cardiac section is now part of the American Board of Radiology’s oral examination, many residents seem to regard cardiac imaging merely as a hurdle they must clear to pass their board examinations. Given the great prevalence of heart disease, it might be reasonable for residents to spend less time learning about obscure genetic conditions and rare tumors they are likely to see only once in their careers and more time on the anatomy and pathology of the coronary arteries. If radiology is to play a prominent role in the future of cardiac imaging, it is vital that today’s radiology residents be trained in cardiac imaging, with the hope that some will choose careers in the field. This raises the broader issue of what it means to be a radiologist. To secure the future of the specialty, it may be necessary to devote less training time to becoming a general radiologist and more time to specialization. Recent proposals have suggested that residents spend only 2 years studying general radiology, then devote a year to research and 2 more years to clinical training in a specific field, such as breast imaging, neuroradiology, or cardiac imaging [9Dunnick N.R. Applegate K.E. Arenson R. Levin D. Training for the future of radiology: a report of the 2005 Intersociety Conference.J Am Coll Radiol. 2006; 3: 319-324Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. In cardiac imaging, proponents argue that most generalist radiologists lack the necessary depth of understanding to provide greater value than cardiologists who pursue cardiac imaging fellowships. To contribute substantially to the diagnosis and management of heart disease will require a cadre of radiologists who focus intensively on both clinical and imaging aspects of cardiac disease. The adage that the specialty that drives the research directs clinical care requires modification. Virtually all of the fundamental research that led to routine coronary angiography was performed by radiologists, yet today radiologists perform only a small percentage of coronary angiograms. However, it is probably accurate to say that those specialties that do not drive the research agenda have little or no chance at playing a substantial role in the corresponding clinical arena. Hence, it is vital for radiologists to participate more substantively in cardiac research. Until recently, most research publications in cardiac MR were authored by radiologists, but the balance has shifted, and the majority of publications now emanate from teams of cardiologists and radiologists. The number of cardiac MR publications by radiologists has flattened out, while cardiologist-only publications are increasing (A. Stillman, personal communication). In terms of funding for cardiac research, it is probably a mistake to look for large commitments from vendors. The fact that results from any industry-funded clinical research would likely benefit all vendors means that no single vendor has a sufficient incentive to invest in such investigation. Insurers generally regard the beneficiaries of research to be the specialists who use the technologies clinically and are reimbursed for their use, and insurers have largely abstained from supporting research. The major source of funding for imaging development and assessment remains the federal government, and the National Institutes of Health has a mandate to foster more effective prevention and management of heart disease. That being said, it is vital that radiologists create and cultivate new sources of funding for clinical research in cardiac imaging. At least one source might be radiologists themselves, who can contribute at greater levels to academic radiology departments and the research funds of national radiology organizations. In terms of clinical practice, radiologists need to define a niche for cardiac imaging in each large department or practice. Specialist radiologists are more likely to add value in the eyes of referring specialists than general radiologists. To add value to cardiac specialists will require radiologists to specialize in cardiac imaging. A person in each large group needs to be designated the cardiac radiologist, and that individual must be competent to fulfill that role. Ideally, the cardiac radiologist would be actively engaged in research in the field (which is probably more difficult for radiologists in nonacademic settings) and in collaborating with clinicians who routinely refer patients for cardiac imaging. A complicating factor in this equation is the shortage of radiologists. On one hand, it might seem desirable that radiologists assume responsibility for all cardiac imaging, including perhaps even echocardiography and coronary angiography, as well as cardiac CT and MR. On the other hand, there are simply not enough radiologists in practice to assume this additional workload. Such a move would be disastrous to an already understaffed field. In fact, many radiologists are so busy with the work they already do that they have little interest in taking on additional responsibilities for cardiac imaging. A related danger is the contentment of many radiologists with the status quo. Many feel that they are already reaping sufficient professional and financial rewards from their practice and have no interest in investing the time and energy to develop new skills in cardiac imaging. An adage states, “A fat cat never hunts.” New domains of clinical imaging are likely to be won not by the most contented specialists but by the hungriest ones and those with the most vision. In this sense, radiologists risk becoming the victims of their own success. To respond to this challenge, radiology needs to relieve the current shortage and create opportunities and incentives for radiologists to pursue new clinical service lines. Another clinical pitfall for radiologists is the tendency to organize their thinking in terms of modalities. If radiology is to play an important role in cardiac imaging, radiologists need to think less in terms of modalities and more in terms of the anatomy, physiology, and pathology of the organ system. The most important question is not “What can we do with this CT scanner?” but rather “What approaches can best contribute the most value to patient care?” Ultimately, the clinical focus is more important than the technologic focus, and radiologists need to begin with the fundamental questions to which their clinical colleagues need answers. Referring physicians do not care what modality is used. They do care about how to provide better care to patients. If cardiologists are seen as the only heart doctors, then radiology’s prospects in the area of cardiac imaging seem dim. Radiologists should consider ways to enhance their image with patients. One possible approach is to meet with patients to discuss the results of their examinations. Face-to-face contact with patients is one of radiology’s most valuable untapped resources. Promoting cardiac imaging in public forums such as community groups can also prove highly effective. It would be helpful for radiologists to visit primary care practices to promote cardiac imaging services. To succeed, radiology needs to promote the presence of passionate cardiac radiologists in each health care market, giving cardiac imaging in-services and grand rounds and serving as active partners in the care of patients undergoing evaluation for cardiac disease. Economics also plays an important role. Radiologists need to cease thinking of themselves as toll collectors who exact a payment every time a patient crosses the imaging bridge. Instead, radiologists need to recognize their distinctive economic contribution, which is that of large-scale imaging production [10Enzmann D.R. A different look at turf.Radiology. 2005; 234: 347-349Crossref PubMed Scopus (6) Google Scholar]. Radiology is the best specialty to keep expensive pieces of equipment such as CT scanners and MR scanners busy all day long. Cardiologists preparing a business case for purchasing a scanner would either need to find noncardiac uses for the equipment or team up with other cardiologists to fill up the daily schedule. Moreover, the infrastructure to support high-quality imaging is expensive, and economies of scale in centralizing that infrastructure tend to support an ongoing role for radiologists. Without forsaking this large-scale niche, radiologists should seek out additional ways to add value, for example, by developing better personal relationships with patients and referring physicians. Image quality and patient safety are crucial, but service and marketing may represent the greatest economic opportunities [11Hillman B.J. Amis E.S. Neiman H.L. The future quality and safety of medical imaging: proceedings of the Third Annual ACR FORUM.J Am Coll Radiol. 2004; 1: 33-39Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. To attract patients, radiologists need to build business models that appeal to primary care physicians. Radiologists also need to stop thinking of themselves as combatants in a winner-take-all match [12O’Connor E.J. Liebscher L.A. Fiol C.M. Beating them or joining them: your radiology group’s path to the future.J Am Coll Radiol. 2004; 1: 755-761Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. They need to give up the counterproductive attitude that the rest of medicine is pitted against them, as some opponents of “self-referral” have come to think. Protectionist measures that seem to promote economic and professional security in the short term actually represent long-term suicide. Radiologists should not devote their energies to establishing an exclusive domain but instead cooperate with other physicians to improve patient care. Radiologists need not control all cardiac imaging to do well for patients, referring physicians, and themselves. Only part of a whole can still be a great deal. Another way radiology can win its share of the cardiac imaging market is by helping others, especially patients and referring physicians. Radiologists need to change existing referral patterns and cultivate new referral sources. Other specialties, such as family medicine, general internal medicine, and surgery, may prefer to send their patients to radiology, knowing that radiologists pose no threat of capturing them. It is unlikely that radiologists stand to gain much by marketing to cardiologists, but there is great potential in marketing directly to physicians who do not see radiologists as such a threat. Patients and primary care physicians are likely to represent far more fruitful referral sources for cardiac imaging than cardiologists. Radiologists need to recognize that policymakers have little or no interest in medicine’s turf battles. They are, however, happy to secure higher-quality and safer care, especially if it results in lower overall costs. Radiologists may be wasting their breath decrying self-referral, but there is much they can accomplish by emphasizing opportunities to keep costs low. In fact, continuing to harp on self-referral may prove counterproductive by making radiologists seem more and more like outliers, radically different from all other physicians. There is nothing to be gained by portraying radiologists as the only kids in the sandbox who cannot play with everyone else. Ultimately, such attitudes undermine radiologists’ credibility as advocates for quality, affordable imaging, and the best interests of patients and society. Instead of battling other specialties, radiologists might do better to seek out avenues of agreement and forge alliances with them. Legislative remedies are not necessarily long-term solutions. Instead of pursuing regulatory relief for what some radiologists deem the unfair competition of self-referral, radiologists can respond to changing forces in the health care marketplace. As one example, certificate-of-need laws seemed the bane of radiologists when radiologists were the only physicians seeking approval to install new imaging equipment. Now that other specialties are seeking approval to purchase their own equipment, radiologists have come to see certificate-of-need laws as quite congenial. It is important that radiologists help create credible standards for credentialing that promote adequate training and experience to perform and interpret particular imaging examinations. There are important differences between national and local efforts. At the national level, there is relatively little the ACR can do to promote cardiac imaging by radiologists beyond developing training standards and appropriateness criteria [13Weinreb J.C. Larson P.A. Woodard P.K. et al.American College of Radiology clinical statement on noninvasive cardiac imaging.Radiology. 2005; 235: 723-727Crossref PubMed Scopus (58) Google Scholar, 14Cohen M.C. Garica M.J. Hodgson J.M. et al.ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance.J Am Coll Cardiol. 2005; 46: 383-402Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar]. Every radiologist does not necessarily exhibit a measurable quality advantage over every nonradiologist. At the local level, however, real victories can be won through hard work in research, education, and forging strong clinical relationships with other health professionals. In sum, radiologists might see themselves less as “prey” than as “predators.” They can operate not in a defensive mode but in a creative mode, seeking to develop new strategies by which to add value to both patients and referring physicians. Moreover, they can cultivate relationships with benefits managers and health care payers, with whom they share a common interest in reducing unnecessary imaging utilization. Radiology’s case for playing an important role in any health care domain should ultimately rest on radiologists’ genuine advantages in terms of quality, safety, service, and cost. The Forum concluded with participants’ recommendations for actions that could be taken by the ACR, other national radiology organizations, local radiology practices, and individual radiologists to promote the performance of cardiac imaging by radiologists. •Promote curricula for cardiac imaging education and develop and disseminate cardiac educational modules.•Recommend to the American Board of Radiology that the prominence of cardiac imaging on the board examination be enhanced, in part by transforming the virtual cardiac section into a full-fledged, independent cardiac section.•Develop opportunities for further radiologist subspecialization in areas such as cardiac imaging, through greater flexibility in how the American Board of Radiology and the Radiology Residency Review Committee define a radiologist.•Develop a permanent educational facility for the hands-on training of radiologists in emerging technologies such as cardiac CT and MR.•Expand residency and fellowship curricula to emphasize more of the basic sciences of radiology, including such disciplines as anatomy, physiology, and pharmacology.•Develop programs that encourage radiology departments to develop local experts in cardiac imaging and other emerging technologies.•Increase the number of cardiac fellowship training slots.•Develop programs that educate residents and practicing physicians in improving patient contact and satisfaction. •Expand resources for cardiac imaging research by radiologists, including both the basic and clinical sciences.•Expand the scope of the ACR Imaging Network® beyond cancer to include clinical trials of diseases of the cardiovascular system.•Support outcomes research for cardiac imaging, including the establishment and maintenance of data registries.•Develop more effective collaborations with industry for clinical trials in cardiac imaging and other emerging technologies. •Encourage radiology departments to establish a section of cardiac radiology or designate cardiac radiologists.•Promote the vitality of subspecialty societies dedicated to the development of radiologists as cardiac imagers.•Develop models of imaging care that place greater emphasis on patient contact.•Assist radiologists in identifying new referral sources and changing referral patterns, as well as service models that reflect these changes in the marketplace.•Identify market segments in cardiac imaging in which radiologists are most likely to be successful.•Encourage increased emphasis on the outpatient sector to address new competitive demands and opportunities.•Develop new practice models that address the needs of patients and referring physicians.•Market cardiac imaging and other underfilled practice niches to trainees.•Develop more effective radiology marketing and branding models for patients and referring physicians.•Emphasize radiology’s strengths compared with other specialties such as cardiology. •Address certificate-of-need issues with state governments.•Promote radiology credentialing and privileging models with institutions and payers.•Develop and disseminate a statement on split interpretations involving radiologists and other specialists.•Renew the focus on quality and standards, especially by enhancing efforts to promote legislation restricting reimbursement to designated providers of medical imaging.•Promote dialogue over common interests between radiology and benefits managers.•Improve relationships with other specialty organizations and hospital associations.•Continue an aggressive advocacy program with government and private payers.•Promote the adoption of the ACR’s practice guidelines as minimum qualifications for the performance and interpretation of imaging examinations We wish to thank all the participants for their valuable contributions to this article and the discussions that spawned it. The Forum chair was Jeffrey Weinreb, and the cochairs were James Borgstede, Bruce Hillman, and Harvey Neiman. Additional participants included Nick Bryan, David Dowe, Reed Dunnick, Mickey Guiberteau, Richard Gunderman, David C. Levin, Van Moore, Cindy Moran, John Patti, David Robbins, Geoffrey Rubin, Arthur Stillman, Jonathan Sunshine, James Thrall, and Kay Vydareny.