A patient has a CT scan. Photo: 123RF
This is the fifth story in an RNZ series about the growing pressures and profits in the fraught field of radiology.
Radiologists say their sector is in "turmoil" amid profound ownership changes and a fight with surgeons buying up stakes in private scanning practices.
The sector's president has emailed colleagues to apologise for appearing to go easy on the surgeons in an earlier interview with RNZ.
"I made comments that could have been better expressed and when selected comments were quoted, this proved most unhelpful.
Dr Sanjay Jeganathan Photo: Perth Radiological Clinic
"I apologise for any and all offence this has caused members," the head of the Royal Australian and New Zealand College of Radiologists, Sanjay Jeganathan, wrote in an email seen by RNZ.
He, the college and the sector are showing the strain from a fight triggered by what Jeganathan called investor "frenzy".
"Private equity firms and investment managers in all their wisdom now view DI [diagnostic imaging] businesses as infrastructure assets [like ports, roads and airports]," he told colleagues.
"With new investors and partnerships entering the market, along with changing referral patterns and practice models, we are witnessing a highly charged shift which is having a profound impact on diagnostic imaging [DI] businesses in New Zealand," wrote Jeganathan, who lives in Perth.
"The battle is mostly over market share for high-tech imaging but radiologists I have spoken to are also worried about the knock-on effects for basic 'community imaging' [eg obstetric scans] and the future sustainability of the radiologist workforce in this environment."
A half dozen joint ventures between surgeons and radiologists are being set up in the three main centres. They will all require staffing with highly paid specialists who train for 15 years plus, mainly in the public system.
This presents a widely acknowledged conflict of interest, because they could refer patients for scans at a practice they own. Research indicates this leads to too much scanning.
Previously, Jeganathan told RNZ such ownership was acceptable as long as it was fully transparent.
But his new email puts the college firmly on the side of those opposing the surgeons.
"We recommend diagnostic imaging be performed by a provider entirely separate and independent from the referrer or the referrer's employer."
This is called "arm's-length" referral.
"We reiterated that from a governance/ principles perspective, no distinction could be drawn between passive and active investment if the investor or a related entity could influence business outcomes."
The fight pits the Institute of Independent Radiologists, backed by the Infratil-controlled Pacific/ Bay/ Auckland Radiology group, against the joint ventures championed by Auckland's Mercy Radiology.
Mercy's Dr Lloyd McCann said Jeganathan had put out a "well-balanced communication".
"We particularly applaud the recognition that mixed ownership models where they exist widely across the sector are not 'automatically' unethical," McCann said.
The institute argues there are risks to patient safety, funding and radiologists' independence.
It has a hearing at the High Court in November, to try to force ACC to stop funding the joint ventures, which could be fatal for them.
New stance welcomed
Institute chair Dr Adrian Balasingam said it was good the president was spelling things out.
"These conflicts cannot be managed, regardless of the amount of disclosure," he said.
The investor rush in the past year has made multimillionaires out of quite a few radiologists, including at Pacific Radiology.
Surgeons have accused incumbents of trying to protect market share.
Jeganathan said Australia's radiology guidelines warned "against conduct likely to substantially reduce competition, a noteworthy reminder to all parties in this debate".
Last month he had told RNZ that "from the public's perspective, it could be argued that the rich doctors are fighting amongst themselves".
'Dismayed' at suggestion NZ being ignored
The Radiologists College told RNZ it would be "inappropriate" for us to quote the internal email, which several radiologists had sent to RNZ.
In it, Jeganathan said he was "dismayed" at suggestions the college leadership was neglecting New Zealand.
"It pains me to see so much turmoil among our members."
He went on to warn: "Actions in the heat of commercial battle" could lead to losing the privileges the sector enjoyed.
The college could not regulate business ownership itself, but had been clear with regulators, he said.
However, Jeganathan added that Australia's rules do not preclude non-radiologist doctors holding shares, while Balasingam insisted they do.
The college has already been facing trans-Tasman strains over how to train more radiologists because New Zealand operates very differently from Australia.
The Medical Council is running a consultation over commercial pressures of all kinds on doctors.
Its new draft statement - an update on 2012 - stresses the importance of integrity, transparency and the potential to overtreat.
Doctors must recognise companies could influence their clinical decisions and take steps to guard against "any bias or conflicts of interest".
"Any payment or benefit you receive from a health-related commercial organisation must be documented and disclosed," is one core principle.
"Generating a profit is a principal goal for many commercial organisations. However, your primary concern as a doctor must always be the care of your patients."