History of the Tennessee Radiological Society, 1934-2000
Webster Riggs Jr, MD

WHAT? Peer through someone’s flesh into his innards? Impossible!
WHAT? Radiologists bill hospital patient as other doctors do? Impossible?
But when we explore the history of radiology, we find the impossible becomes reality.

Historians of radiology are blessed with a very precise beginning. This “big bang” of radiology occurred on November 8, 1895, when Wilhelm Conrad Roentgen, a physics professor in Wurzburg, Germany, became the first to “see through the flesh.” After seeing the bones of his hand on a glowing screen near his cathode-ray tube, he worked the next few weeks to establish the basic physical properties of the x-ray. On December 28, 1895, he presented a paper entitled “On a New Kind of Rays” to the Wurzburg Physico-Medical Society.¹

On January 19, 1896, in the Sunday edition of the Memphis Commercial Appeal, the story broke as “The Discovery of the Century” (although it was placed on page 2 and the New York Sun had reported the story 11 days earlier).²

During 1896 hundreds of articles appeared in scientific journals describing all the forms of basic radiography and fluoroscopy common today. Descriptions of radiography of the GI tract and teeth were reported promptly. OB pelvimetry and even bone age determination from hand and wrist were described. Since most 1890s homes had a hand-held stereopticon viewer in the parlor, doctors could see stereoscopic x-rays as easily as photographs of Niagara Falls.

Generally the history of Tennessee radiology parallels that of the nation, but noteworthy contributions have occurred at the state level.

Only days after Roentgen’s discovery, Dr. John Daniel, a Vanderbilt physics professor, contributed a “Tennessee first” by observing the depilatory effects of x-ray. Daniel’s radiograph of Dr. William Dudley’s head required a one-hour exposure. Twenty-one days later, all the hair on the x-ray tube side of Dr. Dudley’s head fell out. Amazingly soon, the April 1896 issue of Science carried Daniel’s description of the phenomenon. Dr. Dudley, whose hair grew back, became a sports enthusiast and the namesake of Vanderbilt’s Dudley Field.

During the early years of the 20th century, photographers, physicists, and general physicians performed x-ray work. Dr. Maximillian Goltman, a Memphis surgeon, assembled his x-ray apparatus and traveled the state giving demonstrations.²

The rapid acceptance of the roentgen rays exacted a price. As eminent Memphis pathologist, Dr. William Kraus, became known as a martyr to his early experiments, having contracted fatal skin malignancy in his hands from x-ray exposure.²

By 1900 some physicians began calling themselves radiologists and, to meet their scientific and organizational needs, formed the American Roentgen Ray Society in that year. In 1923 the American College of Radiology (ACR) was established to address socioeconomic, ethical, and training issues.³ Currently the ACR is the premier body of radiology that coordinates the activities of all the various radiology organizations, deals with government, and presents continuing medical education. The Tennessee Radiological Society (TRS) is a chapter of the ACR.

In 1934 the ACR was instrumental in establishing the American Board of Radiology, and in that year Tennessee again made history by hosting the first board examination at the Peabody Hotel in Memphis.

The Founding of the
Tennessee Radiological Society

Since many Americans thought radiologists repaired radios, radiologists yearned for greater public awareness. They also wanted more independence from hospitals, which paid them on a contractual basis. In an effort to elevate the quality of radiology practice, the leaders of the ACR protested the use of commercial x-ray laboratories where untrained technicians made “plates” to be interpreted by untrained doctors. These laboratories often split fees with referring doctors. Instead, the ACR advocated radiology as a clinical practice of medicine by broadly trained physicians.

In 1934 Drs. Frank Bogart and Horace Gray discussed the formation of a state radiological society. The first meeting of the Tennessee Radiological Society was held at the Hotel Patten in Chattanooga on April 11, 1934. The seven founding members decided to limit the membership to those practicing radiology as a specialty, and to hold annual meetings in conjunction with the TMA meetings.⁴

The Early Years Through WWII

By 1940 the group had grown to 19 members. From its founding through WWII the TRS meetings were predominantly of social and scientific nature and often involved discussion of radiation therapy. There was little mention of socioeconomic problems. Meetings were not held in wartime 1943 and 1945 but Dr. Horace Gray organized an unofficial meeting at a Fisherman’s Wharf restaurant in San Francisco in 1945.

In 1949 the ACR became involved with the medical use of radioisotopes through the interest of several senior radiologists who had worked on the Manhattan Project building the atomic bomb. They understood the physics of the byproducts of the nuclear reactors.³

The Fifties –
The Interest in Socioeconomic Affairs

In 1950 the TRS adopted a resolution deploring the use of fluoroscopes in shoe stores to measure foot size. (The author can remember as a child putting his hand in the slot meant for the foot in order to see the “bones wiggle.”) After the TRS released its resolution to the press the Tennessee legislature abolished the practice.

During the 1950s the socioeconomic issues in radiology became more prominent at the meetings with discussions of hospitalization insurance and methods of remuneration of radiologist taking center stage.

In 1956 the TRS revised its Constitution and Bylaws based on the work of Drs. Walter Scribner, Cash King, John Whiteleather, Herbert Francis, and George Henshall. The new Constitution stated that the ethical principles of the TRS should conform to those of the American Medical Association (AMA) and the ACR.

The Sixties –
Independent Billing Started

In 1960 the membership roll had reached 68. In the early 1960s the annual meetings were increasingly concerned with reports from members who had attended the national meetings of the ACR. Discussions of problems with insurance carriers also attracted considerable attention. In 1961 Dr. Walter Hankins reported that the ACR recommended that all local radiological societies become chapters of the ACR and that each elect a delegate (councilor) and an alternate. After a lengthy discussion, Dr. George Henshall’s motion that the Society become the Tennessee Chapter of the ACR passed easily.⁴ With Presidents Kennedy and Johnson and a Democratic majority in Congress, the government began to create a national hospital insurance program, eventually leading to the passage of Medicare in 1965. Because radiologists generally were under hospital contracts, Congress viewed radiology as a hospital service, along with pathology, anesthesiology, and nursing.⁵

In 1963 the ACR president was Tennessee’s own Dr. David S. Carroll of Memphis. The day before John Kennedy was assassinated, Dr. Carroll testified before a congressional committee that placing radiology under “hospital services” would irreparably damage this valuable medical specialty.

With powerful Arkansas Representative Wilbur Mills as radiology’s friend, the House version of the King-Anderson Bill passed, with radiology being covered as a “medical” service. But Lyndon Johnson and Sen Paul Douglas influenced the Senate to include radiology as a “hospital” service. The outcome was decided in a conference committee with an equal number of senators, and representatives. The vote in this committee was initially a tie, with the fate of radiology hanging on the vote of colorful Sen. Russell Long of Louisiana, the son of famed Louisiana Gov Huey Long. Sen Russell Long’s mother was being treated for cancer by Shreve­port radiologist Dr. Wynton Carroll. Long, therefore, appreciated radiology as indeed the true practice of medicine, and so voted for it as a medical service as Medicare has now long considered it. After the vote, Wilbur Mills, Chairman of the House Ways and Means Committee, advised radiologists, to end their contractual ties, to hospitals quickly.⁵

The AMA. ACR. and TMA all passed resolutions supporting the practice of radiology to be independent of hospital – known today as “separate billing.”

At the 1965 meeting Dr. Sam Hay reported that the TMA now regarded existing contract between radiologists and hospital illegal and unethical fee splitting. Two meetings were called to discuss the logistical problems of separate billing for radiologists. In July Dr. Cash King moved that the TRS comply with the wishes of the TMA – that radiologists separate themselves from their financial ties to hospitals and bill their patients independently. This was passed. During 1965 separate billing began, with the East Tennessee Radiological Society, formed by Drs. Kent Carter and J.J. Range leading the way. The radiologists in East Tennessee, after initially expressing some reluctance to separate billing, soon became its major advocate. Activity during the late 1960s predominantly concerned implementing the change to separate billing by most of the members. There were also problems with insurance carriers that required communications with the TMA.⁴

The Seventies –
New Modalities and Excesses

In 1971 President Hollis Halford, II led the discussion on impending state legislation concerning required radiation dose measurements and technologist licensure. Dr. Halford insisted that the legislature receive input from radiologists and radiation physicists.

During the early 1970s the ACR began to increasingly influence the affairs of its Tennessee chapter. Since 1970 the ACR counselors throughout the country have functioned as the Democratic policy makers for the ACR. By the mid-70s much of the Furor over independent billing had subsided, with almost all Tennessee radiologists now successfully setting, billing, and collecting their own fees.

Several technical modalities came on board the ship of radiology, which was fueled by Medicare payments for generous in-house diagnostic “work ups.“ Sonography, radionuclide scans, in CT gave radiology more prestige, which attracted bright medical graduates competing for highly regarded residency positions. Radiology was also undergoing natural division, with radiation therapy and diagnostic radiology having separate examinations by the American Board of Radiology. Diagnostic radiology was divided into general, pediatric, neurological, and cardiovascular subspecialties. Some subspecialties were designated by modality, such as nuclear medicine, ultrasound, or mammography.

The Eighties –
Cost Control by the Alphabet

Membership now approached 300. The 1980s were characterized by ideological attempts by government to control burgeoning costs by creating competitive incentives – to let the free market reduce medical costs naturally. Government policies were known by acronyms, such as DRGs. Most doctors could muster less than a positive attitude regarding such onerous policies. Legislation known as RAPs, which discriminated against radiologists,anesthesiologists, and pathologists, was an easy target for some wags to add emergency department physicians, which made “RAPE.” Some preferred to add in-house cardiologists, which created “CRAP.” The ACR, with its Washington staff of lobbyists, was vigilant and effective for radiologists, winning most of the battles.

Since Roentgen’s discovery, new technology has always been radiology’s most lengthy suit and magnetic resonance imaging became the star new addition. Dr. Henry Pendergrass, a distinguished Vanderbilt professor, who had been president of the Massachusetts Radiological Society and had received the Gold Medal from the Radiological Society of North America, enhanced the relationship between the ACR and TRS. His national contacts enabled him to secure the annual meeting of the ACR in Nashville at the Opryland Hotel in 1990. Dr. Tom Duncan presented Dr. Pendergrass with the Distinguished Service Award in 1993.

Also on the national scene of organized medicine in 1988 radiologist Dr. Daniel “Stormy” Johnson became the first radiologist to be elected president of the AMA.

The Nineties –
Complexity at the Centennial

In 1990 a poignant moment in TRS history occurred when Dr. Hollis Halford Ill, who was to become the TRS president in 1994, proudly presented his father, Dr. Hollis Halford II, the Distinguished Service Award.

In 1991 Tennessee again made national radiology news with the legal travails of Lewisburg radiologist Dr. David Alfredson. The local hospital terminated his contract, maintaining that medical staff bylaws did not constitute a contract with him and therefore he was not entitled to a hearing. The Tennessee Supreme Court ruled in Alfredson’s favor, finding that a hospital must follow its bylaws requiring a hearing when it reduces a physician’s clinical privileges. This was another battle won for the independence of radiologists through the support of organized medicine.

In 1992 Dr. Ron Overfield of Nashville, representing the Tennessee chapter of the ACR, authored a resolution submitted and passed at the annual meeting of the ACR. This resolution opposed self-referral to imaging centers owned by the referring physicians. Eventually Rep. Fortney (“Pete”) Stark was instrumental in passing laws that protected the public against such unethical joint ventures. This was one of the many enduring contributions Dr. Overfield made to Tennessee radiology. After he became president of the TRS in 1976, he became the inveterate enthusiastic leader and mainstay liaison figure with the TMA and the ACR for the last half of the historical life of the TRS.

In the early 1990s Dr. Larry Westerfield of Kingsport was the driving force for accomplishing accreditation of mammography centers throughout the state. In December of 1989 he had worked at the first site in Tennessee to be accredited.

The mid-1990s gave Dr. Dan Starnes, a lawyer and a radiologist, the opportunity to demonstrate his leadership ability. As chairman of the legislative committee of the TRS, he regularly testified before the state legislature. In 1994 he wisely brought John Lyell II, JD on board the TRS staff as a lobbyist – just in time, because these lobbying efforts prevented radiologists from becoming hospital corporate employees in Tennessee. Radiologists, anesthesiologists, pathologists, and emergency department physicians are therefore now exempt from such corporate practice of medicine control, espoused by the Tennessee Hospital Association. Also in 1994 the TRS established a political action committee (Tennessee Radiologists PAC) to influence the legislature and contribute to the campaigns of those politicians sympathetic to the rights of radiologists.

In the late-1990s TRS annual meetings were no longer held in conjunction with the TMA. All TRS meetings are now held in Nashville and the TRS sends four delegates to the TMA meetings.

In 2000 Ms. Wilma Cooley followed Ms. Linda Bass as Executive Director of the TRS, with an office in the TMA headquarters in Nashville.

Dr. Donald Owens was the first TRS president to serve a two-year term. He and the current president, Dr. Frank Eggers, established a website and wish to upgrade the meetings by including CME credit from the ACR. Recently the ACR was instrumental in creating the National Institute of Biomedical Imaging and Bioengineering (NIBIB) funded by Congress.

The TRS proudly listed 612 members, which warranted six voting councilors at the annual meeting of the ACR. Over 90% of the practicing radiologists in Tennessee were members of the TRS.

Some doctors eschewed involvement in socioeconomic and political aspects of their profession, somehow convincing themselves it was more honorable not to be distracted from total immersion into the purely scientific aspects of their practice. However, involvement in the business and politics was necessary and commendable. Government, hospitals and then big business had repeatedly attempted to dismantle the independence of physicians by first separating hospital-based specialties from the rest.

Without the forceful efforts from the AMA, ACR, TMA and TRS, the specialty of radiology, with bright scientists guiding the development of new technology and properly applying innovative techniques, would have been destroyed, to the marked detriment of health care worldwide.

It is crucial that practicing radiologists in Tennessee, led by the TRS, set examples of proactive vigilance.

References

1. Eisenberg RL: Radiology-An Illustrated History. St. Louis, Mosby Year Book, 1992.
2. Riggs, WW Jr: The History of Medicine in Memphis. Chapter 37, Radiology, Radiology, Jackson, TN, McCowat-Mercer Press. 1971, pp 302-308.
3. Linton OW: The American College of Radiology: The First 75 Years. Reston, VA. The American College of Radiology. 1997.
4. Riggs, WW Jr: The Tennessee Radiological Society Historical Review. J Tenn Med Assoc 67:16-19. 1974.
5. Linton OW: Radiology’s, three crises. AJR 168:885-888. 1997.