Aspetti etici e deontologici della verifica e del riscontro della qualità (VRQ) nella diagnostica per immagini: Un problema anche di formazione professionale

摘要

I profondi mutamenti nella struttura sanitaria in Italia hanno reso urgente riequilibrare in modo organico e logico il rapporto fra risorse della Sanità e bisogni della salute, fra competenze e nuovi modelli di organizzazione. Le unità primarie della sanità, cioè le USL, come vere e proprie aziende, devono essere sottoposte al controllo e alla verifica della produttività e della qualità nell'impiego razionale e proficuo delle risorse. L'applicazione della VRQ (verifica della qualità nell'assistenza sanitaria) anche nella diagnostica per immagini dovrebbe essere finalizzata a valutare la «performance»: delle singole indagini, del medico radiologo, del medico di medicina generale o specialista non radiologo.%The major changes undergone by the Health Service structure in Italy have urged an organic and logical reconsideration of the relationship between Health Service resources and health needs, between competences and new patterns of organization. The primary units of the Health Service (USL), as actual enterprises, should undergo the control and rating of productivity and quality in the rational and fruitful use of available resources. The application of quality controls in health care (HCQC) to diagnostic imaging should be aimed at assessing of the performance of: the single procedures; the radiologist; the general practitioner or the non-radiologist specialist. These are obviously many indicators but the health care quality assessed by studying the structure of the process and of the result should not miss out: the sensitivity, specificity and diagnostic accuracy of the single imaging techniques; the ROC curves to assess the radiologist's performance; the predictive value, with known sensitivity and specificity, of the procedures, for the professional reliability of the non-radiologist physician. At present, QC indicators in diagnostic imaging cannot rule out the problem of a "radiologic training" of the non-radiologist physician to be able to correctly select the patients to be referred to diagnostic imaging. On the other hand, the radiologist should receive a "clinical training" for the rational use of the available techniques to address the clinical issues raised by the colleague, keeping in mind the cost-benefit factor. The "professional training" experience of the Istituto di Radiologia of the Universita Cattol-ica del Sacro Cuore is reported. The instruction of the undergraduate students from the training course of specialization follows two patterns of "objectives" and "problems". The trainee directly participates in a structure and productivity project playing a major role in the transition from the technological, organizing and functional approach to the clinical management of the patients. These changes cannot be separated from their ethical and deontological implications. The ethical issue begins at the patient's bedside and does not end with technical quality and feasibility, and with the economical opportunity in taking a precise legal and deontological responsibility.