Journal of the American College of Radiology

Collaboration: Can We Do Better?

Paul H. Ellenbogen — 2012-05-01

Collaboration — we know it when we see it. And yet, the definition is variable. Some would define it as working together to achieve a goal. According to Wikipedia, “This is more than the intersection of common goals, but a deep collective determination to reach an identical objective [].”

The Chosen

Bruce J. Hillman — 2012-05-01

Read not to contradict and confute; nor to believe and take for granted; nor to find talk and discourse; but to weigh and consider.—Francis BaconThe January 2012 issue of the Annals of Internal Medicine contains a pair of articles that should interest radiologists []. The American College of Physicians (ACP), the owner of the journal, assembled a panel of experts to develop a list of screening and diagnostic procedures that doctors frequently request on behalf of their patients but have little “value.” Thirty-seven combinations of clinical indications and tests made the list, including 13 involving imaging (). The Annals presents a survey on its Web site (http://www.annals.org) and asks physicians, including non-ACP members, to comment on the choices.

The “Liberation Procedure” for Multiple Sclerosis: Sacrificing Science at the Altar of Consumer Demand

Michael N. Brant-Zawadzki, Daniel S. Bandari, Jose J. Puangco, Barry B. Rubin — 2012-05-01

Multiple sclerosis (MS) is a disease of the white matter within the central nervous system, accepted as autoimmune in nature, and mediated by T and B cells []. A similar disorder, acute disseminated encephalomyelitis, shares this etiology, albeit being a single event often related to recent viral infection or inoculation. Experimental autoimmune encephalomyelitis, an animal model for both disorders, has been studied widely [] since the 1930s. Interestingly, this experimental model in rodents did not show any increase incidence of the disease in iron-overloaded mice [].

Radiologist, Walk Thyself

John N. Morelli — 2012-05-01

I look forward to reading each issue of the JACR for discussion of the most up-to-date, clinically relevant issues in the field. I particularly enjoyed reading the article “Feasibility of Using a Walking Workstation During CT Interpretation” by Fidler et al [], published a few years ago, and Dr Feld's [] subsequent rebuttal. There has subsequently been little attention paid to the specific subject of radiologists' health in the literature. In fact, a PubMed search reveals no matching entries for the terms “sedentary AND radiologist.” Although the search “radiologist AND obesity” yields a litany of articles related to the imaging evaluation of obese and post-weight loss surgery patients, no articles address the fact that diagnostic radiology is a predominantly sedentary profession (perhaps because this is self-evident). This lack of physical activity is striking in comparison with other medical specialties, such as internal medicine, whose practitioners may walk up to 2.5 miles a day during normal work activities []. Recent articles in the epidemiology and cardiology literatures have highlighted the risks in all-cause and cardiovascular mortality associated with sedentary lifestyles, suggesting that the diagnostic radiology profession itself may contribute to poor health of its practitioners.

The PC MPPR: Implications for Practices

Ezequiel Silva — 2012-05-01

The multiple procedural payment reduction (MPPR) for diagnostic imaging applies when multiple services are furnished by the same physician on the same patient in the same session on the same date. In other words, same radiologist, same patient, same session, same day. CMS has expanded the MPPR to now include the professional component (PC) of radiologic services. Under this policy, the second and subsequent interpretations performed by the same physician have their payments reduced by 25%. The reduction does not apply when different physicians, even in the same group practice, provide the interpretations. CMS does not apply the reduction to PC services provided in different sessions on the same date of service. The MPPR policy creates 3 unique challenges for practices that I discuss in this column: (1) What is the definition of separate PC sessions? (2) Once defined, how does a practice identify the same vs a different PC session in its day-to-day operations? and (3) What are the compliance implications of this policy?

Success ≠ Happiness

Richard B. Gunderman — 2012-05-01

To me it seems that to give happiness is a far nobler goal than to attain it: and that what we exist for is much more a matter of relations to others than a matter of individual progress: much more a matter of helping others to heaven than of getting there ourselves.—Charles Dodgson, letter to Lilian Moxon, July 8, 1895

ACR Appropriateness Criteria® Myelopathy

2012-05-01

Myelopathy is a problem that requires imaging to distinguish among numerous specifically treatable causes. The first priority is to determine mechanical stability after trauma. Next, it is crucial to distinguish intrinsic disease from extrinsic compression—for example, by epidural abscess. Osteophytes or disc extrusions and metastatic compression are the most common causes of extrinsic lesions. Imaging approaches rely on clinical features such as pain, fever, trauma, and pattern of progression. CT is preferred initially in acute trauma and MRI in all other circumstances. Contrast-enhanced MRI is added when tumor or infection is suspected or with slow or stepwise progression, especially when pain is not prominent. Vascular imaging is used when arteriovenous malformation, fistula, or occlusive disease is suspected. Because the treatment of myelopathy is often complex, treatment planning may require more than one imaging study or sequential examination to assess interval change. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Optimizing the Structure and Function of the 50-Plus Radiology Organizations, Part 2: A Unified Strategic Plan—A Summary of the 2011 Intersociety Conference

Gerald D. Dodd — 2012-05-01

The member organizations of the Intersociety Conference have agreed that radiology would benefit from consolidation and collaboration of the 50-plus radiology organizations. At this year's annual meeting, the participants concluded that the educational and research missions of the organizations would benefit from the creation of a unified strategic plan that addressed the coordination of annual meetings, online educational materials, research infrastructure, and the creation of a direct relationship between the research initiatives of the organizations and the patient advocacy groups of the Academy of Radiology Research. The socioeconomic mission of the organizations would be enhanced through the creation of a formal communication network with the ACR, and certification could be enhanced by the orchestration of the creation of educational materials related to the maintenance of certification.

Do We Need a National Incident Reporting System for Medical Imaging?

Jason N. Itri, Arun Krishnaraj — 2012-05-01

The essential role of an incident reporting system as a tool to improve safety and reliability has been described in high-risk industries such as aviation and nuclear power, with anesthesia being the first medical specialty to successfully integrate incident reporting into a comprehensive quality improvement strategy. Establishing an incident reporting system for medical imaging that effectively captures system errors and drives improvement in the delivery of imaging services is a key component of developing and evaluating national quality improvement initiatives in radiology. Such a national incident reporting system would be most effective if implemented as one piece of a comprehensive quality improvement strategy designed to enhance knowledge about safety, identify and learn from errors, raise standards and expectations for improvement, and create safer systems through implementation of safe practices. The potential benefits of a national incident reporting system for medical imaging include reduced morbidity and mortality, improved patient and referring physician satisfaction, reduced health care expenses and medical liability costs, and improved radiologist satisfaction. The purposes of this article are to highlight the positive impact of external reporting systems, discuss how similar advancements in quality and safety can be achieved with an incident reporting system for medical imaging in the United States, and describe current efforts within the imaging community toward achieving this goal.

Quality Review: Fleischner Criteria Adherence by Radiologists in a Large Community Hospital

Mark Masciocchi, Brent Wagner, Benjamin Lloyd — 2012-05-01

Purpose: Solitary pulmonary nodules are a common incidental finding on CT and unnecessary follow-up affects cost, radiation exposure, and patient anxiety. The aim of this study was to evaluate the adherence of one institution's radiologists with published criteria in their follow-up recommendations. Methods: A data set of 3,000 CT scans with the word nodule used in the report history or conclusion from 2008 to 2010 was generated. This pool was increased as each study was traced back to the examination when the pulmonary nodule was first identified. The follow-up recommendation of the radiologist was then classified as “adherent,” “incomplete/no recommendation,” “earlier than recommended by the criteria,” “later than recommended,” or a “wider follow-up time frame than recommended.” Results: After the implementation of exclusion criteria, 1,432 examinations were satisfactory for classification. The adherence rates of radiologists for nodules followed in up to 4 consecutive examinations were 57%, 48%, 70%, and 79%, respectively. Overmanagement was the most common deviation from the Fleischner criteria, ranging from 15% to 28% of evaluated reports. Conclusions: Radiologists at the authors' hospital do not always adhere to the Fleischner criteria, most often recommending closer follow-up. The possibility of missing a malignancy while it is still treatable, medicolegal concerns, and lack of familiarity with the Fleischner criteria are all potential factors in nonadherence.

Use of a Dedicated Pediatric CT Imaging Service Associated With Decreased Patient Radiation Dose

2012-05-01

Purpose: The growing use of CT as a diagnostic imaging tool has led to increased concern over radiation dose, particularly in pediatric patients. The ALARA concept has been popularized in dose reduction. ALARA supports the use of low-dose, pediatric-specific protocols. Strict adherence to low-dose protocols can be challenging, particularly in a high-volume radiology department that scans both pediatric and adult patients. The aim of this study was to determine whether the relocation of pediatric radiologic services from a combined high-volume pediatric and adult hospital to a children's hospital improves compliance with adjusted lower CT exposure parameters and thus the estimated effective dose of radiation delivered to pediatric patients. Methods: A retrospective review of abdominal and pelvic CT console dose and exposure parameter data on 495 patients from a combined pediatric and adult radiology department and subsequently 244 patients from a dedicated pediatric radiology department was performed. The console dose-length product was converted to estimated effective dose. Patients were divided into 1 of 8 weight categories for analysis. Results: A statistically significant decrease in the estimated effective dose for abdominal and pelvic CT studies was observed in all but one of the weight categories at the pediatric radiology department compared with the pediatric and adult radiology department. Conclusions: Imaging pediatric patients in a dedicated pediatric imaging department with dedicated pediatric CT technologists may result in greater compliance with pediatric protocols and significantly reduced patient dose. Conversely, greater scrutiny of compliance with pediatric dose-adjusted CT protocols may be necessary for departments that scan both children and adults.

Satisfaction of Search for Subtle Skeletal Fractures May Not Be Induced by More Serious Skeletal Injury

2012-05-01

Purpose: The aim of this experiment was to test whether radiographs of major injuries, those having serious consequences for life and limb, produce a satisfaction-of-search (SOS) effect on the detection of subtle, nondisplaced test fractures. Methods: Institutional review board approval and informed consent from 24 participants were obtained. Seventy simulated patients with multiple trauma injuries were constructed from radiographs of 3 different anatomic areas demonstrated only skeletal injuries. Readers evaluated each patient under 2 conditions: first, in the non-SOS condition, no injuries were present in the first anatomic images, and second, in the SOS condition, the first anatomic images included major injuries requiring immediate medical intervention. The SOS effect was measured on detection accuracy using receiver operating characteristic analysis for subtle test fractures presented on examinations of the second or third anatomic areas. Results: Satisfaction-of-search reduction in receiver operating characteristic experiments for detecting subtle test fractures with the addition of a major injury was not observed. Conclusions: Satisfaction of search was absent when major injuries were presented on radiographs. This finding rejects the hypothesis that SOS arises primarily from injuries requiring major intervention. Similar results have been found previously when major injuries were presented on CT but test fractures were presented on radiographs. This new finding rejects the possibility that SOS is absent because added and test fractures appear on different imaging modalities.

Radiologists' Expectations of Changes in Radiology Fellowship Training Programs

Hyojeong Mulcahy, Felix S. Chew, Michael J. Mulcahy — 2012-05-01

Purpose: In 2010, the ABR began the implementation of a new certification process in diagnostic radiology in which prospective diplomates take a comprehensive examination at the end of 3 years of residency and a final certifying examination 15 months after the completion of the 4-year residency. The majority of newly trained radiologists spend 1 year after residency in fellowship training. The aim of this study was to determine whether radiologists expect changes in radiology fellowship training programs in response to the new ABR certifying process. Methods: An online survey was conducted between October and December 2009, in which active members of 3 radiology societies were invited to respond. Questions were asked regarding expectations of changes in radiology fellowship programs: changes during the current academic year (2009-2010), expectations of changes in the next 3 years, and expectations of changes resulting from the change in the ABR certification process. Results: There were 342 responses to the invitation, for a response rate of ≥22.9%. Most radiology fellowship program directors and radiologists affiliated with fellowship programs saw few changes in their programs in the recent past and expected no significant changes over the next 3 years. Substantial minorities of both groups, however, expected increases in salary and workload. Regarding expected changes in radiology fellowships as a result of changes in the ABR certification process, the 3 groups (directors and affiliated and nonaffiliated radiologists), except recent fellows (29 of 342), expected no significant changes. Most of the recent fellows expected to see some increases in the numbers of applicants, positions filled internally, and positions filled by senior residents and the importance of doing fellowships. Conclusions: Radiologists saw few changes in their fellowship programs in the recent past and expected no significant changes over the next 3 years and no significant changes as a result of the new ABR certification process.

State Population as a Predictor of Radiation Therapy Staffing Levels

John Culbertson, Kira Carbonneau, Myke Kudlas — 2012-05-01

Purpose: Considering the cyclical nature of shortages and oversupplies of staffing levels in the labor force, an accurate prediction of future demand for personnel is of great importance. Historically, the profession of radiation therapy has been plagued with these cycles. This study establishes state population as a strong predictor of radiation therapy staffing levels. Methods: A linear regression analysis was performed to determine the association between state population and radiation therapy staffing levels from 2002 to 2010. Results: State population is a significant and substantial predictor variable for the number of actively employed and registered radiation therapists, with 89.5% to 91.4% of the variance accounted for from 2002 to 2010. Conclusions: Additional research in estimating future demand in radiation therapy is possible. By monitoring change in state population, health care professionals can proactively address cycles of shortages and oversupplies in staffing levels.

Radiology Goes Back to School: Presenting the Face of Radiology to School Children

Meir H. Scheinfeld, Carson Campe, Laura L. Avery — 2012-05-01

Among health care professionals, the critical role of radiology in patient care is obvious. For example, most emergency department patients receive some form of imaging when presenting with abdominal pain []. Among the general public, however, the radiologist's role is less clear. There is confusion as to the role of the radiologist, technologist, and even referring physician in image interpretation []. Furthermore, many people do not realize that radiologists are doctors []. The lack of general knowledge as to the importance of radiologists continues to have serious implications, particularly among policymakers []. One method of addressing this problem has been the ACR's Face of Radiology campaign, designed to educate the adult public that radiologists are doctors who are highly trained and experts in image interpretation [].

New Recommendations for Occupational Radiation Protection

Donald L. Miller, Beth A. Schueler, Stephen Balter — 2012-05-01

Occupational radiation protection is a necessity whenever radiation is used. It is especially important for fluoroscopically guided and CT fluoroscopic procedures, in which occupational irradiation cannot be avoided.

Call for Action: A Resident's Perspective

Anil Chauhan, M. Jordan Ray — 2012-05-01

Radiology residents are challenged in today's era to remain up to date with current political and economic issues facing the field. Of course, this comes in addition to the ever increasing volume of clinical knowledge that must be learned in a short period of time. These challenges vary from patient expectations to governmental legislations and from technological advances to turf wars. As we settle down on one challenge, more always seem to rise to the surface, some predictable and some not so predictable.

Eddie Ernst

Otha Linton — 2012-05-01

“You can call me Eddie,” said the senior radiologist. “Yessir, Dr Ernst,” I responded. With all respect, he was more than twice as old as me, age 77 to my age 30. I was in my second year working for the ACR.

Re: “Integrated Residency Training Pathways of the Future: Diagnostic Radiology, Nuclear Radiology, Nuclear Medicine, and Molecular Imaging”

Dominique Delbeke — 2012-05-01

In the January 6, 2012, online issue of JACR, M. Elizabeth Oates, MD, reported the recommendations of the diagnostic radiology (DR) participants of the ACR/Society of Nuclear Medicine (SNM) Task Force II for combined DR and nuclear medicine (NM) residency training pathways []. As described in the article, the ACR and the SNM charged a task force (16 members representing 8 organizations) with developing realistic models for combined DR and NM residency training programs. Preliminary ideas were shared from July to September, but the members of the task force did not meet as a group because of scheduling issues.

Author's Reply

M. Elizabeth Oates — 2012-05-01

I have read with interest the letter to JACR from the immediate past president of the Society of Nuclear Medicine (SNM) concerning the article “Integrated Residency Training Pathways of the Future: Diagnostic Radiology, Nuclear Radiology, Nuclear Medicine, and Molecular Imaging” []. Although I appreciate and respect Dr Delbeke's, and presumably the SNM's, perspective, I cannot help but reflect, once again, on the fact that the full constituencies of ACR/SNM Task Force II still have not had the opportunity to consider and discuss thoughtfully our ideas, goals, and strategies “live and in person.” As Dr Delbeke notes, logistics certainly contributed initially to our inability to meet during the summer of 2011, but ultimately, the SNM unilaterally used delaying tactics to derail Task Force II as a collaborative effort, thereby thwarting our appointed representatives from debating the merits of the various proposals submitted to the task force by both the ACR and SNM participants.

Re: “Percutaneous Needle vs Surgical Breast Biopsy: Previous Allegations of Overuse of Surgery Are in Error”

2012-05-01

We are concerned over the conclusions made by Levin et al [] on the basis of their analysis of breast biopsies within a Medicare population only. Most patients undergoing breast biopsy are <60 years of age []. Therefore, the findings of Levin et al are not broadly applicable. The investigators' claim that open biopsy (OB) is “not being overused” conflicts with the evidence that has accumulated to date []. A comprehensive survey of the medical literature makes this point clear.

Authors' Reply

David C. Levin, Gordon F. Schwartz — 2012-05-01

We appreciate the comments of Grobmyer et al, the authors of the paper in the American Journal of Surgery [] that we critiqued in our recent paper []. On the basis of the results of our research, we concluded that the rate of use of surgical breast biopsy was significantly less than the 30% stated by Dr Grobmyer and his colleagues in their earlier study. We believe they erred by including all cases with the procedure code 19125 (“excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion”) as biopsies, especially considering that the word “biopsy” does not appear in the descriptor. We acknowledged that although some of these cases might be intended as biopsies, implying a previously uncertain diagnosis, many others might primarily be intended as therapeutic: the complete excision of a lesion. Our analysis indicated that the true rate of surgical breast biopsy in the Medicare population was somewhere between 2% and 18% and suggested that the actual figure was probably closer to 11%. We are pleased that although Grobmyer et al may disagree with the thrust of our paper, they did not challenge our methodology or the data it produced.