Junzi Shi, MD

As a trainee, it can be confusing to determine whether or how to report findings that have little significance to the clinical question. Incidental findings in radiology include a category of diagnostically indeterminate findings that need further evaluation, as well as a category of findings that have no significant clinical impact. There has been considerable heterogeneity in reporting of the latter category, and our discussion will focus on these entities. An incidental finding, such as a simple renal cyst, duodenal diverticulum, and anatomical variants require no follow-up imaging or workup. They are benign without malignant potential. They do not impact the patient’s life; in fact, no one would realize the finding existed prior to the imaging exam. The continued rise in the volume of imaging means that more incidental findings will likely be discovered, and we will need to figure out how to deal with them.


Do incidental findings really have no impact? While a finding may not have clinical significance at the time of the current imaging exam, they may become relevant in the future. Exams are now archived in electronic servers and reports are permanently stored in the electronic medical record. The ability to quickly look back at prior imaging has made a significant impact on our ability to interpret imaging findings. In this system that codes dictations as searchable key words, documenting incidental findings may be useful for long-term patient care. For example, vascular anomalies are anatomic variants that may have clinical impact at a later time. A left vertebral artery arising directly from the aortic arch may result in neurological symptoms. Furthermore, it is important to make the surgeon aware of such variants because they might impact surgical planning for neck and chest operations. Recognizing anatomic variants and their impact is essential for radiology trainees.


Are incidental findings truly harmless? The American College of Radiology Incidental Findings Committee reported that a non-enhanced CT scan of the lower chest, abdomen and pelvis may detect clinically significant incidental findings in 5-16 percent of asymptomatic patients and a higher frequency in symptomatic patients. Further workup of these findings may change clinical or surgical management only in a small percentage of patients. For example, workup of an indeterminate renal mass with CT or MRI renal mass protocol often cannot distinguish between renal cell carcinoma (RCC) and oncocytoma or lipid-poor angiomyolipomas. Therefore it is not surprising that at surgical resection, many solid renal masses are found to be benign. Even for patients with a “radiology success story,” meaning that a renal mass was worked up with imaging, followed by prompt surgical resection of a malignancy, there can be contradictory outcomes. Studies of patients with small renal masses, specifically stage T1a RCC, have shown paradoxically increased mortality after surgery. Less than optimal outcomes have led to mounting questions about the cost versus benefit ratio of recommending further imaging evaluation for each incidental finding.


Would anyone pay more to have incidental findings of little or no clinical significance reported? A medical professional would probably say no, but a patient might say yes. In our current payer system, there is no mechanism to bill for a shorter or longer read. In fact, the current movement in radiology is toward uniform dictation templates to minimize heterogeneity in our reports. Nevertheless, as more patients get scanned and more data is generated, there may be a growing market for radiology consultation or boutique radiology, where patients may get a more personal, in-depth interpretation.


Being able to distinguish benign from potentially harmful findings is an important part of radiology training. Incidental findings are commonly encountered, and deciding how to report them continues to be a daily struggle. Evaluation of incidental findings requires considering what is best for patients. A 2016 article that introduced the concept of not reporting clinically unimportant incidental findings raises an important point that physicians make better decisions when attention is focused on the most important findings. The radiologist’s number one priority is answering the clinical question to facilitate patient care, and reporting potentially harmful findings to ensure patient safety. Overall, higher-resolution imaging and better understanding of clinical significance have allowed radiologists to become an increasingly important part of the medical team.

Articles

The Value of Incidental Findings

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way.”

Famous first quotes such as from “A Tale of Two Cities” by Charles Dickens are indelible and unique. There is a sense of timelessness and wisdom from great works of literature which is what makes generations of readers read them word for word repeatedly. An attempt to summarize the work is incapable of serving justice and risks losing its essence. When it comes to English literature, reading the original book is essential to understanding the author’s viewpoints. However, when it comes to science, does this rule still apply?

Trainees in medicine have growing responsibilities with fast-paced rotations through various specialties ranging from one to four weeks in length. This rarely allows one to spend copious amounts of time reading in depth. As we are asked to bear more duties and expected to have more knowledge, the biggest challenge is balancing clinical duties with academic ones. How do you acquire a large amount of knowledge quickly and efficiently? The challenge of “life-long learning” is how best to improve this process.[[{"type":"media","view_mode":"media_crop","fid":"63594","attributes":{"alt":"Studying radiology","class":"media-image media-image-right","id":"media_crop_1675409018039","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8117","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 113px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Julia Tim/Shutterstock.com","typeof":"foaf:Image"}}]]

It is simply impractical to read entire books in an attempt to cover the medical literature. However, textbooks are the most in-depth exploration of a given topic and have long been the gold standard of learning. Deeper insight is obtained by reading in greater depth. Ideas within a text are organized and presented in a certain logical or chronological order. How ideas are presented may be as important as the ideas themselves. The process of thinking about the book’s content while reading helps to stimulate mental synthesis and combination of ideas. Furthermore, making personal summaries and notes will help with memorization and understanding rather than reading someone else’s summary.

With the age of computers and digitalization of data and literature, there is an increased struggle to catch up with reading. There are over 2.5 million new scientific papers 

 scholarly peer-reviewed journals. Whereas, there used to be one dominant book which led the field and was considered THE book to read, this idea has been largely replaced by frequently updated, focused scientific papers. With the advancement of science and technology, we now publish articles at an increasing rate, which adds to the volume of literature available at our fingertips.

Trainees in turn have adapted to new demands by favoring review books rather than textbooks. However, these two types of references and methods of learning are not mutually exclusive. Strategies for digesting a textbook or reading about a certain topic includes reading backwards. Read the summary first; then go more in-depth for a topic that is less understood. This approach offers a big picture view and an outline skeleton from which one can flesh out the details. Reading backwards involves reading the summary, then headings and subdivision, then the introduction. From there, look at all the figures and figure captions carefully, and skim the text to understand the details and supporting data.

There is no right way to learn. Optimal learning for an individual probably occurs with a combination of all these tactics depending on which position on the learning curve. However, be aware that when a summary or study guide is used instead of the textbook, one may gain knowledge that is not just superficial, but wrong.  Summaries often provide an overview of conclusions and facts but do not explain how the writer came to that conclusion; it is up to the reader to do the work and make sure they understand all the nuances.

Identified and describes supporting evidence

Strongly connects new content to previous learning

Interpretation, connection, and integration result in an accurate conclusion

To Be Well-Read or Well-Summarized?

One of the best moments in my academic life was walking out of the testing center at the end of the last USMLE exam. That feeling was sweet but transient.

 grade as a radiology resident, I am still taking tests. As an advocate for lifelong learning, I figure they are part of the bargain: learn, test, teach, repeat. The purpose of tests is to provide constructive feedback to both student and teacher. However, not all academic assessments are fair nor are they effective.

It can be a daunting task for programs to provide trainees with concrete and useful feedback. ACGME requires program directors to report on resident performance annually, which includes milestones for medical knowledge and competency. The annual ACR in-training examination is one means of providing every trainee with a reportable percentage score. However, limitations to this test make it generally unhelpful in terms of being constructive feedback. Scores are biased towards the most recent rotations a trainee has passed through. The questions include a broad assessment of knowledge meant to be accumulated over four years of training, including physics and quality assessment questions. This is problematic for the younger trainees. As a first-year resident, I took the exam before experiencing several rotations, and my topic-specific scores ranged from 2% to 98%, which was both laughable and predictable.

In addition to the formative yearly assessment, end-of-rotation exams are a common way to assess trainees. These questions are typically written by one of the attendings in the department assigned as the “resident liaison,” and are supposed to address knowledge appropriate to the trainee level.  However, there is significant variability within the exams regarding the broadness of questions and how well they are written. Sometimes there is low correlation to the assigned reading or clinical work. The most effective assessments are ones that are created in conjunction with self-study, rotation-based learning, and post-assessment feedback. [[{"type":"media","view_mode":"media_crop","fid":"61392","attributes":{"alt":"Radiology student","class":"media-image media-image-right","id":"media_crop_9681801218722","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7764","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Phoelix/Shutterstock.com","typeof":"foaf:Image"}}]]

At the graduate level of training, there is more convergence of knowledge even among trainees who have come from different backgrounds. In this setting, tests should focus more on feedback for the trainee and using questions as a tool of improvement rather than for judgment or punitive action. One method for effective, low-risk self-assessment is to test knowledge retained from didactic lectures, which make up approximately 20% of time spent in the hospital. The low-stakes nature of lecture-based exams help to give constructive feedback without necessarily reporting to the program director. Furthermore, the act of going through the “testing-retrieval process” helps to solidify didactic knowledge. As studies in neurobiology have shown, for example by Nabavi et al 2015 in 

, induction of memory encourages long term potentiation

which counters the time-dependent loss of retained material and expands working memory. Regular didactics coupled with self-assessment exams can be geared towards junior residents, and spread out over longer periods of time for senior residents.

Shifting from the annual In-Training exam to periodic topical assessments would be a more helpful method for evaluating trainees. Formal testing is currently sponsored by individual departments. These exams lack formal peer-review and demonstrate a high degree of variability among institutions. Recent interest in developing educational tools reveal peer-reviewed national question banks on the horizon, which can be filtered by subspecialty. For example, 

 thousands of de novo questions and provide a platform for program directors to compare trainee test data with national data. The horizon is promising for improving the educational experience. Ensuring that exam questions are relevant, encouraging self-assessment, and focusing on constructive feedback are all ways to improve the learning process during radiology training.

“Essential characteristics of proficient performance have been described in various domains and provide useful indices for assessment. We know that at specific stages of learning, there exist different integrations of knowledge, different forms of skill, differences in access to knowledge, and differences in the efficiency of performance. These stages can define criteria for test design. We can now propose a set of candidate dimensions along which subject matter competence can be assessed. As competence in a subject matter grows, evidence of a knowledge base that is increasingly coherent, principled, useful, and goal-oriented is displayed and test items can be designed to capture such evidence.” (Glaser, R. “Expertise and assessment.” In M. C. Wittrock & E. L. Baker (Eds.), Testing and cognition. Englewood Cliffs, NJ: Prentice Hall. 1991:17-30.)

Effective assessment of radiology trainees.

Assessing the Radiology Trainee

Let’s play a game.  Lay your hand down on the table, and write the letter A on your thumb. Then,  continue lettering B, C, D, and, lastly, E on your pinkie finger. Now find the quickest path from A to E by connecting the letters.  One way to do it is to draw a path from A down one finger to B up the next finger to C to D to E….but you could also pinch thumb and pinkie together to achieve the same goal. The difference in methods is sometimes called linear vs non-linear thinking. Within the frame of linear thought processes, A flows to B before arriving at C, and so on. Once you lay your hand on the table, it becomes a two dimensional surface and linear thinkers tend to connect the letters by drawing a line in sequential order.  On the other hand, non-linear thinkers use “spatial jumping” and form connections in a non-sequential way. Neither is right or wrong, nor the superior method; rather, these categories are a way to describe thought processes.  In the reading room, diagnostic radiologists often employ linear thinking as a method to logically and sequentially document findings. First, there is the search pattern. As a new radiology resident, I was instructed to figure out my preferred search pattern for each type of exam and to stick with it for each patient. This organizes thought processes and creates a work flow that divides large amounts of data into digestible pieces. Furthermore, having a consistent search pattern reduces the human error of simply forgetting to look.  Secondly, we employ the linear thought process of figuring out differential diagnoses. If A, then B. If C, then D. How many times do we use this a day? As a trainee, the learning curve is to memorize imaging characteristics and differential diagnoses so that these connections can be made faster. In fact, study aids like mnemonics only work if they are memorized in a specific order, otherwise they wouldn’t make sense.  Perhaps writing “MAGIC DR” on our fingers would have been more helpful at the beginning of this exercise. Anyhow, at the start of training, both visual/motor processes and mental processes use linear thinking to process large amounts of data in an efficient and meaningful way.  Over time, the goal is to see so many cases that we know what “normal” looks like. Just as one learns to play a musical instrument or becomes fluid on a bicycle, going through the motions as a radiologist becomes natural (or so I’ve heard). What I mean by this is some motor eye movements become automatic while thought processes become subconscious. I am continuously amazed by veteran radiologists who just “have a feeling” about the image. They can’t quite explain, but they are always right.  Once, while reading out with an attending and both staring at the same image, I asked doubtfully, “How do you know that is not artefact?” and he responded, “Just trust me.” It seems that with experience and years of mastering linear thought processes, senior radiologists have somehow developed “trust” and “feelings,” or maybe some kind of sixth sense. They are no longer bound by the constraints of a linear framework. Rather, they seem to make jumps that astound the most astute memorizer (novice).  They have entered the realm of non-linear thinking. The prowess to pull together clinical data, process a few thousand cross-sectional images quickly, and to draw a conclusion that truly impacts the patient is a feat which takes years to learn. As an aside, I believe this ability is why computer-aided detection will never replace human interpretation. These non-linear connections are not described in textbooks nor included in rote memorization. They come from experience and compilation of trial and error and seeing thousands of images. I believe these connections are also the reason why we seek to learn from more experienced radiologists, hoping to glean some wisdom. They are also the reason we attend live lectures instead of simply reading about a topic. So, next time you draw letters on your hand, consider that we have opposable thumbs for a reason…which might not be evident until we appreciate all the other fingers first.  

The linear and non-linear thinking of diagnostic radiology. 

What do you think?

Looking back at 2016, this year has brought a lot of change. A surprising election, Brexit, the Syrian crisis, and the death of several notable celebrities at the end of December have all brought 2016 to a gloomy close. It also bore witness to my first six months of residency, and the steep climb up the knowledge pyramid did not make this year any easier. However, some of my most poignant lessons in radiology came from patient interactions and what they taught me about how we practice medicine.

Sometimes the practice of medicine goes beyond numbers and statistics, it includes how we treat people in our bubble, not just when they walk into the radiology department. On August 23, 2016, a construction worker 

the external faÃ§ade outside the Harvard Medical School building. It was a sad case in which the worker fell through several layers of scaffolding instead of being caught or cushioned by the safety nets. He was rushed to the hospital and was found to be in critical condition after the accident. The attending physician of the service I was on at the time was eating lunch in a cafÃ© adjacent to the building and witnessed the immediate aftermath of the incident. In the days following, she visited the man and spoke with his family and got to know them. My attending’s compassionate response was perhaps beyond the scope of daily practice, but showed a genuine human reaction which probably meant a lot to the family. I was impressed that she took the initiative to make those visits, and to extend a hand from the medical community to say, “We saw, we’re sorry, we care.” 

We can also reach out in other ways to bridge the gap between patient and provider. During my ultrasound rotation, I noticed that patients often stare at my face during the exam to glean information about their results. We have all trained our poker faces to be perfect and absent of any cracks that the patient can use for misinterpretation; however, I noticed that during painful exams, it has been helpful to show empathy and to respond to the patient’s emotion. One transvaginal exam, in particular, stood out to me. I brought the Spanish-speaking woman with pelvic pain into the room, and made efforts via broken Spanish, hand gestures, and a translator app to communicate with her. During the transvaginal exam, she was trying to be brave but had so much pain that she started crying. My attending took over, and I asked if she wanted to hold my hand. She squeezed hard. Response to human touch is a powerful thing.

After the exam, I took some extra time to translate the results to her verbally and then, to my utter surprise, she gave me a big hug and a kiss on the cheek. Then she quickly ran out and left me a bit shocked. We must have done something right for a patient to show appreciation bordering on affection after a painful transvaginal exam. In our department, approximately a dozen pelvic ultrasound exams are performed every day, and it can seem like a very routine exam. However, in some cases, such as for patients who find the exam particularly difficult to tolerate, it can be appropriate to show empathy and take some more time to prepare and position the patient. After all, it can make a world of difference. 

My last anecdote tells about an utter failure to connect. One day I went to the emergency room to scan a patient with vaginal bleeding who had a normal first trimester ultrasound the week before. She and her husband were holding hands and her faced was heavily lined with distress and misery. She said, “I know I probably lost it…” and started crying as I scanned her. The transabdominal exam showed an embryo without a heartbeat. Before starting the transvaginal portion, I went over the images with the fellow and brought him back into the exam room to scan together. As we finished the scan, he simply walked out of the room without saying a word. I was shocked by the lack of response; it felt like a huge void. I wasn’t sure it was appropriate to divulge the results if the fellow had not done so. I felt awful and wanted to give her my condolences and a big hug, but instead I instructed the patient to return to her emergency room cubicle and I walked back to the reading room. There, we went over the exam with the attending physician and printed the report. As I walked to the work area outside the patient's room to place the report inside her folder and communicate findings to her nurse, I noticed that the patient was sitting on the well-lit bed, in a gown with her knees bent up to her chest, all alone. The curtains were completely open and her stare drilled into a small spot on the side of my head. I walked past her room, speeding up as I did so.[[{"type":"media","view_mode":"media_crop","fid":"55516","attributes":{"alt":"Radiologist with patient","class":"media-image media-image-right","id":"media_crop_1337149042424","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6953","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 167px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©P E A R L/Shutterstock.com","typeof":"foaf:Image"}}]]

Generally, the radiologists conduct the exam, finish the report, and leave it up to the emergency physician taking care of the patient to coordinate input from various providers, disclose medical information, and discuss further steps for care. Perhaps it would have complicated the picture if I had disclosed the results to the patient first, leaving her greatly upset, and the ED physician clueless as he or she walked in to deal with the damages. Nevertheless, I felt like a coward...more than that, I felt like a robot behaving coldly, unnaturally. I still don't know what the best answer in this situation is... to follow humanistic instinct or to follow protocol. 

Radiologists, and physicians in general, often like to be the "valve" controlling the release of information, to turn it on or off. But sometimes this doesn't take into account the patient experience. This poses a question that I will continue to ponder in the upcoming year: how can we enhance the patient experience? As we look towards 2017, which will hopefully bear more good news than bad, we should strive to reduce pain and discomfort for patients, and remember that we as radiologists are delivering not just goods and services but also a human experience.

The Human Experience of Radiology

 about integrating financial education into the infrastructure of young physician training. The ability to make smart financial decisions has been shown to improve professional outcomes in medicine. When physicians are happier, so are their 

 looking at patient satisfaction ratings and physician self-satisfaction ratings showed a positive correlation between general internists who rated themselves to be very or extremely satisfied with their work and how they were rated by patients How physicians feel about their work, including their reimbursement, autonomy, and results, affect the relationship with the patient and patient satisfaction in a big way.

Having the financial acumen to make savvy management decisions can also empower professionalism. Recently, managed care has produced increasing financial pressures and time constraints on physicians. Kenneth Arrow, a Nobel Prize winning economist, 

 that physician professionalism is vital to society in that it encourages a humanistic career while acting on the best available evidence with health equity in mind. A healthy society allows its “caretakers,” the physicians, the ability to thrive and have control over their practice environment. However, in the last decade, the consumer movement in health care has 

 patients and insisted that providers find ways to decrease costs while improving patient and customer satisfaction. Although the intention for “affordable care” and patient satisfaction was prudent, this has led to physicians feeling disempowered and at a loss.[[{"type":"media","view_mode":"media_crop","fid":"53669","attributes":{"alt":"Government","class":"media-image media-image-right","id":"media_crop_8072417006568","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6721","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 179px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Kev Draws/Shutterstock.com","typeof":"foaf:Image"}}]]

Frustrated physicians with a heightened political awareness have taken some 

 positions, including 17 seats in the U.S. House of Representatives and 3 seats in the Senate in 2014. We’ve also increased our financial 

 to national elections, donating a record $270 million to federal candidates during the 2012 election cycle.  In the 2015-2016 election cycle, up to August 22, 2016, health professionals contributed $64.6 million, out of $215.6 million total health sector dollars. Of healthcare dollars 

, the American College of Radiology ranks number 10, contributing over $1.03 million.

No matter what happens this upcoming Nov 8

, each election brings new leaders to the playing field and a hope for change. Continued interest in bundled care and limited networks will mean an upcoming transition, neither good nor bad. Change simply means change. However, building a healthy economy should mean creating an environment in which physicians are in a position to manage the care they deliver and thus enable physicians to always put patients first.

At stake, say physicians, is patient-centered care.

Physician Interest in Government Grows

Disclaimer: Opinions are entirely my own. I was sponsored by AMA Insurance to attend the 2016 Financial Summit. 

Getting that first paycheck from residency was sweet. To many of us, it is our first job...first REAL job. Serving tables in a restaurant and work-study in laboratories just don’t cut it. When I finally got my newly minted piece of paper, what did I do? I kissed the sweet fruit of cheap labor and then spent the whole thing paying bills for the big move to Boston. Practical things first, right?

When it comes to spending versus saving, we’re in a big hole. Physician finances are a mess, everyone knows that. We went to school for science, not for business, and unless an individual is particularly interested in the topic or has their back against a wall, we do not have regular 

 about personal finances. Some institutions are changing the stasis of cluelessness into a dynamic of self-education to improve both personal and professional decisions.

Johns Hopkins University has set up a Business of Healthcare Grand Rounds as a 

 with the Carey School of Business open to all residents. Brigham and Women’s radiology residency program has integrated multiple tracks into the resident lecture series featuring a financial education theme, and the opportunity to develop business acumen further with a mini-fellowship or research project. In fact, one of the five longitudinal tracks that trainees can choose from includes a business-of-medicine focus.

Beyond integration, there are additional opportunities to obtain further expertise through separate full degrees. In fact, the number of joint MD/MBA programs in America has 

 from 6 to 65 in twenty years. Part of the motivation is a heightened awareness of the importance of business acumen in health care management. Another push comes from the industry side. A 

 in 2011 showed that hospitals run by physician CEOs outperformed those with non-medical leadership. Findings from this and other studies prompted interest in hiring more MDs in leadership and management positions. [[{"type":"media","view_mode":"media_crop","fid":"51601","attributes":{"alt":"Finances in radiology","class":"media-image media-image-right","id":"media_crop_3642169903435","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6362","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 170px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©cmgirl/Shutterstock.com","typeof":"foaf:Image"}}]]

The opportunity for business skills to enhance development has been highlighted by the industry’s recent struggles with market pressures, shifting regulatory regulations, and value-based reimbursement. It is becoming more obvious that the less involvement from MDs, the more professionals - and health care infrastructure in general - are at the mercy of the economy.

Additional enrichment comes from seminars and conferences offered in increasing number to physicians. Although one can read about financial basics from online sources, in-person conferences spark conversation and create additional networking opportunities. In the realm of personal finance, 

, for example, is offering the opportunity to speak with a wide range of specialists in an annual physician financial summit. I had the privilege of attending the May 2016 conference, which was hugely insightful. The density of knowledge presented and the opportunity to seek advice from physicians at various stages of their career was invaluable.

Overall, the trend towards increased business acumen in medicine is helping physicians at all levels of experience to become better stewards of both their personal and professional finance. No matter what route is taken – self-education, seminars, lectures, or national conferences - the key is to have integrated conversations regarding smart financial decisions as a part of our best practices. 

Let’s Talk Business in Radiology

On a flight to Hong Kong, I hear overhead “Is there a doctor on board?” As an intern, I’m still a newbie but eager to flex my muscles. I look around to see if anyone else has volunteered. Nope. I make my way towards the front of the plane and I see an attendant leaning over an elderly woman slumped in her seat. Oh dear, this could be anything from a stroke to pulmonary embolus to vasovagal reaction. We happen to be 10,000 feet high in the middle of nowhere, 8 hours into a 14-hour flight.

While I examined and treated the patient, I had the strongest feeling of loneliness I’ve encountered so far in my career. I felt alone in my ability. There’s nothing quite like taking care of a patient on a plane; I was separated from equipment which is usually an arm’s reach away, isolated from supportive medical staff, and instead examined by rows upon rows of curious eyes; I had to perform all the functions while forming a differential and treatment plan in my head. Luckily, the woman recovered and we did not need to make an emergency landing.

When I told this story to my friends after the fact, I ended with a joke, “On a plane full of Asians, you’d think there would be more than one doctor!” They laughed, and then someone said, “Maybe the other doctors were all radiologists!” This comment stuck with me. What was that supposed to mean? Radiologists don’t want to help people? That we are too specialized and lost the ability or interest to assist during emergency situations? I went into medicine to help people, no matter what form that takes. If I could only hold pressure to a bleeding wound, I would still jump up and do it. Any insinuation otherwise is offensive to all of us.

However, maybe there was some truth to that statement. A 1997 

 among internists showed that most respondents would help provide emergency care in a restaurant (69%) and airplane (54%), 44% would help in a highway accident, 33% in a subway, but only 2% would help a man lying on the sidewalk. Reasons cited for not helping included concern for personal risk, it was not their responsibility to help (52%), risk of contracting infectious disease (36%), lack of comfort with medical skills (29%), and fear of legal liability (17%).[[{"type":"media","view_mode":"media_crop","fid":"49382","attributes":{"alt":"Reluctant radiologists","class":"media-image media-image-right","id":"media_crop_4463120778116","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5951","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©shockfactor.de/Shutterstock.com","typeof":"foaf:Image"}}]]

In cases in which a physician refused to act and was brought to court, the jury has not been very sympathetic to these reasons. “A jury of laypersons is not likely to view with great enthusiasm or sympathy statements offered by the defendant radiologist that he or she refused to render care to a patient who was in immediate danger of serious injury or death because the defendant ‘wasn’t qualified,’ ‘didn’t think it was his or her responsibility,’ ‘didn’t want to get involved,’ or ‘was afraid of being sued.’”

 have stipulated that citizens have no legal obligation to provide aid; provided immunity from malpractice litigation if aid is provided, unless there is gross negligence or lack of good faith; and no payment can be accepted for aid given. Only four states - Louisiana, Rhode Island, Vermont, and Wisconsin - have enacted failure-to-act legislation that assigns an affirmative duty, enforced by criminal punishment.

Good Samaritan laws are open to interpretation, and physicians must fulfill numerous conditions to obtain the benefit of immunity. Leonard Berlin, MD, 

, “A physician asked to help during a life-threatening event will find that calculating the legal variables immediately to decide whether a Good Samaritan statute applies is an impossible task.” The number of malpractice suits in the United States has actually decreased about 10% every year for the last three years, according to 

. Ultimately, potential legal liability should not be the main decision-making pivot point but rather based on individual moral-ethical values.

I know that feeling of loneliness on the plane won’t be the last time. We have all chosen a road of long training, stressful decisions, responsibility for human lives, and loneliness that comes from specialization and excellence. However, being lonely is a state of mind as much as a behavioral pattern. As it is, we can change this by forging connections with others: by teaching, mentoring, recruiting help, directing, and managing so that we can successfully work together to solve problems. In the cases in which you do happen to be alone, like on a plane, follow your moral compass, and you won’t be wrong. It’s time for radiologists to stand up and stand up together, raise your voices and lean in. Let’s not be excluded from critical events whether real or perceived.  

A dreaded question for many radiologists can be a teachable moment.

Radiologists, Don’t Fear “Is There a Doctor on Board?”

The intensive care unit is a big consumer of radiological services. Portable chest X-rays are obtained daily for intubated patients; clinicians have lower thresholds for imaging critically ill patients. As a resident in the medical and surgical intensive unit this past month, I found that imaging is crucial to the diagnostic and treatment process. A day’s work includes reviewing images during pre-rounds preparation, discussing these images with the team as we round in front of each patient’s room, and afterwards, following up on new imaging and taking the time to look at studies more in-depth.

As an integral part of the process, some institutions have incorporated “radiology rounds” into the daily routine. For example, the critical care program 

 of Stanford School of Medicine lists visiting the chest reading room as part of the morning routine. These in-person meetings with radiologists may be a good way to promote diligent, quality care. Not only do these meetings ensure that clinicians review imaging for every single patient, but it is also a huge asset to have a live interpretation from the radiologist who can answer real-time questions and address concerns on the spot. This may be ultimately time-saving for the primary team and improve patient outcomes.

Several studies have shown that face-to-face meetings between physicians and radiologists can prevent errors and impact patient safety in a significant way. The 

 looked at in-person communication between radiologists and acute care surgeons and showed that out of 100 patients, significant alterations (43%) were made in surgical diagnosis and planning. These targeted sessions of in-person collaboration seemed to strongly influence decision-making even when the original report contained all the necessary data. [[{"type":"media","view_mode":"media_crop","fid":"47444","attributes":{"alt":"In-person radiology rounds","class":"media-image media-image-right","id":"media_crop_5613851279333","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5594","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©attem/Shutterstock.com","typeof":"foaf:Image"}}]]

Interestingly, there were major discrepancies (RADPEER score ≥3) between the written report and the reviewing radiologist’s read in 11% of cases. These latter changes may be influenced from having more information from the consulting physician about the patient’s condition. Eleven out of 100 studies is a significant number, and suggests that in-person meetings may be of benefit as a reiterative process for improving accuracy of radiology reports. The reading provided by the attending radiologist with the consultation of the surgeon during these rounds is considered to be final.

 looked at discordance in radiology readings between external overnight radiology services and staff radiology readings at a level one trauma center. Five-hundred and thirty four CT scans over three years were reviewed and discordance was measured by a substantive change in patient care. Results showed that the discordance rate was 16%, and 29% of the clinically significant missed findings were identified after trauma service rounds with staff radiology.

In-person communication between radiologists and referring physicians may improve mutual understanding and foster better future communication. Expanding team communications by including members with diversity in training and experience has been 

 to improve overall team effectiveness. Moreover, face-to-face interaction 

 higher levels of positive collaboration while lowering the amount of conflict in comparison to sterile electronic communications.

The model of in-person radiology rounds is an integral part of some services, but may be a radical change for other services. It requires dedication and commitment of time and effort from both radiologists and referring physicians alike.

Do in-person rounds work for you? Does your hospital employ an alternative process? Comments welcome below.

In-person rounds can improve communication between radiologists and referring physicians.

Radiologists, Show Your Face

Prior to starting residency, I was so enveloped in learning the scientific knowledge and book facts that I did not notice how much of medicine is social skill. As an intern in internal medicine, some days over 50% of my work seems like social work and the other 50% talking to consultants. Over the past few months, I’ve recognized how important it is to have a good relationship with specialists. I’ve also recognized the importance of developing trust with the patient and their family by engaging them, and how physical surroundings factor into both kinds of relationships.

The key to successful social spaces is a thoughtful structure that maximizes convenience, provides physical proximity, and channels emotional connection. Restaurants, cafes, malls, airports, and hotels all incorporate some component of social architecture in their design. These principles can also apply to hospitals in which we need spaces for family waiting areas, staff lounges, consultation rooms, cafeterias, etc. These are all places that people come together to discuss wellness and disease, and sometimes the most important conversations may occur outside the patient’s room.

One factor in particular that has disconnected radiologists from their clinical colleagues has been PACS. Electronic medical records and imaging have been a tremendous asset but also a double-edged sword. In the days when radiology consisted of physical films, the reading room was a hub of activity. It was a space for socializing, where general medicine doctors and doctors of all specialties would come visit radiologists and chat about patient cases; a physician’s lounge of sorts, alive with buzz and discussion.[[{"type":"media","view_mode":"media_crop","fid":"45702","attributes":{"alt":"radiology, come out of the dark","class":"media-image media-image-right","id":"media_crop_5555348526073","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5252","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 225px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"By Junzi Shi, MD","typeof":"foaf:Image"}}]]

Nowadays, the atmosphere of the reading room has completely changed. The use of filmless radiography has allowed much broader implications including digital enhancement, real-time distribution, and sending the image anywhere in the world. Better imaging has also contributed to increased utilization. For example, between 1998 and 2001, 

 per Medicare enrollee increased 16% per year for MR imaging and 7%–15% per year for CT, US, interventional radiology, and nuclear medicine. The pressures of sheer volume have pushed radiologists to work faster and read more images in the same amount of time have competed directly with face-to-face time spent with consultants and patients.

Overall, image-capturing technology has advanced by leaps and bounds. But the way we practice medicine - the way the patient interacts with the technology, and the way that we interact with patients - has fallen on the back burner. Physically, radiology has also been displaced into the far reaches of the hospital structure, shifted to the basement or consigned to a corner that is difficult to access. Part of this has been for practical reasons - shielding of radiation and magnets and access to power source. However, radiology has done itself a great disservice by opting out of the social engagement of medicine.

Radiology gets more consults than all of the other specialty services combined and is integral to many clinical activities, yet radiologists have allowed themselves to retreat into the darkness. I believe that there are many clinical, operational, informatics, and architectural remedies as we move forward in the 21

 century. I will be writing more about this topic in my next article.

Longing for the days when the radiology department was alive with discussion.