Karen Childress

As the campaign to encourage the right imaging tests at the right time continues to gather momentum in the medical community, one radiologist is taking an active approach to promoting appropriateness. Austin radiologist Robert M. Milman, MD, who has been giving presentations on imaging to primary care providers for many years, recently turned his attention to educating referring physicians on appropriate image ordering.

While it might appear at first glance that a radiologist instructing referring physicians to be more judicious about ordering imaging studies would be doing financial harm to himself and his group, Milman has the broader picture in mind. He embraces the ACR's Imaging 3.0 initiative to provide better care at lower cost by helping providers determine the most appropriate tests to order.

, a 90-physicain private practice radiology group that provides services to almost all of the hospitals in the Austin area and operates 16 imaging centers. 

 spoke with Milman about his efforts to ensure the appropriate use of imaging in his community, and how you might do the same where you practice.

Where are you giving these presentations, and to whom?

I go to different venues. I speak at meetings of state-wide organizations like the Texas Academy of Family Physicians when they meet in Austin and to local primary care groups. I also give the talks at the University of Texas School of Nursing for advanced nurse practitioner graduate students and at Texas A&M University to medical students.

What do you typically cover in your talk?

The main focus of the presentation is about appropriate imaging or “what to order when.” I go over what different types of studies can and can’t do and discuss the level of radiation exposure to patients - what’s involved in a CT scan versus a plain X-ray, for example, or that there is no radiation exposure at all with ultrasound or MRI. I also cover how to decide on appropriate follow-up studies and some of the lesser discussed risks involved with imaging like false positives and incidentalomas, both of which can cause patients unexpected anxiety.

What do you think draws primary care physician and nurse practitioners to these talks?

Imaging is now involved in the care of so many patients that our referring community really wants to learn about how to order the right study at the right time for the right reason. As radiologists, we can provide information to help doctors get the answers they need in the most efficient and most cost-effective way possible. They appreciate learning how to get from point A to point B when they’re trying to make the right diagnosis for a patient. The feedback has been positive. Also, my group has the ability to offer CME credit for some of the talks, so that helps.

What’s the level of engagement in the part of your audience members?

They’re very attentive and stay with me and stay on topic. For them it’s a picture show because radiology is so visual. No one is interested in dull material, but if you can provide something of worth, people will attend.

One issue that often comes up is related to patient demand. People have access to a lot of medical information today and if they have low back pain they know there is this thing called an MRI machine out there and they think they need that scan. Referring physicians spend a lot of time trying to help patients understand what’s appropriate when it comes to imaging, so I touch on that in my presentations.

What has surprised you since you’ve been offering these presentations?

Mostly that even though the American College of Radiology’s 

 has been out there for quite a while that many primary care physicians are still not aware of it. The traditional method of picking up the phone and calling a radiologist when they have a question is fine - and our group does a lot of that and is happy to do it - but primary care doctors could save a lot of time by using the information that the ACR has available. With a few clicks on the computer they can usually get an answer about what test to order.

How does the practice of so-called “defensive medicine” come into play related to appropriate imaging?

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What do you see as the future for radiology groups given the push for referring physicians to follow appropriateness guidelines?

Most radiologists are becoming aware that the world is changing from a volume driven, fee-for-service model to a value driven, patient-centered model. At the end of the day you want to do the most appropriate test and be as efficient as possible. It’s about making the right diagnosis and treating the patient appropriately. This is a culture change, but resources are not unlimited and costs need to be contained.

Is your group supportive of your efforts to educate healthcare providers?

Yes. There are about 90 radiologists in our group and many of us give CME presentations. I’m the primary one in the group doing talks on imaging appropriateness right now. I’m planning to branch out and start giving presentations about appropriateness specifically related to screening studies such as the latest in breast imaging, lung cancer screening, and the use of virtual colonoscopy.

What advice do you have for a radiologist who is reading this and thinking about offering similar presentations in their community?

Get energized about the topic and put effort into giving the talks. They could contact some of their local primary care groups and offer to come in and make a presentation or they could work through their local hospitals or medical society to get the ball rolling. Groups always appreciate having interesting speakers come in.

Articles

One radiologist is taking a proactive approach to encourage appropriate image ordering by educating his fellow referring physicians. Here’s why he’s doing it, and why other radiologists should, too.

Radiologist Takes Appropriateness Message to the Community

Radiologists are feeling the squeeze, which can bring feelings of anxiety and dread. In 2014, resolve to banish the bad attitude and be happier. Here’s how.

Think back to early this morning and the moment you became aware that you were awake. Safe in your comfortable, warm bed, what went through your mind as you slowly opened your eyes? Did you greet the day with a feeling of optimism, hope, or curiosity?

Or did you wake up with a sense of dread, anxiety, or flatness?

If you generally start your days in one of the former moods, congratulations. If, on the other hand, you’re one of the many busy - perhaps even overwhelmed - radiologists who wake up all too often in one of the more negative moods, it might be time to adopt a new attitude for the new year. This time of year is ideal for reevaluating how you’d like to spend the rest of your days - and the rest of your life.

Being happy is a voluntary way of living, according to pediatric radiologist and physician career coach 

. “Moment by moment, day by day, we make choices about how we live,” said Moskowitz. “Research shows that about half of our happiness is hard-wired. About 40 percent is related to one-time events like getting a raise or buying a new car, but that kind of happiness is short-lived.”

It’s the remaining 10 percent, said Moskowitz, that’s under an individual’s control. And that 10 percent can make all the difference.

Radiologists are under tremendous pressure at the moment as they - along with their colleagues in most other specialties - adapt to changes in healthcare. “Physicians coming out of training today are unprepared for what they’re facing,” said Moskowitz. “The utilization of imaging studies has sky rocketed to the point that there is no time to breathe, eat, or chat with colleagues. Radiologists are expected to operate like machines and be perfect.”

[[{"type":"media","view_mode":"media_crop","fid":"21780","attributes":{"alt":"Peter Moskowitz, MD","class":"media-image media-image-right","id":"media_crop_4082176781537","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1539","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":"float: right; margin: 5px; height: 166px; width: 125px;","title":"Peter Moskowitz, MD","typeof":"foaf:Image"}}]]Under these circumstances, maintaining a positive attitude with any degree of consistency requires more than smiling and pretending that everything is okay. Just as you practice medicine, you can practice improving your attitude and mood. Here are a few habits that Moskowitz recommends for physicians who are looking improve their outlook on life.

Make self-care a priority. Get eight hours of sleep each night, eat well, get regular aerobic and strength training exercise, and experiment with meditation.

Each night before going to bed, write down several things that you’re grateful for. “When this is done regularly is helps you realize how many good things are happening in your life,” said Moskowitz.

Spontaneously do nice things for other people and practice saying thank you more often.

Spend more time outside in the sunshine and fresh air. This is especially important for radiologists who spend most of their time in dark rooms, making them susceptible for seasonal affective disorder, particularly during the winter months.

Put fun into your schedule. Play is restorative and healing.

Carve out time to stay connected with family and friends. “Radiologists get too busy and forget to connect. They get lonely and that can lead to bad things,” said Moskowitz.

Volunteer in the service of those less fortunate. “It doesn’t have to be in medicine. The benefit of this is that it gets your mind off your own negativity and helps you appreciate what you have,” he said.

If you try some or all these suggestions and find that you continue to feel stuck in negativity, take a closer look at how you are working. “Identify the features of your job that you like and dislike,” said Moskowitz. “There may be aspects of imaging that you feel less comfortable with which can lead to a lot of stress. If that’s the case, negotiation trade-offs within your group.”  

In addition, evaluate how much you are working - and to what end. “Many radiologists become accustomed to making a lot of money and that paralyzes them when they consider re-creating themselves.” The solution to this problem, according to Moskowitz, is to move beyond thinking that more is always better. “It’s a trap with a very obvious point of diminishing returns,” he said. “If we focus only on accumulation we miss everything else.”

Take time to figure out what your most closely held personal values are and then live by those values. “Don’t live according to other people’s expectations,” said Moskowitz. If that means working less, the corresponding reduction in pay may be well worth it. “You might earn less but you’ll gain freedom and self-respect by getting out of a bad situation,” he said. Sometimes even a small step like taking a half-day off each week to spend with family or friends is enough to shift one’s attitude.

If you need to make changes but you’re in a group with no flexibility it might be time to and find a new job. “Just be careful not to re-create the same situation somewhere else,” warned Moskowitz.

A shift in attitude might not require anything as drastic as changing jobs. If boredom is the root cause of your disposition, commit to learning something new this year, either within your field or completely outside of it. If you are frustrated with the direction healthcare is going consider getting involved either politically or with a professional organization that is working to influence the future of medicine.

As this new year begins, take time to think about how you’d like to see it unfold. Keep in mind that you are in control of how you spend your days and how you spend your life. The degree to which you manage your attitude greatly influences both.

Karen Childress

Articles

Radiologist Takes Appropriateness Message to the Community

How to Improve Your Attitude in 2014