Loren Bonner

Answering some fundamental questions might be wise before the field of radiology “embarks on such a sea change” of more direct communication with patients, according to authors of a new study published in the 

Journal of the American College of Radiology

“Many in radiology want to directly interact with patients and provide greater value from imaging services,” said David Naeger, MD, study author and assistant professor of clinical radiology at the University of California, San Francisco. “But it seemed to us that people hadn’t rigorously looked at what patients wanted.”

Naeger and a team of researchers set out to do just that. Based on a total of 617 survey responses from patients, they found that the majority-63%-preferred receiving their imaging results from a referring provider, not a radiologist.

“For me, this study highlights that there’s more work to do helping patients understand who we are in the care delivery process and that we’re one of their doctors as well,” said Geraldine McGinty, MD, assistant professor of clinical radiology at Weill Cornell Medical College in New York.

The survey respondents, who were adult outpatients undergoing CT or MRI, came from two different centers. Four hundred and seventy-five (77%) were patients at an academic medical center, and 142 (23%) were patients from an affiliated county hospital. The groups were surveyed over a four-week period.

While many articles, opinion papers, and lectures have encouraged radiology to shift toward more patient interaction, only a handful of studies have sought out the patient in different care settings and asked them how they view radiologists.

Naeger said the few studies conducted on the topic have been inconclusive and offer conflicting results. In addition, most of these studies have involved surveys of outpatients at single institutions, resulting in narrowly selected groups of patients.

“The empirical data seem to be in conflict with each other, which means this is something that merits study,” said Richard Gunderman, MD, vice chair of Indiana University Medical School’s radiology department. Gunderman and his colleagues have looked into the issue as well. [[{"type":"media","view_mode":"media_crop","fid":"40765","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5481898270477","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4224","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: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©cofkocof/Shutterstock.com","typeof":"foaf:Image"}}]]

But Gunderman pointed out that the way survey questions are formulated can skew the data.

“You can show a patient a video recording of a great patient-radiologist interaction and then ask the patient if they would like to have this kind of conversation and of course they will say yes,” said Gunderman.

 study, the primary question in the section that assessed preferences for receiving results asked patients to select from five different scenarios. Surveys in which patients did not answer this question were excluded. In that same section, patients were asked from whom they would want to hear their imaging results: an “expert in treatment and with whom you are familiar” or an “expert in interpreting scans with whom you are not familiar.”

“We did make it realistic: radiologists were not the experts on treatment and they are not someone you’ve met before,” said Naeger. “When you put it all together like that, people did not pick that option.”

Naeger and his team were surprised by the results. Their initial hypothesis stated that if patients were aware that there were imaging experts available, they would want their imaging results from that expert.

“Even when phrased like that, it’s not what they picked,” said Naeger.


Garry Choy, MD, MBA, a radiologist at Massachusetts General Hospital, believes more studies like this need to be conducted so that radiology can figure out where it can have the most impact. He’s been working with a team of researchers at MGH to identify these specific areas.

The effort has been especially effective in oncology. Choy said allowing cancer patients to see a tumor shrinking, for example, “is incredibly motivating and builds a trust that the treatment is working.” In primary care, another promising area for imaging, radiology residents at MGH go to primary care physicians’ offices during their weekly rotation and work on an interdisciplinary team. Choy said they have found that in many cases, revealing an image has helped a patient lose weight or quit smoking.

“I think direct radiologist to patient interaction is applicable to a subset of patients,” said Choy. “Where images don’t matter, we might not play a role.”

But Choy realizes most practicing radiologists can’t feasibly do what they’ve been experimenting with at MGH. Radiologists are under time constraints and the volume of scans is demanding, not to mention radiologists don’t get paid for the time they would interact with patients.

 study asked patients their demographic information as well as questions related to their understanding of the role and training of a radiologist.

While the survey set out to see if patients knew what a radiologist did, Naeger said there wasn’t a particularly strong result in one direction or the other.

Like many previous studies that have been conducted on this topic, Naeger said the results did show that people are not very familiar with radiologists.

Of 616 respondents from both hospital settings, 88% indicated that they “know what a radiologist is and what they do,” though only 56% identiï¬ed radiologists as medical doctors. Forty-three percent believed that radiologists operate CT and MRI scanners, and 32% identiï¬ed that radiologists do biopsies and minimally invasive procedures. Seventy-nine percent of patients correctly answered that radiologists interpret imaging studies.

But awareness about the role of radiologists could be changing in Naeger’s opinion.

 study pointed to another take-away for radiologists: Patients want access to their radiology reports.

“Now that there are patient portals and patients have more access to [radiology] reports, patients will become even more aware,” he said. The report is signed by a radiologist, which highlights that it was interpreted by someone with an MD after their name, according to Naeger.

The next step-which some institutions and practices have already embarked upon-is attaching contact information, such as a hotline, to a radiology report where patients can talk to radiologists directly with any questions.

“Then there are few places that go next step, which is clinics where patients can discuss these things in person,” said Naeger.

But until the U.S. health care system decides to reimburse radiologists for any time spent with a patient, these places will remain few and far between.

Articles

Radiology’s quest for value includes more patient-interaction, but what if patients don’t want to interact with radiologists?

Patients Don’t Want to Talk to Radiologists

Radiologists are among the top 10 most burned out physicians, according to Medscape’s 2015 

. In seventh place-right behind internal medicine, general surgery, and infectious diseases-the report found that 49% of radiologists felt burned out. The figure is a significant increase from last year’s 

, where radiology ranked low on the list at number 18.

Although it’s difficult to predict who might be at risk, radiologists are not immune to burnout despite radiology’s reputation as a lifestyle specialty. And if the Medscape 2015 Physician Lifestyle Report is any indication, it’s an issue that is bubbling to the surface at a rapid clip.

“Unique aspects of our profession, such as its relatively isolated and sedentary nature, might predispose some radiologists to burnout,” said  Michael F. McNeeley, MD, a fellow in the University of Washington’s department of radiology.

The Medscape report defines burnout as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.


"You can’t chop away in a room just reading images without losing interest in what you are doing,” said  John Cronan, MD, chairman of the department of diagnostic imaging at Brown University’s Alpert Medical School and radiologist-in-chief at Rhode Island Hospital.

Isolation was never an issue for radiologists before PACS. In fact, during the days of film, the radiology department was one of the busiest places in a hospital. Today, however, most radiologists read studies in isolated cubicles. This isolation has been synchronized with decreased reimbursement as well, according to Cronan.

“We are motivated to read more and take advantage of not being interrupted by other doctors,” said Cronan. “Thinking that was good, it has led to total isolation, deprivation and radiologists becoming burned out.”

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Although PACS has led to many positive gains for radiology and medicine as a whole, at the same time, it has left radiologists with diminished support, fewer professional relationships, and feelings of isolation and loneliness.

At Rhode Island Hospital, Cronan came up with a simple intervention to help try to alleviate the problem.

“We weren’t going to get the referring physicians back but we could cluster the doctors and radiologists together in an open room,” said Cronan.

They started small by breaking down a wall that separated the reading stations of body CT and body ultrasound. Now it’s one big room they call the body room.

“Some interchange and socialization during the day has been huge,” said Cronan.

At the same time, the hospital’s emergency department needed to increase its capacity. Instead of having another radiologist help read ER studies in a different location, Cronan suggested physically putting the attending physicians and residents in the ER together, which has also been successful, especially among radiologists who would rather avoid ER rotations because of the isolation.

Most recently under Cronan’s direction, Rhode Island Hospital has combined diagnostic and screening mammography radiologists in the same room, as well as neurology and spine MR.

“I have come to the conclusion that we have a higher job satisfaction when people work together-and they like working together as a team,” said Cronan.


According to the 2014 American Medical Group Association (AMGA) 

 Annual Medical Group Compensation and Financial Survey

, which was also discussed at RSNA 2014, relative value unit (RVU) increased at an even higher rate than compensation for radiologists. RVU rates, which are the primary measure of a physician’s productivity, set reimbursement by the Centers for Medicare and Medicaid Services (CMS).

The study found that RVUs for interventional radiologists increased by 5.8% and by 7.2% for diagnostic radiologists. According to RSNA, the rise represents one of the highest in any specialty, except for psychiatry.

Coupled with this are changes to the Multiple Procedure Payment Reduction (MPPR) as applied to RVUs. In 2012, when CMS expanded MPPR to include a cut to the professional component, RVUs should have been reduced too, since an additional second study only gets credited for 50% of the RVUs as opposed to 100%. Notably higher RVUs-when the MPPR should have made them lower-signifies radiologists are working even harder.

Of all the factors that could be contributing to burnout among radiologists, the increase in work volume may be the overriding factor, according to  Peter Moskowitz, MD, a clinical professor of radiology at Stanford University School of Medicine.

“It seems every year that the number of cases and the daily work volume seems to be getting greater at a time when there is pressure to increase individual work productivity,” said Moskowitz.

He says radiologists’ RVUs are being monitored to the point where some hospital administrators are using RVU output to determine salary and bonuses.

“There is tremendous pressure on radiologists to work more and do it faster and that stress is the major problem,” said Moskowitz.

Without interventions, he said it’s hard to see the situation improving.


Moskowitz, who is also founder and executive director of the Center for Professional and Personal Renewal where he coaches physicians on career and life management, said in his 16 years of coaching, radiologists have become his predominant client over the past five years or so.

“It’s becoming more and more of a problem in our field,” he said.

Yet at the same time, he said it’s still the elephant in the room that no one wants to acknowledge. He said the anxiety and depression radiology trainees feel is often not spoken about because many are reluctant to admit they need help in the first place.

Moskowitz cites a particularly high stress rate among radiology trainees, which he has noticed first-hand in many of his radiology residents.

“Burnout is becoming more of a significant issue among trainees in radiology, and if left unaddressed, the natural progression would be that it would start affecting their mood and performance,” said Moskowitz.

McNeeley and his colleagues were the first to look at burnout for radiology trainees. Based on a 2013 study, they found similar levels of burnout among radiologists when compared to internal medicine residents. This correlation signifies something noteworthy because for years radiology has carried a reputation for being a lifestyle specialty.

McNeeley said this could end up misguiding medical students to enter the field for the wrong reasons and perhaps with unreasonable expectations. By the same token, he said it could cause department leaders to underestimate the pressures that their trainees are experiencing and possibly result in a lack of department wellness initiatives that should be in place.

This current situation seems especially worrisome and stressful for radiology trainees. Radiology residents work nights and weekends, take frequent calls, and are not in a position of power, according to Moskowitz.

In addition, they go through a relatively long training period-which includes five years of postgraduate training with fellowships becoming virtually obligatory; they are hit with medical student debt that can easily exceed $150,000 as they begin residency coupled with difficulty finding affordable housing in urban centers when they begin training; and they face an uncertain job market as well as changes in the board certification process.

Moskowitz said those who are single and without the added income from a working spouse are especially susceptible to such financial stress.

“Over time, this financial stress takes a toll,” said Moskowitz.

Both McNeeley and Moskowitz agree that if the topic is not addressed and conditions are not improved, radiology could face a recruitment crisis in the years to come.

Moskowitz said leaders should be concerned if they begin to see residents leaving their training programs before completion.

“It’s a huge issue of tremendous importance-it threatens the very viability of radiology,” he said.

Radiologist burnout is a direct threat to radiology's viability.

Radiologists Are Burning Out

During his State of the Union Address this year, President Obama called on the nation to lead the world into a new era of medicine-one that delivers the right treatment at the right time. He was referring to precision medicine, which he said will cure diseases like cancer and diabetes, while at the same time giving patients access to personalized information to keep them healthy.

With precision medicine now part of the national consciousness, all fields of medicine have an opportunity to step up to the plate. Many of the tools are already in place to understand the correlations between genome, habits, and disease.

“Physicians think they have been doing precision medicine forever,” said James Thrall, MD, chief of radiology at Massachusetts General Hospital. “But they don’t understand it in the sense that we are talking about it-in the sense of phenotyping and genotyping people, identifying precise cohorts of people.”

Normally people associate precision medicine with genotyping-identifying an individual’s DNA sequence. But that’s not the complete picture. According to Thrall, just looking at an individual’s genome won’t necessarily create cohorts, mainly because of epigenetics, or the cellular trait variations that are caused outside of changes to the DNA sequence and other sources of variation in gene expression.

Imaging is one way to observe-or phenotype-the physical manifestations of disease in order to establish these cohorts for clinical trials.

A 2011 publication from the National Research Council (NRC) defined precision medicine as medical diagnosis and treatment based on the individual characteristics of a person. They go on to say that this can be achieved by identifying small cohorts of people who have a similar clinical presentation and biology of their disease, and are likely to respond to the same treatments, as well as have similar prognosis.

By identifying which subpopulations respond best to a drug therapy or certain follow-up treatment, much more efficient clinical trials can be done with the ultimate goal of treating patients based on the precise characteristics of their disease.

“In the era of precision medicine, instead of having large cohorts of people that may have different characteristics, you look for people with similar characteristics,” said Thrall.

It turns out there are only four ways to phenotype a patient. Imaging is one way, along with clinical history and a physical exam, lab testing, and histopathology and immuno pathology.

“A good phenotyping system segments patients into different prognostic categories,” said Thrall.

For example, a colleague of Thrall’s developed a scoring system for patients exhibiting intracerebral hemorrhage based on the number of spots of contrast seen on CT angiograms. Five different scores, categorized by levels of bleeding or not bleeding, segment the patient into various risk categories.

Thrall said there are at least five clinical trials going on currently where this scoring system is being used.

“I’ve come to think of it like this: When a radiologist renders a report, the report is actually a description of the imaging phenotype of disease manifestation, but we’ve just never thought of it in those terms,” said Thrall.

He urges radiologists to start talking about imaging biomarkers and phenotypes instead of rank and signs.

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Imaging has the capability to influence precision medicine in many ways, especially with molecular imaging. For instance, Hodgkin’s lymphoma patients receive an FDG PET scan after a few rounds of chemotherapy. In one case of imaging phenotypes, where there’s no abnormal uptake of tracer, patients end up having a normal life expectancy. But in cases where there’s a continued presence of abnormal uptake, those patients have significantly lowered life expectancy.

“As a predictor of prognosis, the use of imaging to create these two phenotypes is far better than something called the International Prognosis Scoring System,” said Thrall.

Going forward, molecular imaging will likely play the biggest role in broadening precision medicine outside of oncology and into metabolic disorders and neurological diseases. In fact, the theme at this year’s annual 

World Molecular Imaging Society (WMIS) Congress

“We’ve been using imaging to characterize the cellular and molecular underpinning of tumors and defining tumor genetics-that’s the very heart of precision medicine and that’s been molecular imaging,” said H. Charles Manning, PhD, World Molecular Imaging Congress program chair.


Dr. Eliot Siegel, professor and vice chair of research informatics at the University of Maryland School of Medicine, sees another opportunity for radiology to participate in precision medicine. The more accurate identification of follow-up treatment for the millions of smokers aged 55-77 who will receive low-dose lung CT screening now that the Centers for Medicare and Medicaid Services will cover the screening.

“What if we could perform personalized screening not just based on age and smoking history, but based on index of likelihood of developing cancer or other disease?” said Siegel.

Current recommendations for follow up and management of lung nodules have been established by the Fleischner Society. The criteria are mostly based on a patient’s smoking history and nodule size. Siegel said there is an opportunity to personalize these recommendations-make them more precise-by adding additional parameters, such as the lobe in which the nodule is found, nodule shape, patient age, ethnicity, and other factors using National Lung Screen Trial Data.

According to Siegel, there is another database to help determine the a priori probability that a patient will develop lung cancer. He said the Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial dataset, published in 2009, is a resource that can be used for matching patients with the outcomes of demographically or diagnostically comparable patients. PLCO enrolled 155,000 patients to determine whether certain screening exams reduced mortality from prostate, lung, colorectal, and ovarian cancer.

“So rather than just creating a set of recommendations based on the size of the nodule [and smoking history], you can use multiple parameters and a large database and then make the recommendations for follow up very precise,” said Siegel.

At the same time, the precision criteria derived from the database can be used to determine which patients should be screened in order to create the highest yield in the most cost-effective way.

“We use these databases and others like them in making decisions about who to screen in the first place but also [we use them for] what I should do when there’s a positive finding-how aggressive should I be as far as a follow-up imaging, biopsy, or surgery,” said Siegel.

Right now, data from large clinical trials guide many treatment decisions, often in a one-size-fits-all manner. But in the future, decisions will increasingly be made based on patient-specific characteristics, according to Siegel.

While some of the tools might be there, not all of the capabilities are. Siegel would like to see databases that are more accessible for searching.

Variability in medical imaging data also presents a challenge if radiology is going to have an impact on precision medicine.

“Standardization in medical imaging helps enable smaller, faster, and smarter clinical trials for providing the evidence needed to bring new patient-specific treatments to the public,” said Daniel Krainak, PhD, from the FDA’s Magnetic Resonance and Electronic Products Branch in the Office of In Vitro Diagnostics and Radiological Health.

A number of research groups, including the FDA, are currently identifying the major sources of variation and developing techniques to reduce uncertainty so that image-based measurements and assessments are more accurate and precise.

Other challenges include clinical validation of image analysis tools and the development of novel techniques that combine images with other sources of data, such as in vitro diagnostic tests, family history, patient demographics, and genomics.

With these challenges met, and radiologists eager to make their mark, imaging’s role in precision medicine will only expand as new therapies and prevention techniques are developed.

Identifying the important role of imaging in the new era of precision medicine.

Radiology’s Role in Precision Medicine

It’s a delicate dance radiologists and referring physicians play these days.

“Sometimes radiologists need to leave out clinical judgment and just let us make the call,” said Marcus St. John, MD, an interventional cardiologist at Miami Cardiac and Vascular Institute at Baptist Hospital of Miami. “But I understand, they are physicians and they are not reading a study in complete isolation.”

In an age where radiologists feel that their profession is at risk of becoming commoditized, and nearly everything is communicated through the report, staying relevant is more important than ever. Sometimes that means inserting clinical expertise - even if it puts referring physicians on the defensive.

St. John said he appreciates the information radiologists provide, and he relies on reports they provide for diagnosis as well as input on appropriate imaging, but he wants to make the clinical decisions for his patients.

David Winchester, MD, a cardiologist with a focus on noninvasive imaging at the University of Florida Health Shands Hospital, said his radiology colleagues often debate about what to include in the report. “We don’t want to tell someone how to take care of their patient, but we also want to provide them with useful information,” he said.

Winchester, who also helps run UF’s Chest Pain Evaluation Center at Shands, said they elected to do cardiac CT angiography as their noninvasive imaging test of choice. When physicians have to make a critical decision for each patient about whether to send them home or admit them, the study serves as an important clinical reference. 

“We sort of artificially have to take a complex description of somebody’s coronary anatomy and distill it down into what is actionable,” said Winchester.

In such critical situations, he stresses the need for clear communication in reports, which can include information on what should be done.


The often strained relationship between referring physicians and radiologists has been brought on largely by the change in the way they communicate, said Richard Gunderman, MD, vice chair of Indiana University Medical School’s radiology department.

“The relationship is much less consultative than I would prefer,” he said.

“In some ways, the technology has tightened the relationship,” said E. Kent Yucel, MD, radiologist-in-chief at Tufts Medical Center in Boston.

But solutions are constantly in the works to try and enhance more personal connections for physicians that technology has tended to erode.

Cecelia Brewington, MD, professor and vice chair of radiology at the University of Texas Southwestern Medical Center, said her department has begun using a tool from Primordial Radiology Solutions that is integrated with UT Southwestern’s radiology department’s PACS system. It includes an avatar, or headshot, for the radiologistin the work list.

Although the tool is mostly used within radiology, certain critical care departments, like the ICU and ER, are included. “I think this is something that can help to improve the relationship and make it more personal,” she said.

Brewington said her department has also begun using the Lync system from Microsoft to share screens with other physicians. Companies are expanding enterprise messaging communication within those systems as well.

Other facilities, like NYU Langone Medical Center’s radiology department, tak[[{"type":"media","view_mode":"media_crop","fid":"30209","attributes":{"alt":"radiologists, referring physicians better together","class":"media-image media-image-right","id":"media_crop_3796662468242","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3159","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: 166px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]e it a step further with a virtual consult option for radiologists and referring physicians within the multimedia radiology report.

Some tools that were developed to communicate emergency findings are being used more often as every day communication tools. Yucel said his department has solved some communication issues with programs that allow radiologists to record a voice message and attach it to the report.

“Although it’s indirect, I think it has improved our communication,” he said.

Referring Physicians Seek Input from Radiologists


Robert Wears, MD, an emergency room physician and professor in the Department of Emergency Medicine at the University of Florida, said seeking advice from radiologists on which imaging test is best for a patient is one of the most common interactions he has with radiologists - especially with so much variation in advanced CT imaging. Common questions can be whether to give contrast or not, and then if that contrast should be IV or oral.

If he’s interested in one type of study, he’ll call up radiology and ask about the best way to order the study.

“All of these things depend on what you are primarily looking for and they have different logistical constraints,” he said.

He’s also noticed that as ultrasound technology has improved, there’s been a battle over whether it can be better than CT in certain cases - an area where radiologists can also influence patient-centered choices.

Within interventional cardiology, St. John said he often seeks input from radiology on the best imaging test to give a patient.

“When it comes to slightly more esoteric imaging tests or questions, our interactions with radiologists are often to not only find the best test but depending on the situation, we’ll actually go review the study with the radiologist just to complete our understanding of the issues to make the best informed decision,” he said.

If one of his patient’s has a weakness of the heart, for example, there could be several potential causes. Depending on what the physician is looking for, a cardiac MRI or a CT angiogram may be appropriate.

“Radiologists are often the best specialists to help you decide,” he said.

St. John’s imaging colleague, Ricardo Cury, MD, chairman of radiology and director of cardiac imaging at Miami Cardiac and Vascular Institute, said the collaborative effort among the different specialties at his institution is nurtured by leadership within various departments.

“Radiologists are uniquely positioned to lead the development of clinical pathways in their home institution with a multidisciplinary team, and guide the implementation of best practices by following appropriateness criteria,” he said.

Winchester said radiologists have a lot to offer just by knowing which imaging approach is best for a given patient. In his work, he can reach back to referring physicians and either tell them a test is unnecessary or encourage them to order a different test.

He thinks collaborative relationships are important as medicine becomes more specialized too. For example

at North Florida/South Georgia Veterans Health System, where he also works, they have both PET and SPECT imaging available. Although they can make PET available as a direct order, they have taken the stance as an imaging department on deciding who gets PET or SPECT because it’s not something the average primary care physician would know about.

“In settings where you can have collaborative relationships, I think that makes for the best choices for the patient,” he said.


Both radiologists and referring physicians seem to agree that one of the best ways to improve communication is through participation in multidisciplinary care conferences or multidisciplinary hospital committees.

“In some ways, it’s the only vehicle we have now for direct contact,” said Yucel.

Multidisciplinary conferences, especially in the academic setting, can occur weekly, bi-weekly, or monthly. In any case, they get everyone together in the same room.

Wears said they often invite radiologists to come to their emergency room conferences to comment on images. He said it has always been helpful - perhaps most in a social sense.

“After you’ve seen someone and spoken to them face-to-face, it’s easier on the phone to call them by their first name and express your concerns without having to be quite so careful because you are dealing with a stranger,” he said.

Though the relationship can be strained, radiologists and referring physicians have a lot to offer one another.

Loren Bonner

Articles

Patients Don’t Want to Talk to Radiologists

Radiologists Are Burning Out

Radiology’s Role in Precision Medicine

Radiologists, Referring Physicians Work Better Together