Marcia Frellick

Advances in surgical technology and demand for real-time multispecialty expertise are often putting radiologists and surgeons side-by-side in the operating room and changing the way they interact.

When the relationship works well, respect is mutual and each clinician is able to take full advantage of the other’s expertise. When it doesn’t, tensions arise and frustrations build.

The relationship is particularly important in reconstructive surgery, Oren Tepper, MD, plastic and reconstructive surgeon at Montefiore Medical Center in the Bronx, New York, said.

“There’s definitely more of the back-and-forth collaboration between surgeons and radiologists that people hadn’t seen before,” he said. “There’s an increasing desire and a need to sit and go over the films together.”

At Montefiore, Tepper works with radiologists on skull and facial reconstructions and traumatic deformities. Together they map out blood vessels via magnetic resonance angiograms to locate the best places to take tissue from and the best location for attaching.

Years ago, if a patient came in with severe facial trauma and multiple bones had to be put back in place, he or she would have been taken to the radiology suite for scans and then back to the OR. Now surgeons and radiologists can look at the images together in the OR, Tepper said.

“More than ever there’s a need to have radiology input in real time,” he says. “It’s not unusual for us to have a head-and- neck radiologist come to the operating room and review a CT scan while the patient is on the operating room table.”


Respecting the other’s need for efficiency helps strengthen the relationship between radiologists and surgeons at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, said Robert Kane, radiologist and co-chief of ultrasound.

“We schedule our cases as much as possible and we have a 10- to 15-minute response time,” Kane said. “Surgeons will send a call down to us that they’ll be ready to scan in 10 to 15 minutes and our part of the bargain is we’ll be up there ready to go… So neither of us stand around waiting for something to happen.”

A. James Moser, MD, FACS, executive director for the Institute for Hepatobiliary and Pancreatic Surgery at Beth Israel works with a team including Kane on image-guided surgery. He gave an example of how the relationship plays out during pancreas surgery where many of the lesions are small and you can’t feel them in a minimally invasive operation because you don’t have the tactile feedback.

The team looks at an image that Kane produces in the console so they have both a 3-D image of the operative field and an ultrasound in the same image.

“So the interface of somebody with Kane’s skillset is extremely important,” he said. “The surgeon’s view of the operating field changes dramatically when it’s being done in a minimally invasive fashion.”


The nature of how surgeons and radiologists visualize images can potentially lead to frustrations in communication

As chairman and CEO of EchoPixel, a San Jose, California-based, company that develops medical imaging solutions, Ron Schilling, PhD, works with both surgeons and radiologists.

He says when tensions develop between the two groups, it usually comes down to two things: language and money.

Regarding language, the trouble comes when radiologists, who see images two-dimensionally, try to explain their findings to surgeons, whose view is 3-D.

EchoPixel and other companies have developed software that translates data acquired through CT or MR or other modalities and produces an image in the dimension that is most meaningful to the physician requesting it. Any doctor can access the patient data and have an anatomically meaningful view.

But without a common language, the gap between the ways images are viewed can lead to built-in tensions when radiologists and surgeons discuss images, Schilling said.

 “At the Mayo Clinic, you will not find tensions like this…but in a lot of other places I can see when those tensions arise, especially when the radiologist is throwing their material over the wall and the surgeon gets it, but it doesn’t relate to the surgeon the way it should…. as we go forward with Obamacare, it’s going to demand that there’s an excellent interaction among all docs.”

The other factor that builds tensions centers on reimbursement, he said. He gave the example of a cardiologist who recommends an angiogram, using a catheter to determine whether there is disease in the arteries. The radiologist may recommend a minimally invasive CT angiography or MR angiography for the patient, which is much less expensive. 

The cardiologist may be less likely to recommend the less expensive procedure, “Because that’s taking money out of the cardiologist’s pocket,” he said.

At the root of a good surgeon-radiologist relationship is an appreciation for what the other does, Schilling said.


In that spirit, at Emory Healthcare Network in Atlanta, Georgia, where radiologists make up 125 of the 1,800 physicians on staff, radiologists and surgeons are part of a weekly oncology conference which also includes specialists such as radiation therapists and pathologists. Together they discuss roughly 25 cases each week.

 “Because we bend over backwards to support [surgeons], they are very supportive of us,” says Emory radiologist William Torres, MD, FACR. “The radiologists who do biopsies, drains and ablations often go to the operating room and work with the surgeons to do these procedures. In some places that’s not true and the ablations in the operating room are done by the surgeons themselves, but at least in our institution, we have a very collaborative way of doing things.”

The relationship is particularly important with the complexity and volume of MRI, especially body MRI, at Emory. “We do as many as any place else in the world,” Torres said. Surgeons need radiologists’ expertise to see the whole picture, he said.

The sheer volume and the number of sequences – often 20 for each body MRI – has made the radiologist-surgeon relationship even more critical in oncologic surgery, gynecologic surgery, transplants and general surgery, he said.

Having PACS has made it less common for surgeons to come to the reading room to view images, so in-person collaboration has become both choice and necessity, Torres said.

 “If a radiologist wants to sit in a dark room and read, they are not going to have the same kind of relationship as we do…you want to make yourself useful and relevant and the only way you do that is by working with the surgeons and find out what they need and be able to provide it to them.”

Articles

Technology has put radiologists and surgeons side-by-side when it comes to patient care, but the relationship can be tricky if not navigated properly.

 Radiologists and Surgeons: Can’t We All Just Get Along?

Currently, the root cause analysis procedure is only standard following a sentinel event. But some professionals argue that limiting the practice to sentinel events results in missed opportunities for improvement.

The Joint Commission works with accredited organizations to thoroughly review all factors that may have played a part in the event from human error to communication gaps to mechanical failures. While such an analysis is unquestionably important with events causing death or serious injury, radiologists say, there is also need for analysis with a much broader scope of errors or inefficiencies.

“If only serious adverse events are analyzed, there will be very few opportunities for learning and improving,” Jonathan B. Kruskal, MD, PhD, professor of radiology, Harvard Medical School, and chairman of the department of radiology at Beth Israel Deaconess Medical Center in Boston told 

“Too often I attend [morbidity and mortality] meetings where adverse events are described, or cases shown, and the discussion simply moves to the next case with no consideration of what went wrong, how to fix it, how to prevent it from happening again, and how to share the lessons learned,” he said.

Radiologists can learn from near misses, which are often harder to identify and are not often reported, Kruskal said.

The challenge is that radiologists are not well-trained to do RCAs and therefore do them ineffectively or not at all, Kruskal said. While radiologists have become good at diagnosing why the PACS didn’t work, for instance, being open to analyzing clinical errors has been a tougher sell. “This is why we are trying to train more of our colleagues.”

The educational goal is to share different methods for conducting an RCA, show how contributing factors are categorized and can then be considered, how the focus should be on process and not just the human factors that led to an adverse outcome, and how mitigating strategies can be identified and implemented.

The biggest task is orchestrating a cultural shift so physicians want to do these analyses, because they know the outcome will help them do something better.

“Instead of hiding our mistakes, the ideal culture encourages self-reporting such that cases can be pooled and analyzed to identify improvement opportunities,” Kruskal said.

One way to institutionalize RCAs to increase awareness and so clinicians expect to conduct them would be to alternate by month an RCA meeting with a morbidity and mortality meeting, Sumir Patel, MD, chief resident, radiology, Medical College of Georgia at Georgia Regents University in Augusta, said.

At these meetings, it’s important to involve all levels of employees, not just high-level executives. “You want to be able to get the information from the boots on the ground,” Patel said.

Radiologists can use RCA to solve day-to-day problems such as work flow issues, Patel said.

Suppose you have a work list and you see certain studies that have not yet been completed by your radiology technologist, even though you can see the images on the screen. You have clinicians calling for results, but you don’t know whether the examinations have been completed.

That situation would benefit from an RCA to examine and streamline the current process so everyone is clear when the complete results are available.

Another example is if people are referring you for interventional procedures but clinicians don’t know the best way to contact you. You can use RCA to look at the issues complicating the referral stream, Patel said.

These issues may seem minor, but examining all of the factors at play, categorizing the errors, correcting the errors or inefficiencies and disseminating that information to an entire organization takes a structured analysis.

RCAs go beyond routine examinations of errors or inefficiencies. They are formalized with follow-up structures with checklists and plans of action. 

, for instance, asks clinicians to examine 24 questions including what controllable environmental factors were at play; how equipment performance affected the outcome; what other areas of the organization could encounter the same problem; and how actual staffing compared with ideal levels.   

“If you’re just brainstorming…you might be limited in scope. You might be satisfied with the one example that you found,” Patel said.

RCAs can also turn up latent errors you didn’t know existed. Addressing those errors proactively can help avoid producing sentinel errors down the road, he said.

Sometimes radiologists aren’t part of hospital RCAs – either because radiologists don’t make it a priority or they aren’t included by others – and they need to be key players, Patel said.

“As radiologists have a seat at the table, they’re not going to be the dinner on the table,” he said.

Root cause analysis isn’t reaching its potential in the radiology community. 

Widening the Scope of Root Cause Analysis

In his position as chairman of the radiology department at the University of Washington, Norman Beauchamp, MD, MHS, gets to be both talent scout and someone who can enable careers.

At a recent RSNA 2013 session in Chicago, he offered a few tips for fellows and residents to help them “become someone you absolutely wouldn’t want to lose.”

1. Choose an environment for success. Before you even start your job, interact with your boss and make sure he or she is someone you can trust, respect and communicate with. Determine in negotiations whether they are interested in your success.

2. Be driven to be positive, professional and personable. “Don’t act as if it’s a job; act as if you’re an owner.”

3. Keep learning. Study people who are doing the job right. Who seems indispensable?

4. Get a mentor. The best mentors need to be recruited. Sometimes the best mentors are the busiest and you may need to ask persistently.

5. Have a vision and a plan. “Never, ever go to a meeting with someone you report to without an agenda.” Include in the agenda your top three goals, what you’re working on, what you need help with.

6. Don’t be a complainer. Present problems as opportunities and tell the boss how you’ve tried to solve it. “Solvers are absolutely indispensable.”

7. Be a leader. Step in when others are unwilling to do so. Help others believe in themselves.[[{"type":"media","view_mode":"media_crop","fid":"12399","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9836482713146","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1517","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;","title":"Norman Beauchamp, MD, MHS","typeof":"foaf:Image"}}]]

8. Create something. “I tell our residents, I tell our fellows that the first question I will ask them if they are interviewing for a job is ‘Tell me what you did to make the department better that wasn’t your job.’” Build a website, form a professional group, stage a fund-raiser or charity run, organize a volunteer day, suggest curriculum changes.

9. Maintain an unwavering belief in yourself. If you don’t believe in yourself, how will others?

10. Build a team. Surround yourself with excellence. Your productivity will skyrocket. Be generous in giving credit to all who did the work that resulted in success.

11. Manage your time. Don’t reverse delegate. If a member of your team isn’t executing, talk with them but don’t do the work for them.

12. Understand the rules. Make sure you know what it takes to get promoted. Ask every year when you meet with your boss, “Am I on track for promotion?”

Norman Beauchamp, MD, MHS, offers his tips for how residents and fellows can really become a valued member of the radiology group.

12 Ways Radiology Residents, Fellows Can Be Indispensible

CHICAGO - How can radiologists improve their partnerships with referring physicians? At a recent RSNA 2013 session, the referrers gave their perspective.

When asked about challenges in ordering studies, “23 percent of referring physicians stated that ordering the correct studies is often or always a problem … and 10 percent say they often need to contact the radiologist because of too much information in the report,” according to a study cited by panel moderator Judy Yee, MD, FACR of the University of California-San Francisco.

Sally Reynolds, MD, is the medical director of the emergency department at Lurie Children’s Hospital in Chicago. She gave examples of how she depends on radiologists.

One thing that has changed in her practice is that she’s seeing many more adults. At Lurie Children’s the cardiac department now takes care of patients until they’re 35. The urology department takes care of some patients into their 30s.

“It’s impressive the number of people I see now that I was never really well-trained to see at that age. So what I’m really looking for is for all radiologists, and anyone I consult, to help me think broadly about the patient, to make sure I haven’t missed something,” Reynolds said.

One example of when a radiologist can be a vital contributor is in determining whether the object a child has swallowed is a battery or a coin.

“We had a bad experience, where the kid said he ate the nickel, we thought he ate the nickel, the radiology resident said it was a nickel - and it was a battery. And he has a reconstructed trachea now. Every hour makes a big difference in the outcome,” she said.

Also, when a report says “need for further studies,” Reynolds said she would like the radiologist to include whether that study needs to be immediate or next week.

She urged radiologists to let physicians know if they’ve ordered the wrong test. “As we try to decrease radiation, the last thing I want to do is zap the wrong thing or order the wrong test,” she said.

Finally, because the number of ICD codes has multiplied, she needs radiologists to be very specific, for instance, about fractures including type, percent angulation and displacement.

Stephan Wyers, MD, a general surgeon at University of Chicago, said it helps for radiologists and referring physicians to have a healthy appreciation for other person’s perspective - what the other’s work day is like, when you know you’re interrupting them, what irritates them.

“The communication piece has to be easy, open and frank. We’re all trying to take care of the same patient but we may see it from different sides,” Wyers said.

His preferences for what he’d like to see in a report:

Use of a standard language, such as BI-RADS for breast images

Elimination of dated language such as “phlegmon” or “pancreatic abscess.”

Highlighted images. If there’s a key image, pull it out, put arrows right on a lesion.

Strong opinions in narrative form, no waffling. Avoid descriptors such as “ill-defined” or “hazy.”

Information on any previous imaging and how it compares.

“I’m not so interested in the technical details of how the study was done - sequence of the MRI, how much contrast was used,” he said.

Both speakers agreed that one of the most frustrating phrases to see on a report is “clinical correlation needed.”

“This phrase is so ubiquitous it makes me wonder whether they take the radiology residents aside and say, ‘Look, no matter what you do, say this in the report,’” Wyers said.

CHICAGO - Referring physicians offer some insight into what they want from their radiology colleagues, from better collaboration to clearer reports.

Author | Marcia Frellick

Articles

Radiologists and Surgeons: Can’t We All Just Get Along?

Widening the Scope of Root Cause Analysis

12 Ways Radiology Residents, Fellows Can Be Indispensible

What Referring Physicians Want from Radiologists