Mina S. Makary, MD

COVID-19 dominated healthcare in 2020. The virus simultaneously crushed some radiologists with an overwhelming workload while leaving others parched for scans to interpret. But, it is now a New Year with a brand new horizon. What can you expect out of the next 12 months?

 spoke with Mina S. Makary, M.D., an interventional radiologist with The Ohio State University Wexner Medical Center about what he saw as areas in the specialty and industry that deserve your attention. From the lingering pandemic to technological developments to radiology’s culture, he shared his insights.

This is the biggest issue radiology is dealing with right now. We’re continuing to learn more about its imaging manifestation, including the extra-pulmonary manifestations. It doesn’t only affect the lungs. There are also neurological and cardiac findings. Learning more and more about this disease – having a bigger knowledge base and further characterization of COVID – is going to help us as radiologists as we prepare for future pandemics.

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It will also affect our workflow and healthcare systems. The initial wave had a huge impact, and now we’re getting into the second wave that’s even higher than the first. It impacts radiology workflow, department readiness, workforce resilience – all kinds of factors. We will need to focus on how we will utilize our resources most effectively – where do we want to scan our patients, how many can we help in a safe fashion, and with what precautions? How will we deal with staff issues if members of our teams end up exposed and we have to work with less resources? We must determine how to optimize our departments to continue to deal with this epidemic from a clinical, personnel, and business standpoint.

The American College of Radiology and other radiology associations are lobbying Congress because there are new Medicare cuts in 2021. This is coming in the middle of a pandemic when there is less volume and less revenue in healthcare systems, groups, and radiology practices. It’s just going to be another layer that will impact a great deal of everyone’s practice – especially radiologists who are in smaller practices that are trying to make it through.

Over the last few years, the impact of artificial intelligence and machine learning has been exponential, and it’s only going to keep growing that way. More and more – every day – new applications are coming up to help us improve specific disease diagnosis.

One thing we will continue to work on, as a specialty, is how we can integrate this technology into our clinical workflow. Rather than worrying about artificial intelligence replacing radiologists, everyone is now thinking about how artificial intelligence will augment their performance to become better, quicker, and more accurate. Our goal now is to determine the best role for it. There are a lot of amazing applications coming up with opportunities for improving patient care with the new wave of technology focusing on improving a radiologist’s efficiency.

In the past, we had plain film. Then, we had a huge efficiency impact on our specialty with the introduction of PACS systems that we now use to view images. That took us from looking at individual films that you’d hang up in the dark room to being able to view studies and large number of images in an electronic way. Now, the next big jump is being able to handle thousands and thousands of images, and artificial intelligence is being leveraged to help us take our specialty through the next transformation phase in 2021 and beyond.

This may not necessarily be in 2021, but in the long term, 3D printing will continue to be among the next generation of technologies for radiology. And, it is huge – so much so that RSNA dedicates an entire section to just 3D printing. It’s being used for patient education, to train surgeons and other colleagues with practice surgeries, and for surgical planning. If we need to visualize a complex structure, a 3D printer can create a model we can use to observe, teach, explain the disease better to students and patients.

In addition to these growing innovations in the diagnostic core of radiology, the interventional side is also evolving new ways to implement cutting-edge therapies using imaging guidance. There are many exciting procedures that have been developed that are now gaining more and more applications. For example, geniculate artery embolization where interventional radiologists, through a small incision and vascular access via microcatheters and wires, are able to target the vessels that contribute to knee inflammation in patients with moderate-to-severe osteoarthritis. Patients can feel significantly improvement in pain and quality of life after this same-day outpatient procedure without the need for invasive surgery.

Additional innovative ways embolization is having a huge impact include for men with symptomatic enlarged prostate glands and in women who are suffering with fibroids. For example, instead of a hysterectomy, we can stop the blood flow to the fibroids and shrink them while preserving the uterus, so the patient can go home same-day with quick recovery, no scars, less risk of complications, and in a cost-effective fashion. So, there are a lot of minimally invasive therapies that are developing, and radiologists are at the center of this revolution. Not only we are effective in diagnosing patients, but we are now more than ever also using that knowledge to treat patients and provide great outcomes in minimally invasive ways.

Our country has had a larger national conversation about race, gender, and equality issues over the past few years. As a reflection of this, there is a move in organized radiology for diversity and inclusion across the board. We can see that all levels of organizations, such as the American College of Radiology and the Society of Interventional Radiology, promoting diversity and providing opportunities to all members from a variety of backgrounds. These trends are only going to continue to grow and make us stronger as a specialty. It serves to make us one big family.

Articles

It’s a New Year – what should you keep your eyes on and where should you anticipate change?

Six Trends to Watch in 2021

The ongoing COVID-19 pandemic has resulted in significant disruptions to the healthcare system, including imaging care. One study estimated decreases in imaging volumes of 50 percent-to-70 percent for at least three months and encouraged measures like reduced working hours, salary cuts, and even layoffs to help offset the revenue cuts due to the pandemic

. To comply with social distancing measures and protect personnel and patients against the spread of disease, many radiology practices have adopted teleradiology, or remote interpretation of medical images.

This has been a significant change in routine for many practitioners, and it is not entirely clear what work will look like once the pandemic subsides and providers are allowed to physically return to their workplaces. In this piece, we explore the challenges for adopting telemedicine and remote services in the imaging arena, as well as potential benefits that may encourage radiology practices to leverage teleradiology for the long term.

By definition, teleradiology is performed remotely and misses out on the benefits associated with being physically present. Keeping a physical presence can help foster a more collaborative community and bolster teamwork and relationships, whether it is with radiologists, radiology technologists, nurses, or other inter-and multi-disciplinary stakeholders. Referring physicians also appreciate having onsite radiologists for consultation purposes and collaborative conferences, such as tumor boards.

For residents and fellows, sitting side-by-side with attending radiologists during read out and reviewing imaging studies together can be beneficial for their education and development, though techniques like video calls and screen-sharing address some of these issues

. In addition, certain procedures, such as intravenous contrast administration, require the presence of an onsite radiologist, and the minimally invasive procedures of interventional radiology cannot be conducted remotely. In these cases, teleradiology is not an option.

Practices that adopt teleradiology need to equip personnel with tools to complete their work, but this process can be complicated. Home workstations must be powerful enough to handle image-intensive applications, and monitors must comply with regulatory specifications for quality assurance to ensure reliable visualization of findings, particularly for modalities, such as mammography with requirements specified by the Mammography Quality Standards Act

In addition, radiologists working remotely will need an adequate internet connection. Workflows can quickly become frustrating and, potentially, affect patient care if image-rich studies are bottlenecked by a slow connection. Furthermore, information technology services may be necessary to ensure that images are sent in a HIPAA-compliant manner. Notwithstanding some of these challenges, some radiology practices have documented how successfully and rapidly they equipped their radiologists for remote work during the pandemic

, but practices without adequate funding or technical support infrastructure will not be able to adapt as quickly.

Despite its challenges, teleradiology greatly expands access to diagnostic radiology services. An analysis of Medicare-participating radiologists within the United States found that rural areas were less likely than non-rural areas to have local radiologists

. In addition, rural areas with local radiologists tended to have a lower percentage of subspecialist radiologists than did non-rural areas.

Teleradiology can bridge the gap in imaging services between rural and non-rural areas. Patients in areas that lack local radiologists can still get diagnostic radiology services through radiologists working remotely. Care teams that wish to consult an expert on image interpretation can use teleradiology to get advice from an available radiologist. Generalist radiologists who want a second opinion from a more subspecialized colleague can simply transmit the images and communicate electronically. With teleradiology, patients and experts in rural areas can get high-quality imaging advice without having to travel to more populated urban areas with more advanced healthcare systems.

Furthermore, the ability to quickly recruit radiologists through teleradiology can address staff shortages during weekends, evenings, and holidays and better equip practices to handle unexpected surges in imaging volumes. Staff shortages are more pronounced in rural areas, where there may not be enough local radiologists to provide around-the-clock coverage.

Teleradiology benefits more than just diagnostic radiology. Interventional radiologists often meet with patients in clinics to perform examinations and pre-operative assessments. Through phone or video calls, teleradiology allows interventional radiologists to reach patients who cannot make it to physical appointments. These patients may have co-morbidities that restrict their ability to travel or put them at high risk of complications from infection, or they may live in rural or underserved urban areas without reliable access to healthcare

 Teleradiology can provide basic services and continuity-of-care to patients who otherwise would not be able to obtain them.

As a field, radiology is especially open to new technologies and innovations that have the potential to improve patient outcomes and care workflow, and teleradiology is no exception. Image interpretation, in particular, with the creation of centralized databases and distribution of images through secure internet connections, often lends itself to remote work. Due to the pandemic, radiology practices everywhere have had to rely more heavily on teleradiology to keep providers safe.

Once the pandemic subsides, however, relative reliance on remote work will inevitably shift again. Many practices will likely consider or have the opportunity for a hybrid model in which some radiologists work onsite and others work off-site. Onsite radiologists will be necessary to supervise certain procedures and cultivate relationships with technologists, nurses, trainees, and other providers; while other radiologists will take advantage of teleradiology and its substantial potential for greater collaboration and patient reach, particularly in rural areas.

Teleradiology was already being utilized before the pandemic began, but the pandemic has brought it to the forefront of radiology practices and has energized our community to consider how we can use it to benefit our patients even more.

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1. Cavallo JJ, Forman HP. The Economic Impact of the COVID-19 Pandemic on Radiology Practices. 

. 2020;296(3):E141-E144. doi:10.1148/radiol.2020201495

2. Nadgir R. Teaching Remotely: Educating Radiology Trainees at the Workstation in the COVID-19 Era. 

. 2020;27(9):1291-1293. doi:10.1016/j.acra.2020.05.018

3. Hardy K. Managing Monitors for Digital Mammography. 

4. Tridandapani S, Holl G, Canon CL. Rapid Deployment of Home PACS Workstations to Enable Social Distancing in the Coronavirus Disease (COVID-19) Era. 

. Published online May 20, 2020:1-3. doi:10.2214/AJR.20.23495

5. Sammer MBK, Sher AC, Huisman TAGM, Seghers VJ. Response to the COVID-19 Pandemic: Practical Guide to Rapidly Deploying Home Workstations to Guarantee Radiology Services During Quarantine, Social Distancing, and Stay Home Orders. 

. Published online June 30, 2020:1-4. doi:10.2214/AJR.20.23297

6. Rosenkrantz AB, Wang W, Hughes DR, Duszak R. A County-Level Analysis of the US Radiologist Workforce: Physician Supply and Subspecialty Characteristics. 

. 2018;15(4):601-606. doi:10.1016/j.jacr.2017.11.007

7. Hoffman DA. Increasing access to care: telehealth during COVID-19. 

Teleradiology presents both benefits and challenges for post-pandemic imaging.

Teleradiology in the Age of COVID and Beyond

Stroke is the leading cause of disability and the fifth leading cause of death in the United States. Despite the significant morbidity and costs, stroke therapy recommendations have not been well-established until recently, and radiology now plays a central role in the treatment of those patients.

Radiologists are ideally positioned to practice stroke intervention, given their acumen with image interpretation and experience with endovascular therapies. Formerly, the paradigm treatment for ischemic stroke consisted of intravenous thrombolytic therapy, which is easy to administer, typically in the setting of the emergency department. Recently, several randomized clinical trials suggested that endovascular thrombectomy provides superior outcomes.

In particular, the MR CLEAN trial, a multi-center clinical trial involving 233 stroke patients randomized to an endovascular treatment arm, revealed endovascular thrombectomy within six hours after stroke onset was effective and safe. Patients in the endovascular arm achieved improved functional outcomes in 83 percent of cases compared to 19 percent in the medical management arm. Interventional radiologists performed the majority of the thrombectomies in this trial.

CT Predicts Stroke Patients Benefitting From Endovascular Thrombectomy

Four other ongoing trials were terminated early, given the results of the MR CLEAN trial (1). The other four trials (ESCAPE, EXTEND-1A, SWIFT PRIME, REVASCAT), despite premature termination, also demonstrated evidence that significantly better outcomes could be achieved with thrombectomy compared to medical management. Accordingly, the American Hospital Association guidelines changed in 2015, engendering many hospitals to offer this service. The updated guidelines stated a Class 1a recommendation for the use of thrombectomy for anterior circulation large vessel occlusion strokes, up to six hours since the patient was last known well.

Unfortunately, the existing trained radiologist workforce and infrastructure of the healthcare system have not been adequate to meet the demand to deliver safe and timely treatment; high volume practitioners have been necessary to achieve the best clinical outcomes, but eligible patients have been infrequent enough to adequately sustain practice volume.

Specialized stroke care centers, thereby, have been developed for endovascular interventions as a means to funnel patients to high-volume practitioners. Similar models for cardiac ischemia, trauma, and pediatric critical care exist. Despite these efforts, disparity between thrombectomy demand and capable-physician supply still persists. Thrombectomy is currently only available to 2 percent-to-3 percdent of eligible patients in the United States. The current thrombectomy rate is 3 per 100,000 people and is expected to grow to 24 per 100,000 person-years, given the new guidelines (2).

Given these demands, accompanied by the delayed treatment time for transferring patients to designated stroke centers, alternative models have been proposed to train more radiologists to become capable of safely providing these specialized therapies. The traditional training paradigm for diagnostic radiology residents planning to specialize in interventional neuroradiology (INR) entails a neuroradiology fellowship, followed by an INR fellowship. Similarly, in order to practice INR, most interventional radiology residents are required to complete neuroradiology and INR fellowships.

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The Society of Interventional Radiology has championed a new training pathway where proctors train interventional radiologists. This pathway is suggested to be comparable to conventional neurointerventional fellowships and, therefore, serves as an alternative pathway to provide radiologists with the experience necessary to safely perform acute stroke interventions. A proctor needs to have performed 50 acute ischemic stroke cases as a primary operator, with at least two years of practice data with outcomes meeting national standards. Options for learning from a proctor could include one of the following three options (3):

Hands-on training not limited to interventional techniques, but also including workup before and after management for thrombectomy

Full-time training at a different institution, given the unpredictable case rate for stroke care

Travel consultant, where the proctor travels to institution to provide hands-on training

A case study at Johns Hopkins University (JHU) demonstrated success with this model. JHU recruited an INR physician to teach four interventional radiologists how to perform cerebral thrombectomies. The trainees were available for six months, and the INR physician was flown-in by helicopter for each eligible thrombectomy case. Upon completion of training, 35 of the stroke cases were reviewed, and compared to the quality guidelines outlined in the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) meta-analysis published in 2016.

JHU 90-day mortality was 14 percent while HERMES was 15.3 percent. Therefore, upon being trained, the interventional radiologists had 90-day mortality ratings similar or better than the current benchmark (4). As demonstrated by the previous case study, and building upon their expertise in imaging and image-guidance, radiologists are able to acquire the skillset necessary to safely perform endovascular treatment in a short timeframe.

In summary, the morbidity and mortality of stroke is a detriment to patients and society, and, until recently, treatment attempts have often been ineffective or limited to a select group of patients. An immense opportunity now exists for radiologists to manage acute stroke patients with endovascular therapy and achieve excellent outcomes for many patients up to six hours after stroke onset.

Currently, the infrastructure of the healthcare system faces challenges in its ability to pair a capable physician and a patient in need. Radiologists are, however, ideally situated to contribute to this treatment revolution and lessen the disparity between the demand and the access for endovascular stroke therapy.

Vadlamudi V. Updates on Endovascular Therapy for Acute Ischemic Stroke. SIR-RFS Webinar. June 5, 2018.

. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA. 

Sacks, D, AbuAwad, M, Ahn, S, et al. Society of Interventional Radiology Training Guidelines for Endovascular Stroke Treatment. 

Journal of Vascular and Interventional Radiology

SIR: Stroke treatment training program improves outcomes.

Interventional radiologists are uniquely positioned to practice stroke intervention. 

The Changing Landscape of Interventional Neuroradiology

Patient understanding and informed consent is particularly important when dealing with ionizing radiation. But, how can we expect patients to understand the risks they are taking when 28 percent of surveyed physicians are not even aware that forms of imaging like mammography utilize ionizing radiation at all?

Patient education is largely influenced by patient-physician communication, it and plays a large role in a patient’s ability to provide informed consent. Additionally, effective communication and teaching is thought to enhance the patient-physician relationship and increase patient levels of trust and satisfaction with the experience. This piece investigates patients' perceptions of radiation from magnetic resonance imaging (MRI) and computed tomography (CT) imaging in the healthcare setting. This analysis further reviews recent work that quantified the degree to which effective patient and physician education is taking place and identify areas for improvement and growth.

According to a survey of emergency department patients, when asked to compare the perceived radiation dose of MRI, CT, and a conventional chest X-ray, approximately 30 percent of individuals answered that they all had equal amounts of radiation.

 In that study, when comparing each to a conventional chest X-ray, roughly 40 percent thought that CT was 10-to-100 times greater, while 28 percent thought MRI was 10-to-100 times greater.

Right away, we can see that at least one-third of patients are unaware that MRI emits no radiation at all. Even more shockingly, when asked to compare radiation exposure levels between CT, MRI, and a nuclear power plant disaster, less than 40 percent of participants were certain that CT scans involved less radiation exposure compared to just 20 percent with MRI.

When looking at patients’ understanding of lifetime cancer risks associated with various imaging methods, the numbers were varied. When asked, “Do 3-to-5 abdominal scans increase lifetime risk of cancer?,” less than 5 percent answered yes for MRI.2 The results look encouraging, however, when posed the same question about CT. Just over 5 percent answered yes.

Roughly 25 percent for both groups reported having no idea.

 These results are unsurprising given the limited information available to patients on lifetime risks and specifically the effects of a single scan. Furthermore, a survey of physicians found that 90 percent either did not know or severely underestimated the amount of radiation associated with CT.

In a specific example, only 65 percent of patients in a study receiving a mammogram reported being informed of the risks before the procedure.

 Discouragingly, 60 percent of informed patients still over-estimated the amount of radiation they had received.

 In another study, the number of patients reporting a lack of communication about the radiation associated with their scheduled tests were as high as 92 percent.

 It is in this same study that 28 percent of surveyed physicians stated they were unaware of mammography utilizing any ionizing radiation.

Effective patient-physician communication is key to ensuring informed consent is obtainable and has even been shown to have therapeutic effects for patients.

 However, with low percentages of patients reporting communication about radiologic testing and physicians self-reporting knowledge gaps in these areas, patient education is hindered. Evidence is supportive of the benefits of educational presentations for ordering providers’ understanding of radiation exposure and risk.

Radiologists, therefore, must be aware of and work to address the knowledge gaps reported by attending physicians. Whether through direct communication with patients about risks, hosting educational conferences for colleagues, or simply re-distributing pertinent information, radiologists have a responsibility to ensure patients are educated on the radiological tests they are undergoing.

Based on the results of these studies and surveys, it can be concluded that both patients and physicians have misconceptions and lack comprehensive knowledge about the risks and benefits of diagnostic and therapeutic imaging modalities.

 Physicians that undergo radiologist-designed educational training are more informed on these risks and, therefore, can better communicate radiation risks and benefits to their patients, thus increasing patient understanding and ability to provide informed consent.

 As an additional benefit, this increased communication positively affects patients’ feelings of trust and understanding towards their providers and future procedures.

 As of now, further work is needed to clarify misconceptions surrounding radiologic imaging and the associated risks of ionizing radiation.

1. Ricketts, M. L., Baerlocher, M. O., Asch, M. R., & Myers, A. (2013). Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital. 

Canadian Association of Radiologists Journal

2. Repplinger, M. D., Li, A. J., Svenson, J. E., Ehlehbach, W. J., Westergaard, R. P., Reeder, S. B., & Jacobs, E. A. (2016). Emergency department patients’ perceptions of radiation from medical imaging. WMJ: 

official publication of the State Medical Society of Wisconsin

3. Renston, J. P., Connors, J. A., & DiMarco, A. F. (1996). Survey of physicians' attitudes about risks and benefits of chest computed tomography. 

4. Hollada, J., Speier, W., Oshiro, T., Marzan-McGill, R., Ruehm, S. G., Bassett, L. W., & Wells, C. (2015). Patients’ perceptions of radiation exposure associated with mammography. 

5. Travaline, J. M., Ruchinskas, R., & D'Alonzo Jr, G. E. (2005). Patient-physician communication: why and how. 

Journal of the American Osteopathic Association

, 105(1), 13.

6. Zener, R., Johnson, P., Wiseman, D., Pandey, S., & Mujoomdar, A. (2018). Informed consent for radiation in interventional radiology procedures. 

7. Hobbs, J. B., Goldstein, N., Lind, K. E., Elder, D., Dodd III, G. D., & Borgstede, J. P. (2018). Physician knowledge of radiation exposure and risk in medical imaging. 

Journal of the American College of Radiology

Improving patient communication not only augments patient understanding of their radiation exposure with imaging studies, but it bolsters trust in their healthcare providers, as well.

Mina S. Makary, MD

Articles

Six Trends to Watch in 2021

Teleradiology in the Age of COVID and Beyond

The Changing Landscape of Interventional Neuroradiology

Patient Perceptions of Imaging Modalities and Ionizing Radiation