Mina S. Makary, MD

Standard radiology reports often follow a narrative or free-form format, allowing the radiologist to highlight radiologic findings of importance while diminishing those insignificant to the clinical context. Unsurprisingly, researchers have noted that less than four percent of radiology reports are written at an eighth-grade level, with the average report requiring college-level reading skills.

 In the past, institutions have placed an embargo on radiology reports. While patients may request access to them, the embargo allowed referring providers a few days to review the report and discuss the results with the patients and their families.

However, with the widespread adoption of electronic health records (EHR) and the 2016 passage of the 21st Century Cures Act, patients now have unprecedented speed and access to their radiology reports. Quite often, patients will have read their reports before their referring providers. Since the 21st Century Cures Act, there has been a 78.3 percent spike in patient calls regarding radiology reports.

 Disruptive innovations and new legislation have pressured radiologists to provide reports that balance the clarity of information with manageable language for providers and patients.

Accordingly, let us take a closer look at the current concerns and preferences of physicians and patients on radiology reports, immediate solutions, such as structured reporting, patient summaries, and infographics to improve patient inclusivity, and long-term goals to redesign the traditional report and implement an interactive radiology report.

What Referring Physicians and Patients Prefer to See in Radiology Reports

Historically, patient concerns about radiology reports have centered around accessibility and comprehension. Most patients wanted their report as quickly as possible regardless of the result.

 Electronic health records and the Cures Act have primarily resolved this concern. The content of radiology reports remains a crucial barrier to comprehension. By analyzing patient discussions in online forums, Alarifi and colleagues categorized three major subthemes for the improvement of radiology reports: report representation, image utilization, and understanding.

 Patients wanted a well-formatted report with structured information and clear content display. The images needed to be clearly shown and appropriately adjusted for brightness and contrast to eliminate any ambiguity in visualization. Finally, patients wanted a better understanding of medical jargon and instructions and access to additional resources to aid their comprehension.

From the providers’ perspective, more than 90 percent of referring clinicians surveyed valued an itemized, structured report over ones provided in a free-form style.

 In practice, however, a survey of 265 United States radiologists found that only 51 percent used structured reporting consistently.

 Moreover, the referring providers often misinterpreted the radiology report similarly to patients despite being the intended audience. In a study performed by Rosenkrantz and colleagues, when radiologists used an expression other than “cyst” or “benign cyst” to describe low-risk incidental lesions, this resulted in increased alarm and higher follow-up by both the patient and referring physicians.

 The fact that referring providers have misunderstandings about radiology reports is a notable area for improvement.

Assessing the Pros and Cons of Structured Reporting

Structured reporting is not new in radiology. The most established form of structured reporting is the Breast Imaging Reporting and Data System (BI-RADS) format, which was developed to address concerns about confusing interpretations. Initiatives are already in place to aid radiologists in transitioning from free-form radiology reports. The RSNA Radiology Reporting Initiative developed a free library of templates (

 ) based on best practices to enable consistent, high-quality reports.

The advantages of a structured reporting format are numerous. First and foremost, structured reporting reduces diagnostic errors. A checklist and systematic search pattern minimize cognitive biases arising from a radiologist’s “satisfaction of search,” in which a radiologist prematurely stops searching for additional diagnoses after finding the initial diagnosis.

 Quattrocchi and colleagues found a 28.5 percent increase in clinically significant extraspinal findings in structured reporting compared to free-form reporting.

 Reducing such cognitive biases can improve patient care and the overall report.

The systematic method also improves referring provider’s comprehension of the report. While physicians may be the intended audience for the radiology report, discrepancies between radiologists and referring clinicians arise due to non-standard terminology. Bosmans and colleagues found that 17 percent of referring providers found radiology reporting unnecessarily complicated.

Structured report templates can prompt radiologists to incorporate critical findings with clinical conditions while reducing syntactic and semantic errors. A computed tomography (CT) coronary angiography study demonstrated such benefits when referring physicians’ comprehension improved with a structured report.

 In a separate pancreatic cancer study, a structured report improved surgeons’ confidence in tumor resectability.

 In this manner, referring providers can better utilize the radiologist’s expertise to enhance their clinical acumen.

Admittedly, structured reporting has its shortcomings. “Eye dwell problem,” or the tendency for the radiologist to focus on the word template rather than the imaging itself, has the potential to disrupt workflow.

 Complicated cases with multiple abnormalities may exacerbate this issue. In these cases, the disease process may render radiology insufficient in conveying all of the findings to the intended audiences. Direct communication with the referring provider or the patient could be necessary. A structured report’s utility can be helpful in organizing the findings and highlighting key areas of concern.

Perspectives on Making the Radiology Report More Patient-Friendly

While structured reporting may bridge the gap between radiologists and fellow clinicians, there is still a sizable disparity between the patient and the radiologist. This is where consumer-friendly supplementation can have an impact in complementing the radiology report.

Several methods of implementation are currently being tested. The most direct and simplistic solution is creating a “patient summary statement.” A radiologist would summarize the pertinent findings, briefly explain the clinical correlation, and inform patients with follow-up instructions in patient-friendly language.

 In a patient-centered section, the radiologist could focus the patient on areas of clinical concern and minimize potential distractions in the findings. Furthermore, the benefit is the increase of patient inclusivity without significant disruption to a radiologist’s workflow.

A more detailed, consumer-friendly report would be the creation of an infographic directed explicitly at the patient. Von Eckstaedt and colleagues at the University of Virginia redesigned the traditional radiology report with an infographic for lung cancer screening patients.

 The infographic provides brief information about low-dose CT scans, patient results, and follow-up instructions. More importantly, the report is filled with visual aids that correlate with the simplified language to improve patient comprehension.

Patients in the study had an overwhelmingly positive response with 65.2 percent preferring the infographic to the traditional report.

 Although this approach is more involved than a patient summary, consumer-friendly infographic reports can potentially organize complex and less structured data into a medium suitable for patient use. Conversely, routine radiology procedures may utilize a predesigned infographic template for multiple patients, thus, expediting workflow. Due to the novelty of the approach, the effects of infographics have not been quantified in the radiology literature at the time of this publication.

Exploring Future Directions for Radiology Reports

While patient summaries and infographics can increase patient inclusivity, the core content of a radiology report would remain inaccessible due to the technical, medically specific terminologies necessary for the precise, accurate, relevant description of image findings. Proposals for report redesign and interactive radiology reports seek to remedy that problem.

Based on suggestions and concerns from patients, Alarifi and colleagues sought to redesign a patient-friendly radiology report. The redesign included much of the previously mentioned solutions, including structured reporting, a patient summary section, and follow-up instructions. Two standouts of the redesign include the annotation of written findings and a correlating clinical imaging section.

The clinical imaging section further enhances the written findings, using annotated diagrams with anatomical references as a visual aid. An impressive aspect of the imaging section is the personalized clinical context in which the patient’s radiography sits between “normal case” and “worst case” scenario reference images. The visual differences between the patient’s image and the clinical references allow the patients to examine their disease process without reading complicated medical jargon.

The reception to the redesigned radiology report was positive with more than 70 percent of respondents marking “agree” or “strongly agree” to the questions about understanding the report. Another notable aspect of the study was that improvements in the redesign were unrelated to age, gender, economic status, ethnicity, and health literacy.

 Utilizing clinical images to correlate the written findings may be a potential direction toward a more patient-friendly report. Additionally, referring providers may also use the annotated and reference images as a visual aid to enhance treatment discussions with patients and their families.

A redesigned radiology report may take some time before it is fully optimized to achieve a readily accessible level. There may also be multiple competing strategies individualized to different institutions before standardization.

Another proposed solution is an interactive radiology report like Scanslated.

 Kemp and colleagues' interactive web-based application uses natural language processing to annotate a patient radiology report. After a radiologist completes the report, the software processes it before making it available to the patient in 48 hours. The patient can log on to his or her account and review the patient-friendly report. Unlike many other annotated reports, a standout feature of Scanslated is its inclusion of animated diagrams.

The developers of Scanslated hope to improve patient education and health literacy through user interaction with the program. The pilot study did reveal a notable increase in engagement. Patients who opened the annotated links spent an average of 5.8 minutes compared to 1.8 minutes for those who just read the text.

 The pilot study also received positive responses with 85 percent of respondents believing the application improved their understanding.

 The advantage of natural language processing to annotate a report would be the rapid deployment of such services across different institutions and clinics.

Both studies demonstrated marked improvements in patients’ subjective understanding of the radiology report. While quantification and confirmation of patient knowledge are necessary to optimize the best approach to patient-centered reporting, the studies reaffirmed patients’ appetite for greater engagement and comprehension.

Recognizing The Opportunity with Emerging Patient Empowerment and Value-Based Care

Including patients as a new target audience for radiology reports presents an extraordinary opportunity for radiology. As health care shifts from volume-based to value-based care, patients increasingly take ownership of their health and engage in shared decision-making. Despite challenges, direct access and immediacy of radiology reports increase the visibility of radiologists as an integral part of the patient care process. Radiology reports play a vital role in patient autonomy as it is often an essential piece of data utilized by patients seeking second opinions or consultations.

Therefore, greater adoption of structured reporting and the tailoring of patient-centric subsections are immediate and impactful methods to promote patient inclusivity and improve peer clinician communication. Referring physicians can more readily learn from the radiologist’s expertise, and patients can now receive concrete and actionable plans from their radiology reports. Importantly, this promotes a greater connection and interaction between the patient and his or her health-care team.

The future steps of redesigning and utilizing interactive radiology reports would continue to break down barriers to health-care access and literacy. The current push for patient-centered radiology reports creates a unique opportunity for radiologists to elicit the needs of patients directly. It also allows patients to shape the delivery and communication of their health information. While the development and adoption of redesigned reports are still in the early stages, the overwhelming support from patients offers clear assurances in favor of patient-centered radiology reports.

1. Martin-Carreras T, Cook TS, Kahn Jr CE. Readability of radiology reports: implications for patient-centered care. 

2. Mehan Jr WA, Gee MS, Egan N, Jones PE, Brink JA, Hirsch JA. Immediate radiology report access: a burden to the ordering provider. 

3. Basu PA, Ruiz-Wibbelsmann JA, Spielman SB, Van Dalsem 3rd VF, Rosenberg JK, Glazer GM. Creating a patient-centered imaging service: determining what patients want. 

4. Alarifi M, Patrick T, Jabour A, Wu M, Luo J. Understanding patient needs and gaps in radiology reports through online discussion forum analysis. 

5. Bosmans JML, Weyler JJ, De Schepper AM, Parizel PM. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. 

6. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. 

7. Rosenkrantz AB. Differences in perceptions among radiologists, referring physicians, and patients regarding language for incidental findings reporting. 

8. Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. 

9. Quattrocchi CC, Giona A, Di Martino AC, et al. Extra-spinal incidental findings at lumbar spine MRI in the general population: a large cohort study

10. Ghoshhajra BB, Lee AM, Ferencik M, et al. Interpreting the interpretations: the use of structured reporting improves referring clinicians' comprehension of coronary CT angiography reports. 

11. Brook OR, Brook A, Vollmer CM, Kent TS, Sanchez N, Pedrosa I. Structured reporting of multiphasic CT for pancreatic cancer: potential effect on staging and surgical planning.

12. Babu AS, Brooks ML The malpractice liability of radiology reports: minimizing the risk. 

13. Gunn AJ, Gilcrease-Garcia B, Mangano MD, Sahani DV, Boland GW, Choy G. JOURNAL CLUB: structured feedback from patients on actual radiology reports: a novel approach to improve reporting practices. 

14. Von Eckstaedt HV, Kitts B, Swanson C, Hanley M, Krishnaraj A. patient-centered radiology reporting for lung cancer screening. 

15. Alarifi M, Patrick T, Jabour A, Wu M, Luo J. Designing a consumer-friendly radiology report using a patient-centered approach. 

16. Kemp J, Short R, Bryant S, Sample L, Befera N. Patient-friendly radiology reporting -- implementation and outcomes. 

Articles

In a thorough review of the literature, these authors discuss current approaches and emerging initiatives to increase the understanding of radiology reports by referring physicians as well as patients. 

Reinventing Radiology Reports in the Age of Value-Based Care

Incidental findings, or incidentalomas, are coincidental imaging findings in an asymptomatic patient or findings in a symptomatic patient undergoing imaging for an unrelated reason. With higher imaging utilization and improved imaging resolution, the prevalence and burden of incidentalomas are rising.

 Management of incidentalomas is frequently challenging because of uncertain or absent classification systems. Poor patient communication often complicates the situation, resulting in under- or overdiagnosis. These factors could increase clinical practice errors and raise legal liability.

Due to the heterogeneity of imaging modalities and disease processes, the prevalence of incidentalomas is highly variable. A 2018 umbrella review revealed that CT chest incidentalomas (including CT cardiac, thorax, abdomen, spine, and heart) are the most prevalent at 45 percent, followed by CT colonography (38 percent), cardiac MRI (34 percent), and MRI of the brain (22 percent) and spine (22 percent).

 Conversely, incidentalomas found on CT chest for pulmonary embolism (2 percent) and whole-body PET/CT (< 2 percent) were the least prevalent.

Although most incidentalomas are not an immediate danger to patients, some findings, such as neoplasms, may have a significant impact on one’s health. Malignancy rates vary substantially between organs. Breast incidentalomas reportedly have the highest malignancy rates at 42 percent.

 Renal, thyroid, and ovarian incidentalomas were malignant in greater than 25 percent of cases while extra-colonic, prostatic, and colonic incidentalomas were malignant 10 to 20 percent of the time.

 Brain, parotid, and adrenal glands had the lowest malignancy rates at less than 5 percent.

Unsurprisingly, incidentalomas have become a challenging clinical issue for radiologists, referring providers, and patients. Adherence and follow-up have ranged from 36 to 67 percent depending on patient population, availability of guidelines, clinical settings, and system-level communication.

Accordingly, let us take a closer look at avenues for improvement and examples of strategies to improve the management of incidentalomas.

Addressing Communication Concerns About Incidentalomas

It is uncommon for radiologists to communicate directly with patients regarding their results as patients often receive instructions from their primary care physicians (PCPs) or the ordering physicians.

 However, Zafar and colleagues found that PCPs were unlikely to act on incidentalomas without "explicit radiologist recommendations" if they had no prior experience with the finding or if it occurred in an unusual clinical context.

 Surveys have shown that "clear and actionable follow-up recommendations" exist in only 52 percent of cases.

 As such, incidentalomas without specific recommendations may not receive adequate follow-up.

Specific and clear recommendations can also alleviate overdiagnosis. Ambiguity in reporting language has increased misunderstandings in referring providers and patients. In Rosenkrantz's study, descriptions such as "statically likely to be a cyst," “too small to characterize," or "most likely a cyst" were all associated with less than 1 percent perceived likelihood of malignancy by radiologists but resulted in up to 46 percent follow-up by the referring physician.

 Rather than qualitative recommendations, radiologists could provide a numerical risk estimate to minimize ambiguity in their reports. The increased clarity would prevent patient misunderstandings and alleviate anxiety.

The American College of Radiology (ACR) Incidental Findings Committee has published white papers outlining imaging and clinical criteria for follow-up of incidentalomas and has made them readily available for use.

 Radiologists may use these guidelines to improve potential areas of ambiguity in their reports and direct referring physicians to evidence-based management.

However, no guidelines exist for incidentalomas in the spine, breast, brain, colon, prostate, or parotid glands.

 In those cases, specific evidence-based recommendations may be challenging. Furthermore, risk assessment for some incidentalomas is not possible without further imaging. For example, liver lesions on single-phase CT require additional imaging to characterize the lesions, and multiple co-morbidities in the patient could further complicate the read.

 The incidentalomas should trigger an interdisciplinary conversation between the radiologist and the referring provider.

While the radiologist provides expertise on the image findings, the referring provider can provide clinical context via history, physical examination, and previous treatments because the clinical context may be challenging for radiologists to ascertain. The benefit of interdisciplinary collaboration would extend to the patients as it prevents discordant treatment and follow-up plans, minimizing patient confusion and alleviating anxiety.

While more precise reporting would improve incidentaloma follow-up, patients could still fall through the cracks. The Joint Commission identified timely reporting of critical tests and diagnostic procedures as part of the National Patient Safety Goals in 2005.

 In practice, however, implementation has been inconsistent. Surveys have shown that in institutions with policy guidelines requiring closed-loop communication, actual compliance with these guidelines occurred 26 percent of the time.

 Clinical effectiveness outcomes looking for rates of treatment, diagnosis, and clinical outcomes are limited so there is potential for a large number of incidentalomas going undetected.

Emphasizing Closed-Loop Communications and System-Level Changes

Closed-loop communication requires close interdisciplinary collaboration. Multiple studies have attempted to evaluate intervention strategies that improve follow-up, and those that demonstrate the highest levels of improvement utilized system-level interventions.

 After reviewing these study findings, we have categorized three central communication nodes as common intervention points and discuss the available methods to improve incidentaloma follow-up.

Communication Node 1: Radiology Team to Clinical Team

The radiologist has reviewed the index imaging study and is now relaying the information to referring provider. Due to the 21st Century Cures Act, which was signed into law on December 13, 2016, the patient can also view the radiology report. In this communication node, the radiologist has the most expertise. The purpose of this communication node is to accurately convey findings and recommendation guidelines to the clinical care team.

Several studies have demonstrated improved adherence and management when evidence-based guidelines are readily available to radiologists. After Zygmont and colleagues created a 16-page electronic summary guideline for the emergency department (ED), the correct management of ultrasound and CT incidentalomas improved from 67.5 percent to 80.2 percent.

 Interestingly, the team did not teach radiologists guideline content but rather informed the radiologists on the importance of following guidelines. The ease of accessibility was sufficient to yield improvement in management.

Similarly, Kim et al. found that adherence for society recommendations on follow-up imaging of ovarian cysts increased from 50 percent to 80 percent after integrating electronic guidelines.

The availability of guidelines for references eliminated potential confusion when recommending follow-up. The integration of guidelines into dictation devices would serve to optimize workflow.

However, providing electronic guidelines to radiologists without sufficient referring clinician involvement did not demonstrate a statistically significant increase in adherence.

 A potential solution without significant workflow disruption would be creating a guideline-based radiology report. In a preliminary study, Woloshin and colleagues utilized an "enhanced report" to include clinician management strategies for pulmonary nodules. Eighty-eight percent of the surveyed clinicians strongly preferred the enhanced report, and 75 percent felt that the information gave them more confidence in management.

 While the utility of the "enhanced report" has not yet been tested in clinical practice, the study demonstrates a proof of concept that would enhance communication between the radiologist and the referring clinician.

Communication Node 2: Clinical Team to Patient

Once the information has been accurately relayed, the clinical care team would inform patients about the results, educate them on treatment options, and coordinate follow-up plans. The radiologist plays a more supportive role while the clinical team takes on the primary responsibility to ensure a shared-decision plan.

The type of clinical team plays an influential role in incidentaloma follow-up. Outpatients had the highest follow-up at 66.7 percent, followed by the emergency department (ED) patients at 46.0 percent and inpatients at 36.0 percent.5 Among outpatient physicians, PCPs were most likely to follow up at 67 percent, followed by internal medicine at 50 percent and surgery at 38 percent.

 The results are unsurprising. Outpatient PCPs and internal medicine physicians are comfortable with the longitudinal management of patients whereas surgeons are more likely to be focused on surgical issues. Patients who arrive at the ED may not have regular PCPs in the institution, contributing to lower follow-up rates.

Therefore, closed-loop communication would be essential to ensure that clinicians adequately adhere to evidence-based guidelines for follow-up. Shelver and colleagues utilized a lung nodule registry that interacted with the electronic health record (EHR) to ensure tracking completion.

 If tracking is indicated for the patient, support staff will activate an EHR alert until the referring physician addresses the incidentaloma. After the implementation of the tracking system, patients who were lost to follow-up or received delayed care decreased from 74 percent pre-intervention to 10 percent post-intervention.

Baccei and colleagues implemented a similar alert system in the ED with positive effects.

 If an incidentaloma was discovered, the radiologist selected a checkbox labeled "incidental ED findings," which would route a report directly to the ordering ED physician's email. The alert would prompt the ED physician to converse with the patient or family regarding the findings. With additional optimization, the researchers noted a greater than 93 percent compliance rate in the study.

 The dramatic improvement after implementation demonstrates the value of closing the communication loop.

Communication Node 3: Health System to Patient

Once the patients have been informed of the incidentalomas and understand the following steps, the health system must actively ensure appropriate follow-up. The support staff becomes a significant part of the communication node as time progresses beyond the index imaging and patient discussion.

The support staff role is particularly vital when physicians do not receive the radiology report prior to patient discharge, such as in the ED. Baccei and colleagues created a "safety net" that used an Outlook e-mail inbox to track incidentalomas.

 A dedicated follow-up team monitored the inbox for incidentalomas to ensure that the ED provider had completed the workflow. The radiology report was also faxed to the patient's primary care provider if one was listed in the EHR. Furthermore, phone messages and certified mail requesting a call back serve as additional protection in preventing losses through follow-up.

In a separate study, Wandtke and colleagues took a similar approach.

 They re-sent the radiology report, called the PCP’s office, and sent a letter to the patient if follow-up was incomplete. These interventions increased the examination completion rate from 43.1 percent to 70.5 percent. This follow-up tracking system may be even more vital for ED patients, inpatients, and surgical patients who are more likely to be lost to follow-up.

Successful intervention strategies to appropriately address incidentalomas will likely involve system-level changes. The identified communication nodes serve as targets for intervention. Differences in institutional resources and workflow likely prohibit a universal solution. Therefore, early interdisciplinary involvement in designing and executing interventions would minimize misunderstandings in intervention strategies.

Managing incidentalomas presents both a challenge and an opportunity. Their increased prevalence, complicated by unclear clinical context, has the possibility of leading to critical safety errors without sufficient follow-up. At the same time, there is also a risk of overtreatment for incidentalomas, and this causes undue anxiety for patients.

However, the situation creates the opportunity to improve interdisciplinary care. When radiologists make guideline-directed recommendations, referring clinicians can become more knowledgeable in managing incidentalomas, and radiologists can receive feedback to optimize their reporting and minimize ambiguity. It also opens a discussion between different disciplines on management strategies when there are separate medical society guidelines.

When there are incidentalomas without clear guidelines, close patient follow-up would provide us with the opportunity to better characterize the disease. Despite the current challenges, interventions like the ones mentioned above have shown dramatic improvements in patient follow-up and appropriate management and have the potential to become best practices across image modalities and practice settings.

1. Berland LL. Overview of white papers of the ACR incidental findings committee ii on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. 

2. O'Sullivan JW, Muntinga T, Grigg S, Ioannidis JPA. Prevalence and outcomes of incidental imaging findings: umbrella review. 

3. Liao GJ, Liao JM, Lalevic D, Zafar HM, Cook TS. Location, location, location: The association between imaging setting and follow-up of findings of indeterminate malignant potential. 

4. Mabotuwana T, Hombal V, Dalal S, Hall CS, Gunn M. Determining adherence to follow-up imaging recommendations. 

5. Hansra SS, Loehfelm TW, Wilson M, Corwin MT. Factors affecting adherence to recommendations for additional imaging of incidental findings in radiology reports. 

6. Moore CL, Kadom N, Seidenwurm D, et al. Incidental findings: a survey of radiologists and emergency physicians. 

7. Zafa HM, Bugos EK, Langlotz CP, Frasso R. "Chasing a ghost": factors that influence primary care physicians to follow up on incidental imaging findings. 

8. Rosenkrantz AB. Differences in perceptions among radiologists, referring physicians, and patients regarding language for incidental findings reporting. 

9. American College of Radiology. Incidental findings publications. Available at: 

https://www.acr.org/Clinical-Resources/Incidental-Findings

10. Oren O, Gersh BJ, Bhatt DL. Improving communication of incidental imaging findings: transforming uncertainty into opportunity. 

11. Joint Commission. Advancing safety with closed-loop communication of test results. 

12. Crable EL, Feeney T, Harvey J, et al. Management strategies to promote follow-up care for incidental findings: a scoping review. J Am Coll Radiol. 2021;18(4):566-579.

13. Zygmont ME, Shekhani H, Kerchberger JM, Johnson JO, Hanna TN. Point-of-care reference materials increase practice compliance with societal guidelines for incidental findings in emergency imaging. 

14. Kim DC, Bennett GL, Somberg M, et al. A multidisciplinary approach to using appropriate follow-up imaging of ovarian cysts: a quality improvement initiative. 

15. Woloshin S, Schwartz LM, Dann E, Black WC. Using radiology reports to encourage evidence-based practice in the evaluation of small, incidentally detected pulmonary nodules. A preliminary study. 

16. Shelver J, Wendt CH, McClure M, et al. Effect of an automated tracking registry on the rate of tracking failure in incidental pulmonary nodules. 

17. Baccei SJ, Chinai SA, Reznek M, Henderson S, Reynolds K, Brush DE. System-level process change improves communication and follow-up for emergency department patients with incidental radiology findings. 

18. Wandtke B, Gallagher S. Reducing delay in diagnosis: multistage recommendation tracking. 

Greater imaging utilization has increased the prevalence of incidental findings or incidentalomas, but unclear clinical context and guidelines complicate management. Accordingly, these authors offer a thorough review of the literature and discuss new opportunities for improving interdisciplinary management strategies. 

Managing Incidentalomas in Radiology: Embracing Challenges as Opportunities

Continued fallout from the global shortage of iodinated contrast media (ICM) has forced hospitals and providers to triage patients, reduce imaging utilization, switch imaging modalities, and postpone imaging studies. Effective strategies to blunt the impact of the ICM shortage are urgently needed as this crisis continues to have a profound impact on patients and health-care systems.

Like many other modern-day crises, the ICM shortage originated from the COVID-19 pandemic. A large percentage of the world’s ICM supply is manufactured in Shanghai, China. Strict pandemic lockdowns led to a near total cessation of manufacturing and shipment of the contrast media out of the country, which led to widespread shortages across the world. Although the Shanghai factory returned to full operation last month, some imaging facilities may continue to have challenges with shortages until their supplies of ICM are restored to optimal levels.

Given this risk, it is prudent to develop and implement strategies that can effectively minimize the impact of the ICM shortage while maintaining high quality patient care. Multiple societies have put forward recommendations involving possible solutions, including triaging patients, using alternative imaging modalities, using alternative contrast agents, reducing overall imaging utilization, and creating central command structures.

(Editor's note: For related content, see "Lessons Learned from the Iodinated Contrast Media Shortage: A Neuroradiologist's Perspective" and "Emerging Strategies for Managing the Acute Shortage of Iodinated Contrast Media.")

One of the simplest but also most challenging of the recommended strategies involves changing what imaging tests are done and when. This can be achieved through triaging and delaying elective imaging. Triaging involves the difficult task of assigning a priority to each patient’s contrast needs. Keefe and colleagues proposed a three-category triage tier list, which includes emergent, delay for one month, and delay for three months.

 This novel strategy enables clinicians to ensure that patients with emergent needs are served quickly while also enabling health-care systems to extend their limited supplies until the crisis abates.

Another widely suggested remedy is the use of alternative imaging modalities. Possible alternatives include magnetic resonance imaging (MRI), ultrasound, and non-contrast computed tomography (CT) studies. Given the large overlap between MRI and contrast CT indications, increasing the use of MRI during this crisis has been broadly recommended.

However, there are limitations to this substitution. The primary impediments are the limited number of MRI scanners, their relatively higher cost, and the nature of the pathology. One solution to this is the use of “focused” protocols that minimize overall MRI time, which can enable each scanner to serve a larger number of patients with appropriate disease conditions.

Using alternative contrast agents is another frequently prescribed solution to this problem. Multiple alternatives, including carbon dioxide (CO2) and gadolinium, have been suggested, particularly when it comes to interventional radiology.

 Each of these substitutes has benefits and drawbacks that must be carefully considered.

Using CO2 is beneficial because it is not allergenic nor nephrotoxic and has no dose limit due to excretion by the respiratory system. However, CO2 also has risks, such as organ ischemia and emboli. It is also contraindicated for multiple conditions and procedures.

 Gadolinium is another off-label, but well studied alternative to iodinated contrast dyes. Gadolinium is advantageous since it has a low risk of nephrotoxicity. However, it is restricted by the necessity of small dosages and has limited ability to generate high quality angiographic images.

A final broad recommendation is the creation of a centralized hospital command for the allocation and distribution of iodinated contrast dye. Instead of leaving each department to handle the crisis on its own, the creation of a multidisciplinary, multispecialty, and centralized command that can effectively coordinate a hospital-wide response during this critical period is essential. This centralization of command can remove ambiguity and the burden of procurement and allocation from individual physicians and departments. This strategy can allow for more equitable and balanced distributions of limited resources.

In conclusion, although the current ICM shortage is cause for great concern, the future is promising. The Shanghai factory has reopened and other factories across the world have begun to ramp up their ICM supply to help mitigate the crisis.

 A combination of patience, effective triaging, alternative imaging, alternative contrast agents, and novel command structures will enable radiology to weather this storm and fully return to normal in the near future.

1. Reeder SB, Hess CP, Zaharchuk G, Moy L. Editorial for “Magnetic resonance imaging as an alternative to contrast-enhanced computed tomography to mitigate iodinated contrast shortages in the United States: recommendations from the International Society for Magnetic Resonance in medicine. 

 2022 Jun 2. doi: 10.1002/jmri.28282. Online ahead of print.

2. Keefe NA, Desai KR, Kohi MP, Salazar GM. Interventional radiology approach to contrast media preservation strategies. 

 2022 May 19;S1051-0443(22)00940-X. doi: 10:1016/j.jvir.2022.05.011. Online ahead of print.

3. Hicks L. Global contrast media shortage blamed on COVID lockdown in China. Medscape. Available at: 

https://www.medscape.com/viewarticle/973810

 . Published May 11, 2022. Accessed June 21, 2022.

As the iodinated contrast media shortage continues to have a significant adverse effect on radiology, these authors assess the pros and cons of emerging strategies and imaging alternatives.

Iodinated Contrast Media Shortage: Practical Solutions and Applications in Radiology

Over the past several years, radiology has adapted to new technologies and modalities to enhance both the effectiveness and accessibility of medical education. For example, flipped classroom techniques and educational gaming applications have emerged as creative methods to deliver interactive radiology content. However, social media remains an underutilized space that is filled with potential to serve as a remote learning tool for teaching trainees and medical students.

As an image-based specialty, radiology stands to gain the most from educational trends encouraging quick presentation, processing, and response. In the past two decades, radiology has adopted these platforms for a variety of uses including but not limited to networking with colleagues and students around the world, sharing interesting patient cases, and responding to immediate trends within the field. However, there are several opportunities to expand the role of social media platforms in medical education.

For most of this time, Twitter and Facebook have been the primary social media platforms to engage trainees and medical students online, representing “Social Media 1.0.” In contrast, “Social Media 2.0” reflects a shift in the virtual landscape in which didactic vehicles are sought after to engage viewers in more visually oriented ways. This is particularly the case with platforms such as Instagram and TikTok.

Accordingly, let us take a closer look at this evolution and outline both current and future uses for social media platforms in radiology medical education.

Twitter is one of the most popular social media platforms for professional networking and education in radiology. Online learning through Twitter is continuous and personalized for users to engage in self-improvement, networking, shared cases, and journal clubs. Jaffe and colleagues summarized the primary ways Twitter is and can be used in medical education.

 Educators can share discrete concepts or facts through a basic tweet, or they can link tweets sequentially using images, polling, or reference links to create a lesson. Posing clinical questions or sharing links to case reports and studies can prompt conversation and discussion in real-time.

In another intriguing use case with the University of Chicago Internal Medicine Residency Program, Bergl and colleagues evaluated a chief resident-controlled Twitter account that aimed to advance its program’s educational mission.

 These authors found that 69 percent of 61 residents believed that their overall education was enhanced from tweets related to the teaching points from morning reports, pathology from interesting cases, and educational radiographs/scans.

Twitter can facilitate discussion and engagement between radiologists, residents, and medical students across the country as well. Interestingly, Kauffman and colleagues found that the most engaging radiology content on Twitter are case images and scroll-through videos while news links received the fewest engagement in terms of retweets and likes.

 For radiology, this finding may signal the need to shift our focus toward establishing a larger presence on alternative platforms.

Radiology has a well-established presence on Facebook. Facebook serves both as a marketing and branding tool for radiologists and their practices/organizations. Groups on Facebook, such as Radiology Chicks and Breast Imaging Radiologists, have long been active as a community hub for radiologists to share meaningful cases or discuss broader trends in practice, technology, and education. Similarly, groups related to specific diseases such as breast cancer or patient support groups exist for radiologists to communicate directly with patients and share high-quality information. Similar to Twitter, Facebook groups have also been used to foster learning opportunities between medical students, radiology residents, and practicing physicians. The ability of those in radiology to utilize social media effectively is clear, but Twitter and Facebook only represent the beginning stages of a broader campaign to raise awareness, highlight the field, and innovate medical education.

Instagram, on the other hand, primarily delivers content through images and videos with captions, making it particularly well-suited for radiology. Currently, there are several high-volume accounts, such as @radiopaedia and @thexraydoctor, that promote radiology educational material. Shafer and colleagues demonstrated the potential effectiveness of Instagram as a vehicle for radiology education through their Instagram account, CTisus.

 In under two years, their consistent and diverse catalogue of posts has generated meaningful engagement as the account has accumulated over 6,000 followers, and they have reached an international audience. Notably, the majority of their followers are 25 to 34 years old, which represents the age of the vast majority of medical students and radiology residents.

During the 2020 National Residency Match Program (NRMP) application cycle, Johnson and colleagues found that radiology residency programs were most active on Instagram (58.9 percent) compared to Twitter (29.3 percent) or Facebook (29.55 percent).

 Given this interest and level of engagement, the utilization of image-based platforms to reach medical students interested in radiology, residents, and the general public should be pursued.

While Instagram is primarily suited for image- and video-based delivery, TikTok’s content form is exclusively video. TikTok is the latest addition to the suite of social media platforms and has appeared to gain a large amount of platform users throughout the COVID-19 pandemic. The primary use case on TikTok is not for education, but neither were Twitter or Facebook in their early development. The novelty of TikTok is an opportunity for the field of radiology to find a footing in the social media environment of the 2020s and generate both educational and creative radiology content that can be widely disseminated. 

Similar to Instagram and Twitter, TikTok content is received by “followers” of an account. However, unlike any other social media platform, TikTok users frequently spend time on the app on their “For You” page, a curated, endless series of posts displaying personalized content. Thus, TikTok may allow for radiology content to be shared without limits, increasing interest and engagement with the field.

Diversifying the platforms in which case studies, articles, and other educational material are shared should be encouraged as our understanding and use of novel modalities matures. Ultimately, Social Media 2.0 offers compelling platforms that may serve as supplementary means to promote the field of radiology.

Benefits of Adopting a Novel Social Media Strategy

The opportunity for a stronger radiology presence on social media is clear, and the field is uniquely situated to integrate image-rich platforms into the education of trainees and medical students. As radiology residency programs seek ways to innovate their educational curriculums, emerging platforms can be used to offer students increased flexibility and convenience. Social Media 2.0 can serve as a conduit through which residents and faculty may expose radiology to and engage with medical students.

Active learning and peer-to-peer interaction are key concepts that are integral to social media use in radiology medical education. By “following” radiology accounts that use images and share relevant cases, learners seek out the material that provides the highest value and a means of interacting with fellow students or trainees as well as faculty members. This can ultimately promote collegiality throughout all levels of training.

Importantly, these interactions are not limited to people within an institution or within a specialty as social media can expand opportunities for networking and collaboration. Furthermore, unlike in-person lectures at any institution, these radiology posts and threads remain visible for current and future students and physicians internationally, dissolving geographic boundaries.

Finally, Social Media 2.0 is live and responsive to immediate trends, and image-rich platforms enable innovation in radiology and compelling insights to be shared and discussed in real time. Social Media 2.0 is already in its early stages. With sufficient investment, radiologists can seize this period to increase awareness about the field, enhance collaboration and engagement, and augment medical education for trainees and students more effectively than ever before.

1. Jaffe RC, O'Glasser AY, Brooks M, Chapman M, Breu AC, Wray CM. Your @Attending will #tweet you now: using Twitter in medical education. 

 2020;95(10):1618. doi: 10.1097/ACM.0000000000003314. PMID: 32195691.

2. Bergl PA, Narang A, Arora VM. Maintaining a Twitter feed to advance an internal medicine residency program's educational mission. 

3. Kauffman L, Weisberg EM, Zember WF, Fishman EK. #RadEd: how and why to use Twitter for online radiology education. 

4. Shafer S, Johnson MB, Thomas RB, Johnson PT, Fishman EK. Instagram as a vehicle for education: what radiology educators need to know. 

5. Johnson JL, Bhatia N, West DL, Safdar NM. Leveraging social media and web presence to discuss and promote diversity, equity, and inclusion in radiology. 

The enhanced immediacy, peer-to-peer interaction and networking capabilities of social media platforms, particularly newer vehicles such as Instagram and TikTok, may help reinvent educational models in radiology.

Mina S. Makary, MD

Articles

Reinventing Radiology Reports in the Age of Value-Based Care

Managing Incidentalomas in Radiology: Embracing Challenges as Opportunities

Iodinated Contrast Media Shortage: Practical Solutions and Applications in Radiology

Social Media 2.0: An Emerging Space for Radiology Education

Pathways to Medical Device Innovation: Exploring Collaboration Between Interventional Radiologists and Biomedical Engineers

Are We Prepared for a Looming Radiologist Shortage?

Exploring the Opportunities of Teleradiology in the Wake of COVID-19

Virtual Biopsy: A Safer Future for Cancer Management

Uterine Fibroid Embolization: Past, Present, and Future

Lung Cancer Screening: Challenges and Opportunities