Timothy V. Myers, MD

As we enter this year, having narrowly missed the fiscal cliff, we continue the hair-raising episodes of life in American health care.

The problem with writing down a list of New Year's resolutions is that at some point, someone is going to remind you that last year, you actually took the time to write a list. And so, it is time to review my list and see how well I did.

Last year, the radiology leadership pushed many things. By far the best has been the Image Gently campaign. The most important effort I did last year was to increase the number of calls I made to clinicians. This is a great place to start. A simple conversation goes a long way in changing the way our colleagues think about using imaging. A collegial discussion on the best algorithm to use for imaging specific problems can yield very positive results.

Recommending ultrasound or MRI as the first test where appropriate, decreasing the use of contrast when not needed and eliminating imaging completely when possible benefits patients and decreases costs.

Can we ever learn too much - not just about radiology but about health and health care in general? Reading more tweets, blogs, Facebook pages and articles outside radiology raised my awareness significantly as to what is happening in other parts of the health care system. Radiology, while a foundation, is not the end of the story when it comes to health care. Understanding the trials and tribulations of our colleagues is important. What is happening in health care in general, and not just in the United States, will impact your practice, like it or not.

I must admit, this is one area where I came up short of my goals. I did step up significantly and increased my participation within a national professional organization, the American Society of Emergency Radiology; however, my involvement in nonprofessional, political activities that affect radiology did not receive the same focus. During a presidential election cycle, the number of voices clamoring for something drowns nearly every opportunity to actually be heard.

This year, I want to continue to increase my participation in other professional organizations. More importantly, I also want to seek more opportunities and become involved in the political process. Between now and approximately 12 to 15 months from now, the government actually governs. After that, the next cycle of elections begins and politicians tend to stop hearing though they continue to look like they listen. So, now is the time to get involved if we want to actually make real changes.

I am a member of a number of professional organizations within radiology. This number did not significantly change from previous years. A number of our professional organizations did see a loss of membership due to a variety of issues including the continuing economic problems our country has been facing.

Now is not the time to abandon these organizations. Sometimes, involvement is just paying dues so these organizations can continue to do their good work. I have selected those organizations I want to support. Every radiologist should do the same to their fullest extent.

So, there we have it. There were some areas of improvement, and some where I fell short of my goals. I believe that 2013 is going to offer us the same roller coaster of issues we saw in 2012. As noted, there is the potential for even greater changes as Congress and the president try to govern and make substantial changes before the next election cycle.

Professional organizations are continuing their mission and vision as well as gearing up to impact any changes positively for patients and their members. We - and when I say “we” I mean “you” -need to be heard. To be heard, you need to be involved.

And so I leave you with a quote from Sean Connery, and the movie The Untouchables: "What are you prepared to do?"

Perhaps you also took time to write a list, if not physically, at least mentally. Share some of your thoughts and how you did with last year's resolutions.

Articles

Let’s review my 2012 goals to image gently, learn more, be heard, and get involved in the health care community. There were some improvements, some shortfalls.

A Radiologist’s New Year’s Resolutions, Revisited

“Four score and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.  Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived, and so dedicated, can long endure.” - Abraham Lincoln, Gettysburg Address

As we close in on the 150th anniversary of these words, it occurred to me there is a parallel playing out before us in radiology. Certainly it does not have the force and depth of meaning as the civil war, but the forces at work within and around radiology will shape how we practice for years to come.

The words from Lincoln came to me while reading about the partnership of 

 (ORP). According to press releases, this partnership will form “the nation's first integrated national radiology practice.”

But wait, isn’t ADI already part of at least the beginning of a “collaborative model in which data and best practices are shared, clinical practice information is interchanged, and certain practice expenses are consolidated. [Whose] goal is higher quality and more cost-efficient delivery of medical imaging.” In other words: 

The concept of SR began as a vision of a consortium of large, strategically placed large groups who would, in time, form a national radiology group. The question was, and continues to be, can a group so conceived long endure - at least if run by and for radiologists?

With the formation of ORP, does this signal the end, or at least the beginning of the end of SR? Certainly there have been significant issues and roadblocks as SR has tried to live up to its potential. Not the least of which is the difficulty of herding such a large number of feral cats, a.k.a. radiologists, in any specific direction.

Each group comes with its own list of problems and difficulties as well as a wish of what the vision, mission and future of SR could and should be. On one side these issues include pressure from hospitals and systems to become employees, loss of income and the difficulty of moving from large, but basically mom-and-pop radiology groups to corporate radiology companies. On the other side, there is pressure from the more advanced radiology groups to move more rapidly and seize the momentum created by the formation of SR and benefit from their “first-to-market” position.

This latest move - by one of the largest, most advanced and entrepreneurial groups, ADI - to seek an alternative path to formation of a national radiology company, has three potential outcomes. First, SR could throw in the towel and come to the conclusion that while the idea of a national radiology group is the right move, SR is not the correct vehicle to get there. Second, other aggressive groups could move in their own direction to both position themselves for more aggressive growth and counter ADI’s bold move, also leading to the demise of SR. Or third, SR could find its way out of the doldrums and begin its own move to aggressively lead the remaining aligned groups to realize its potential.

I don’t know which of these will happen. I happen to share the original view of the best way forward: private practice radiology groups aligning to form a strong, organized, entrepreneurial collective that can support its own as well as each individual group’s strategy for growth and expansion. I believe that only this type of association of radiologists will have the long-term best interests of radiology and the radiologists at heart. But, Lincoln’s question remains: Can “any (group of radiologists) so conceived, and so dedicated, long endure?”
 

The formation and alternative approach of national radiology group Advanced Diagnostic Imaging has three potential outcomes for Strategic Radiology.

Strategic Radiology: The Beginning of the End?

October is Breast Cancer Awareness month. I don't think anyone living anywhere near the mainstream of society has missed that fact. Pink ribbons can now be found on just about everything. Clever slogans regarding breast cancer can also be found in abundance, including:


• Big or Small, Save Them All!
• Real Men Wear Pink

Another women-related issue also shares the month of October. "There is another issue?" you ask. Yes, but it is not typically spoken of in society, the way breast cancer is. In fact, the subject is avoided as much as possible. The very fact most people have no idea what I'm talking about is a clear indication this is true.

National Coalition Against Domestic Violence

, October is also National Domestic Violence Awareness Month.

But, isn't breast cancer much more important? It must be since we are so aware of it; Or does it just have better marketing?

Domestic/Intimate Partner Violence in Perspective



Let's see if you know the answer to a few questions:

1. According to statistics, 39,510 women will die from breast cancer this year. What is the number of women estimated to die from domestic/intimate partner violence this year?

A. 1,000 B. 5,000 C. 10,000 D. More than 15,000.

D. It is estimated that 16,800 murders will occur as a result of domestic/intimate partner violence. In a report from New York, 44 percent of murdered women were killed by their partners.

2. Which of these carries a higher probability to occur during a woman's life?

A. Breast cancer. B. Domestic/intimate partner violence.

B. According to statistics, women have a probability of one in eight for developing breast cancer during her lifetime. In the United States, the probability of a woman suffering from domestic/intimate partner violence is one in four.

3. Which is higher, the number of women living with breast cancer or the number of women living in a violent environment?

B. Approximately 2.6 million women were alive with a history of breast cancer in January 2008. An estimated 5.3 million victimizations occur each year. These result in 2 million injuries, of which 550,000 will require medical treatment. And, as noted above, nearly 17,000 murders.

Domestic/intimate partner violence should be considered a serious health concern among women. More than 95 percent of cases involve women. Certainly, it can be proven it is as serious in the lives of women, day-to-day, as breast cancer. The issue is that we are not "aware" of it.

This is just the good news. The bad news is that while the United States numbers are not good, we are not the worst; not by a long shot. The World Health Organization and others estimate that in some locations, up to 70 percent of the women have suffered domestic/intimate partner violence at some point during their lives, and up to 70 percent of female murder victims were killed by an intimate partner. To put it in perspective, if this were true in the United States, of the estimated 157 million women, 110 million women would have suffered from domestic/intimate partner violence. Nearly every woman you know would have been abused at some point during her life. And don't even get me started on the fact that an estimated 2.8 million children live in households touched by violent crime.

Billions of dollars are spent each year diagnosing, evaluating and treating women afflicted with breast cancer. With domestic/intimate partner violence, not only are there no large national programs at multiple medical centers to study and help these victims, there are no real, high profile programs to even begin an open discussion similar to that seen with breast cancer.

I am not saying we should in any way lose sight of breast cancer as a significant health issue for women; However, there are other real, and potentially more severe and ever present women's health issues. I believe we should be aware of all the issues women face.

Three Things Radiologists Can Do to Raise Awareness:



1. We can become aware of the fact that we see evidence of domestic/intimate partner violence nearly every day, in every practice, and we don't even recognize when it has occurred. In pediatrics for example, with every case we review, we look for the subtle and overt signs of abuse. We need to do the same thing with every women's imaging case we see.

2. When we see signs of potential abuse, we need to raise the question with the patient’s clinician or emergency room physician. Again, in pediatrics, when we have even the slightest suspicion of abuse, we immediately sound the alarm. This needs to be done with domestic/intimate partner violence as well.

3. Finally, we can work more closely with the emergency room team when they suspect abuse. In pediatric cases, we frequently get a heads up about that potential. With women's imaging I have rarely in my 21 years as a radiologist been alerted to the possibility we were imaging a patient with suspected domestic/intimate partner violence.

A great case in point can be found this week on the 

Case of the Week file from Virtual Radiology

, where domestic/intimate partner violence was initially suspected by the radiologist reading the case.

I encourage victims, their loved ones and anyone concerned about this issue to learn more by calling the National Domestic Violence Hotline at 1-800-799-SAFE, or visiting 

If you do nothing else during October to be aware of the issue of domestic/intimate partner violence, visit the Remember My Name Online Memorial to see some of the names of those who have had their lives taken from them as a result of these senseless acts of violence.

National Coalition Against Domestic Violence domestic violence facts

Costs of Intimate Partner Violence Against Women in the United States

October isn’t just for breast cancer awareness. It’s also National Domestic Violence Awareness Month. Here’s what you as a radiologist can do.

October Awareness Month - The Other Killer of Women

Health care has become an environment where some organizations judge success by the financial well-being of those with an “MD” behind their names. Although doctors are responsible for the end product of the practice - patient care - sustained, long term success is inseparable from the success of the team driving the patient, referring physician and radiologist experience.

The support team begins with the front desk and clerical staff who answer calls and greet patients and referring physicians as they enter the department or imaging center. The team includes the technologists who perform the examination and prepare the case for interpretation by the radiologist. The team is completed by the billing staff responsible for properly preparing the patient’s bill and answering question from the patient and third party payers. Hovering over this team are the “middle managers.” These professionals are outside the upper leadership circles and act as the bridge between the radiologists, the CEO or business manager and the team that supports them.

Forward-thinking practices that want to make great gains in patient satisfaction, client retention, overall productivity and profitability will work to cultivate a team approach, involve team members in planning and take time to listen to what their team has to say. Creating a new culture around team participation, honesty and respect will result in greater gains for the organization and ultimately drive practice growth.

From a middle manager’s point of view, there are four things that every great medical organization needs to do to create a successful team environment:

. A poor leadership team brushes things off, deflects questions when the answers are negative and doesn't respond to staff concerns. Although answers may be hard to come by, providing your entire team with an answer, no matter how painful, is always better than silence. Team members don't hate bad news as much as they hate no news. Silence from the leadership will breed more dissatisfaction and stress among the staff than the realization of even their worst fears. Even if they don't want to hear it, in today's economy it has become expected that tough decisions must be made.

Between the health care reform bill, slashed reimbursement rates and hospitals attempting to take over independent practices, radiology has a large target on its back. A successful practice will acknowledge these facts to everyone - not just partners and board members. If your staff is aware of the difficulties the practice faces, and hears directly from the group leadership what is being done to prepare for these challenges, the team can go to work with greater confidence, even if they are going into a tougher day-to-day job.

If a middle manager comes up with a great idea, validated by those doing the work, it would be prudent for the leadership to give it some consideration. If the idea has merit, a timely course of action should follow.

Keeping the middle manager in the loop throughout the decision-making process will create transparency. If the answer ends up being a no-go, be sure to give feedback on what didn’t work. When your team knows explicitly what didn’t work, a good manager will motivate the team to come up with alternatives or changes to the original suggestion.

A specialty as medically and technologically sophisticated as radiology needs to allow room for growth and experimentation. Many managers who find themselves locked in comfort zones will shy away from trying new workflows, adhering to the familiar adage "this is the way we've always done it." It is important to recognize that not every idea is successful. Your team works just as hard trying new things and being open to radical changes that don’t pay off as when they hit a home run. Ensuring your team will remain open to changes and trying new things depends on how the senior leadership rolls with the positive and occasionally negative outcomes of the changes that are implemented.

 When your practice is considering changes, ask your team what you are doing well and what could be done better. Hearing nothing or only that you're "not doing anything wrong" is not the same as doing everything well. If your team believes something can be improved, discuss those items and have the team work out the needed modifications.

Take suggestions from your patients. You would be amazed how many of them work in similar process-driven environments and can point out areas where their experience would have been improved. This can also be done via online surveys sent to a patient’s email following their visit. This information can furnish your practice critical data for advertising, such as “over 90 percent of our patients are satisfied with our practice.”

Finally, take time to listen to your referring clinicians. Remember, these are your target clients. Their experience in obtaining information or improving their patient’s care will impact what they think about your service. Have a support team in place to investigate and consider any suggestions they make. Your next great workflow idea could be standing next to you asking if you could take a quick look at this case.

4. Create a reward culture to keep your best team members happy.

 Providing incentives and the potential for upward mobility within the company are paramount to keeping your best team members happy. Taking care of your “all-star” team members sets a precedent that hard work and innovation are appreciated and rewarded. This not only keeps your staff working hard, but incentivizes every team member to reach that goal.

When your team finds and implements workflows and changes, these can be tied to performance goals for departments, individuals or even those across different sections. Whether it's done as bonuses, team target goals or outside the box rewards like additional time off and flex hours, giving team members and managers a goal to strive for will keep the gears moving and promote an entrepreneurial atmosphere.

Make no mistake - each of these items is very difficult. They may require extensive commitment, planning and a possible cultural shift from the top down of your entire organization. Practices that do these things well will be positioned not only to have happy, committed team members for the tough road ahead, but the potential for even greater gains in the new business atmosphere of modern radiology.

Frederic Smith is the client operations manager for St. Paul Radiology in St. Paul, Minn., one of the largest private practice radiology groups in North America and serving the greater Twin Cities metropolitan area for more than 90 years.

From the front desk to technologists to billing staff, a strong support team in a culture of honesty and respect will ultimately drive practice growth.

Timothy V. Myers, MD

Articles

A Radiologist’s New Year’s Resolutions, Revisited

Strategic Radiology: The Beginning of the End?

October Awareness Month - The Other Killer of Women

4 Ways to Build a Successful Radiology Support Team