Radiologist Takes Appropriateness Message to the Community

As the campaign to encourage the right imaging tests at the right time continues to gather momentum in the medical community, one radiologist is taking an active approach to promoting appropriateness. Austin radiologist Robert M. Milman, MD, who has been giving presentations on imaging to primary care providers for many years, recently turned his attention to educating referring physicians on appropriate image ordering.

While it might appear at first glance that a radiologist instructing referring physicians to be more judicious about ordering imaging studies would be doing financial harm to himself and his group, Milman has the broader picture in mind. He embraces the ACR's Imaging 3.0 initiative to provide better care at lower cost by helping providers determine the most appropriate tests to order.

Milman is with Austin Radiological Association, a 90-physicain private practice radiology group that provides services to almost all of the hospitals in the Austin area and operates 16 imaging centers. Diagnostic Imaging spoke with Milman about his efforts to ensure the appropriate use of imaging in his community, and how you might do the same where you practice.

Where are you giving these presentations, and to whom?

I go to different venues. I speak at meetings of state-wide organizations like the Texas Academy of Family Physicians when they meet in Austin and to local primary care groups. I also give the talks at the University of Texas School of Nursing for advanced nurse practitioner graduate students and at Texas A&M University to medical students.

What do you typically cover in your talk?

The main focus of the presentation is about appropriate imaging or “what to order when.” I go over what different types of studies can and can’t do and discuss the level of radiation exposure to patients - what’s involved in a CT scan versus a plain X-ray, for example, or that there is no radiation exposure at all with ultrasound or MRI. I also cover how to decide on appropriate follow-up studies and some of the lesser discussed risks involved with imaging like false positives and incidentalomas, both of which can cause patients unexpected anxiety.

What do you think draws primary care physician and nurse practitioners to these talks?

Imaging is now involved in the care of so many patients that our referring community really wants to learn about how to order the right study at the right time for the right reason. As radiologists, we can provide information to help doctors get the answers they need in the most efficient and most cost-effective way possible. They appreciate learning how to get from point A to point B when they’re trying to make the right diagnosis for a patient. The feedback has been positive. Also, my group has the ability to offer CME credit for some of the talks, so that helps.

What’s the level of engagement in the part of your audience members?

They’re very attentive and stay with me and stay on topic. For them it’s a picture show because radiology is so visual. No one is interested in dull material, but if you can provide something of worth, people will attend.

One issue that often comes up is related to patient demand. People have access to a lot of medical information today and if they have low back pain they know there is this thing called an MRI machine out there and they think they need that scan. Referring physicians spend a lot of time trying to help patients understand what’s appropriate when it comes to imaging, so I touch on that in my presentations.

What has surprised you since you’ve been offering these presentations?

Mostly that even though the American College of Radiology’s appropriateness criteria program has been out there for quite a while that many primary care physicians are still not aware of it. The traditional method of picking up the phone and calling a radiologist when they have a question is fine - and our group does a lot of that and is happy to do it - but primary care doctors could save a lot of time by using the information that the ACR has available. With a few clicks on the computer they can usually get an answer about what test to order.

How does the practice of so-called “defensive medicine” come into play related to appropriate imaging?

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What do you see as the future for radiology groups given the push for referring physicians to follow appropriateness guidelines?

Most radiologists are becoming aware that the world is changing from a volume driven, fee-for-service model to a value driven, patient-centered model. At the end of the day you want to do the most appropriate test and be as efficient as possible. It’s about making the right diagnosis and treating the patient appropriately. This is a culture change, but resources are not unlimited and costs need to be contained.

Is your group supportive of your efforts to educate healthcare providers?

Yes. There are about 90 radiologists in our group and many of us give CME presentations. I’m the primary one in the group doing talks on imaging appropriateness right now. I’m planning to branch out and start giving presentations about appropriateness specifically related to screening studies such as the latest in breast imaging, lung cancer screening, and the use of virtual colonoscopy.

What advice do you have for a radiologist who is reading this and thinking about offering similar presentations in their community?

Get energized about the topic and put effort into giving the talks. They could contact some of their local primary care groups and offer to come in and make a presentation or they could work through their local hospitals or medical society to get the ball rolling. Groups always appreciate having interesting speakers come in.