The 2012 Radiological Society of North America (RSNA) conference delivered fresh concepts for the radiology community. RSNA adopted the theme “Patients First,” and encouraged radiologists to consider the individual patient behind the image. At Health Imaging, our fresh spins included snapshot interviews with RSNA attendees in a Question of the Day feature, a photolog and daily guest blogs, in addition to our hallmark reviews of educational sessions and new products.
The editorial team has selected some of our favorites below. For complete coverage, please visit healthimaging.com/conferences.
Lung cancer screening—where hope and fear converge
“My biggest hope was that the National Lung Screening Trial (NLST) would work,” said Reginald Munden, MD, MBA, of MD Anderson Cancer Center in Houston. Munden also shared his biggest fear—that NLST would work.
Lung cancer screening differs from other organized screening initiatives, Munden said, because findings have to be managed differently. Hence, learning from the experiences (and mis-steps) of early adopters is essential.
“I can’t emphasize enough the need for a multidisciplinary team,” he said. This team should include a radiologist, primary care physician, surgeon, pulmonologist, prevention physician, oncologist and radiation oncologist. Other key players include a physicist to answer questions about radiation; a coordinator to serve as the face of the screening program, meet patients and answer their questions; a marketing representative; and a patient advocate.
One of the first steps to establishing a screening program is to establish guidelines regarding who will be screened and how often. MD Anderson initially used guidelines a bit broader than NLST, but reverted to NLST recommendations as the data apply to those criteria.
Other decisions can be more challenging. For example, both physician ordering and patient self-referral of studies bring pros and cons. Self-referral is the standard in mammography but an anomaly in lung cancer screening, said Munden. On the plus side, a physician order requires the patient to visit a physician, who can provide counseling about smoking and the risks of screening. However, this approach requires two visits for the patient, which might deter some appropriate candidates.
Providers also need to decide on a payment model: self-pay or no fee. Lung cancer screening costs range from free to $400-$500, according to Munden, and two private payers, WellPoint and Blue Cross/Blue Shield, cover the exam.
Munden anticipates wider coverage in the future, and cautioned that practices may run into issues if they initially offer free screening and then start charging when insurers cover the exam. On the flip side, providers may be able to cost-justify free screening with downstream revenues.
Screening is limited to the healthy, wealthy individuals in practices that use the self-pay model, said Munden. However, they may minimize the equity issue if they tap into philanthropic funding to cover costs for other patients.
“Marketing can make or break the program,” said Munden. The initial deluge of hundreds of calls when MD Anderson announced its screening program slowed to a trickle within weeks. “Patient interest dies over time. You need to keep numbers to sustain a program,” he explained.
Another lesson learned came on the implementation side. Munden admitted he underestimated its import. “Have a phone hotline system for the screening program. It’s an emotional decision. If there is a delay, people can convince themselves not to screen.” MD Anderson uses a toll-free phone number and trained operators to use a decision tree analysis to answer patient questions.
Another operational issue is scheduling. MD Anderson initially blocked off Friday afternoon, a typically slow time, for lung cancer screening. The plan failed. Referring physicians wanted immediate access for patients who requested screening, and with 12 scanners at his disposal Munden can fit in most patients immediately.
Munden also recommended standardized reporting. If radiologists begin inundating physicians with a variety of non-standard reports, screening could fail, he said. MD Anderson sends patients a copy of their report to ensure that results are communicated.
Finally, he recommended that providers develop and maintain a good database to lay the groundwork for future research to improve lung cancer screening in practice.
Can imaging informatics resurrect the doctor’s doctor?
When his father retired from radiology, the senior Chang told his son he was glad to be retiring because Chang and the rest of the “PACS people” had destroyed radiology, Paul J. Chang, MD, professor and vice chairman, radiology informatics, at The University of Chicago Medicine, told the audience during the Eugene P. Pendergrass New Horizons Lecture.
Legend has it, prior to PACS, radiologists were doctor’s doctors. Medicine and surgery rounds started in radiology every morning. There was no need for computerized physician order entry (CPOE) or clinical history because clinical collaboration was built into the progress.
Chang delivered the bad news: We aren’t going back to film. The good news is that imaging informatics can be harnessed to rebuild this model for the 21st century.
However, he acknowledged the role of PACS in the demise of the “doctor’s doctor.” The first two generations of PACS focused on images and workflow rather than value and discouraged collaboration. Radiologists became insulated. Their role as the doctor’s doctor evaporated.
The current challenges in radiology—decreased reimbursement, increased consolidation and competition and alignment—present an opportunity, according to Chang. Radiologists can add value in the changing healthcare delivery system by managing imaging in a capitated, aligned model.
“We have to be viewed as irreplaceable and prove we add value,” Chang insisted, offering a simple formula for value: Value = Quality + Efficiency + Safety.
One challenge, said Chang, is that all three inputs must be leveraged simultaneously. “This can only be accomplished by leveraging IT.” Current imaging informatics systems remain immature and limit radiologists to commoditization rather than meaningful service. “We need more agile ITsolutions,” he said.
Chang, an original “PACS person,” explained the IT tools to drive these changes exist or can be developed. “The real challenge is changing us. We have to get beyond optimizing the reading room.”
Mock trial ends in split jury
A mock jury trial that reconstructed the hypothetical malpractice case of a 35-year old woman who died of breast cancer after five CT exams and a coronary CT angiogram in 1998-2000 ended with a split decision on Nov. 25. Nevertheless, the proceedings achieved their purpose, Leonard Berlin, MD, of NorthShore University Health System in Chicago, told Health Imaging.
In the suit, the patient and her family claimed that the radiologist who read the exams should have discussed with the woman’s physician or the woman herself the possible link between radiation exposure and cancer.
The radiologist’s defense was based on the claim that the link between diagnostic radiation exposure and cancer is unproven, obviating the need to caution the woman or her physician, particularly since the physician believed the CT studies were necessary.
The session showed the audience how a malpractice trial works and also explored a jury’s response to the issue of radiation exposure and cancer.
“The message to radiologists is that they have a moral and possibly a legal duty to pick up the phone and discuss options with the referring physician, if they are aware of an ionizing radiation exam that is of questionable indication, particularly in a young person or is a repeat exam,” Berlin said.
Rebecca Smith-Bindman, MD, of University of California, San Francisco, who testified for the plaintiff in the case, said the trial is a cautionary tale. She called for radiologists to develop two types of systems. They should ensure that all exams are performed at the lowest possible dose needed to achieve a diagnostic quality image. They also should ensure that there are processes to identify questionable exams and communicate the possible risks to the referring physician.
Gunderman pushes rads to find the stories behind the images
During the annual oration in diagnostic imaging, Richard B. Gunderman, MD, PhD, urged radiologists to learn more about the patient behind the images that they are reading, and challenged radiologists to share their personal stories.
“Our degree of engagement and inspiration in the practice of radiology—as in medicine at large—hinges on our ability to dig deeply and see beyond the superficial aspects of the image,” he stressed.
Gunderman shared a story when he “missed something,” by failing to recognize the identity of a person behind a head CT scan of an 89-year-old man who had a history of dementia and had suffered multiple falls.
The man behind the CT image turned out to be Charles B. Huggins, MD, who was awarded the 1966 Nobel Prize in Medicine for discovering that hormones could be used to control the spread of some cancers. He was the first person to demonstrate that cancer could be controlled by chemicals.
His identity unknown, Gunderman diagnosed him with bilateral acute on-chronic subdural hematomas. “I did my job,” he said. “I described those findings, the diameter of the hematomas, the degree of mass effect and the mid-line shift. Then, I moved onto the next case.”
Gunderman conveyed this story because “I missed something. I don’t want you to make the same mistake. You and I, in the interest of efficiency and throughput, fail to pause and fail to marvel about what’s before our eyes. And in this case, I failed to shed a tear and failed to say a prayer for the story that lay behind these head CT images.”
When Huggins made his initial discovery, he was quoted as saying that he couldn’t walk home because his heart was pounding too hard. At 89-years-old, he couldn’t walk across the room without falling. “We as radiologists can see patients’ state of health or disease quite clearly, but those images tell us nothing or precious little about their lives,” Gunderman said.
“At meetings, like the RSNA, we spend a lot of time thinking about equipment, bemoaning cuts in our budgets, worried about what’s going to happen to the compensation of radiologists and nervous about job security,” Gunderman said. “We may be measuring our success in terms of publications or awards we received. We are in danger of spending too much time counting our money and not enough time on what really makes us tick.”
While acknowledging that these metrics contain some importance, he noted that “if these are the signposts by which we navigate our careers and our lives, then we will soon find ourselves on the path to perdition.
“Radiology, like all the human endeavors, makes it possible to get the technical aspects correct—we can be extraordinarily precise and utterly inaccurate,” he added. “To understand the image, it is insufficient to see only the image. There is no radiology without a radiologist. We need to focus more time and attention on the human excellence of radiologists.”
He went on to say that the character of the radiologist accounts for a great deal of his or her success in practice and life. If these personal aspects are neglected, then the field of radiology will suffer, according to Gunderman, who added that if radiologists only focus on throughput, it’s a recipe for alienation and burnout.
“We are not just technicians or revenue generators; we are in fact physicians and human beings who entered a venerable human calling,” he said. “Stories are everything—the context in which we work and live is everything. There is no great practice of radiology devoid of context. We need to re-contextualize what radiologists do and who radiologists are.”
He asked the audience: What is the nature of the story that you tell your colleagues, your patients and yourself about being a radiologist? “The story we tell ourselves about our future has the ability to shape our future,” Gunderman concluded. “When was the last time you told a really great story about being a radiologist? We can be only as good as the stories we tell.”
Question of the Day at a Glance
At RSNA 2012, Health Imaging debuted a ‘Question of the Day’ series,
surveying attendees on key questions.
What’s the most exciting technology or practice development happening right now in imaging?
“The most important thing I’ve seen so far is the ability—and actually a trend that’s starting—to integrate images in the electronic medical record. With the [EMR] you have a chronological record of the patient’s care, but you also want to be able to see a chronological record of all the imaging tests that a patient has had. That fulfills the ability to provide total care to the patient.”
—John H. Smith, IT planning director, radiology & imaging systems, Stanford University, Stanford, Calif.
The conference’s theme this year is “Patients First.” Why is this an important theme for RSNA?
“Patient safety should be important to every doctor, not just the clinicians. As radiologists, we should be the ones more involved in educating the clinicians and make sure the patient gets the lowest possible dose, and working on techniques that have no dose, such as MRI.”
—Isabel Oliva, MD, assistant professor of diagnostic radiology, Yale University, New Haven, Conn.
What about this year’s conference most interested or impressed you and will be something you bring back to your practice?
“I’m going to bring back to my practice the issues of screening breast ultrasound, the pros and cons. It seems there’s a trend for more and more practices to be adopting screening breast ultrasound…I was particularly interested to see how many places in Europe are doing screening breast ultrasound on women with dense breasts.”
—Martha Mainiero, MD, radiologist, Rhode Island Hospital, Providence