Month: March 2020

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Radiology In The Post Covid-19 Era: How Will The Specialty Change?

covid-19

For almost all of us, the COVID-19 pandemic has affected our daily lives in some form or another. Some folks have been temporarily furloughed or lost their jobs. Other radiologists are infected and sickened by the virus. And, we all feel a level of heightened anxiety. But, one day, this situation shall end, hopefully, sooner rather than later. Moreover, with the end of the pandemic, the field of radiology will never be the same. It will be a post-COVID-19 era, a new world for radiology.

So, what will change in our field after the dust settles, and we approach a more “normal” life once again? This question is what I will attempt to answer to give us an idea. So, let’s divide my predictions into the following categories: demand for radiology residency, remote learning, teleradiology, and finally, numbers of onsite radiologists. No, I am not the oracle of Delphi, and I cannot foretell the future with certainty. However, my sixteen-year experience in the field of radiology and work with radiology residents allows me to make some educated guesses about what we can expect to change in radiology at the end of this pandemic.  Let’s give this a whirl!

Increased Demand For Radiology Post Covid-19

Medical students throughout the country are in the thick of the action. And, they can now see the role that different physician specialists play in a pandemic. I am sure that many medical students will notice that radiologists play a vital role in the diagnosis and management of COVID-19. Yet, they tend not to be on the front lines like the Emergency Physicians, internists, and surgeons. Not to say we don’t come in contact with these patients. But, for many medical students, I believe this critical role we play, and our overall relative decreased exposure to contagious disease will become an attractive feature that draws more applicants into the fold. I would imagine seeing more applications to radiology residency for the next several match cycles.

Remote Learning For Radiology Residents

Due to the restrictions on group meetings, most programs, by now, have shored up their capabilities to give teleconferences and administer online learning materials. Before, for many residencies,  it was only an adjunct to learning. Now, just like for public education, it has become a necessity and will become ingrained into the fabric of all residencies throughout the country. I believe this will stick.

Universal Teleradiology

For practices that didn’t have much of an online presence outside the hospital, they now will. If you read my previous article, Coronavirus: A Clarion Call For Universal Home Teleradiology, you will understand that it is incumbent on practices to develop an online presence to decrease exposure to disease, and increase efficiency and workforce flexibility. Hospitals and practices are waking up to these issues. And, these changes are taking place right now forever transforming radiology.

Fewer Onsite Radiologists

Of course, hospitals and practices need onsite radiologists to fulfill their obligations. We need to do the biopsies, treatments, direct patient care, interventions, and more.  However, we do not need to do much of the work onsite. And, all radiologists will, therefore, have more flexibility to read from home, outside the normal confines of an office or hospital. Teleradiology will no longer be only for teleradiologists, but rather a tool for all radiologists. And, thus, you will see fewer radiologists sitting at hospital workstations. Instead, clinicians will call many more radiologists at their home offices with their questions.

Radiology In A Post Covid-19 Era

Yes. The field of radiology will never be quite the same. We are moving toward different practices and norms. And, increase demand/applications for our specialty, ubiquitous remote learning, universal teleradiology, and a leaner number of radiologists stationed at hospitals and practices are some of the features that you will most likely notice in a post-Covid era. Although some of you may disagree, it makes logical sense as we are developing the infrastructure for these changes as the pandemic continues to smolder. So, look around your departments over the next several months and years. Just like the addition of PACs, or when CT became part of bread and butter radiology, you will be taking part in the next sea change of our field!

If you think of other changes or disagree with my predictions, shoot me some comments or an email about what you think.  I would be interested to hear your opinions!

 

 

 

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Is There A Deadline For A Final Radiologist Interpretation?

deadline

Ever notice that there is always at least one or two cases that stick around on the worklist day after day? Perhaps, it was a complicated case for which someone is waiting for a consult. Or, maybe the technologist took the wrong MRI sequence and needed to bring the patient back. Regardless, you will see this all-too-familiar case on the worklist for what seems like eons at a time. But, at what point does the case become a hazard to the patient, institution, or radiologist? Is there a formal deadline for a final interpretation? Can radiologists even get paid for these ancient cases? And, at what point, do we need to bite the bullet and dictate the darn thing?

Believe it or not, this deadline for radiology case interpretation is a complex issue. It is not quite like the “best by” date on a package of bread. (although that date can be a little confusing as well!) And, like most complex issues in this world, the answer to how long you can sit on a case depends. Furthermore, I would go as far as to say that each case has several different shelf lives depending on the eye of the beholder. Each time is more relevant to a specific entity within the health care system. Let’s categorize them into the standard institutional time limit for the institution, the deadline for excellent patient care by the radiologist, the legal time limit for the attorneys, and the expiration time for reimbursement by the billers. So, let’s go into through what each of these means.

Hospital Statistical Deadline

Many of you have probably heard of the time to transcription. Well, that is an example of a statistic that many hospitals, practices, and institutions monitor closely. In some centers, if there is a case that goes past that typical time, the institution may flag it or call the doctor to let them know. Each institution has its numbers based on the type and the place performed.  For instance, an ER x-ray may have a mean time to transcription of a few hours. And, a non-emergent MRI may have a typical time to transcription of 24 hours. We can consider those cases that significantly surpass these time limits to exceed the standards of the hospital or the credentialing societies. And, sometimes, this may be at a detriment to patient care. Other times, not as much. (depending on the case!) All this brings us to the next limit.

Quality Patient Care Deadline

OK. So, you’ve run past the “hospital statistical deadline.” But all is not lost. Depending on the situation, you may be well within the expiration date for quality patient care. Sometimes, it pays to wait past the hospital’s statistical expiration time. Let’s take, for example, an oncological CT scan that sits waiting for comparison. If you were to dictate it right off the bat, you would have a meaningless report. Why? The oncologist most likely wants to know if the lung cancer metastatic disease is better, worse, or unchanged. In this situation, you cannot provide that answer with only a single time point. So, the hospital statistical expiration time often does not necessarily match up with the time it takes for quality patient care.

Legal Deadline

Simply put, this time is when the radiologist or institution becomes legally responsible for any findings missed because of a lack of interpretation. This time frame is a little bit more shadowy and vague. To understand this expiration time, think about the nighttime floor film that has a pneumothorax. If you do not read this case in a reasonable amount of time, and the findings go unnoticed, you and your group can be in for some trouble. But, this legal time limit can vary depending on the situation. Indeed, if the clinician notifies a radiologist to read the film immediately, and the radiologist does not, that could be a cause for immediate liability. On the other hand, if the clinician ordered a study without any priority notification, the timing for radiologist liability can become a lot longer. Additionally, in any given case, the time of delay in interpretation that can cause radiologist liability can vary widely depending on the situation, location, and jury (if the case goes to trial!)

Reimbursement Deadline

And then finally, we have the reimbursement expiration time. Believe it or not, this was difficult information to find on the web. In my opinion, it is because insurers do not want to advertise these dates. But, Scott Raley, the client service manager from Zotec Partners, gave me a few benchmark dates to remember. He stated that the reimbursement expiration time for Medicare cases is one year, and Medicaid is 180 days. For private insurers, this time can vary depending on the contract negotiated. But it typically ranges from 90-180 days. So, these times vary widely.

The Deadline For Final Radiology Interpretation- More Than Meets The Eye

Whew. So, there you have it. The shelf life of a radiology case can vary depending on the eye of the beholder. For the hospital, it’s one time. For the radiologist, it’s another. And if you are a lawyer or a biller, you will worry about other times of expiration. The bottom line is that you should be aware of all the consequences of those films that lag on the list forever. So, if you see one of these cases on the worklist, don’t just let sit. See if you can figure out why it’s there and follow it through to its conclusion. The patient, hospital, and radiologist will benefit immensely!

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Coronavirus: A Clarion Call For Universal Home Teleradiology

coronavirus

OK. By now, you are probably somewhat sick of hearing about the coronavirus. But, the illness certainly brings up specific issues in radiology that should rise to the forefront. As a microcosm, within my practice, we are intensely discussing preparations for the coronavirus storm that has begun. Will the next patient be a coronavirus victim, and will she expose our radiologists? What will happen if some of our radiologists become sick and cannot perform our duties? Can we provide the services that our customers and the hospital expect?

Without definitive guidance on what to do next, we are currently debating the appropriate responses. But one thing is clear. In this environment, we need to have the ability to read cases from home. Teleradiology from home is no longer a luxury but rather a necessity.

Hospitals, residencies, and practices that do not provide teleradiology are at risk of giving poor health care to their patients. Therefore it is the responsibility of hospitals and large imaging centers to supply the resources necessary expeditiously for remote reading. And, we have discovered that teleradiology in an emergency helps the most to decrease exposure, increase radiologist efficiency, and increase the flexibility of the radiologist workforce. So, let’s talk about these issues specifically.

Reducing Radiologist Exposure

Sure, we will need to have someone on the premises to perform specific responsibilities like interventional treatments, radioactive iodine administrations, etc. However, do we need all our radiologists to be present? Probably not. Why increase the risks to employees and physicians when you can mitigate exposure to the coronavirus? In the case of coronavirus, you want to protect the elderly radiologists and those families with babies or the infirm elderly at home. The ability to perform teleradiology decreases the number of staff members on the frontline, especially those at most risk. Thereby, you will have fewer radiologists and families affected by the virus. And, it is not necessarily just the coronavirus. The same goes for any pandemic. Do you really need to increase the number of infected hospital workers/radiologists?

Increases Radiologist Efficiency

One of the side effects of a pandemic is a potentially large amount of patients that need imaging. How do you provide these services with a fixed number of radiologists available? Well, for one, teleradiology enables a group to increase the capacity of imaging reads throughout a system. It becomes easier to read additional studies when the need arises. With a workstation at home, you can pick up a case at almost any time to help out when needed. And, one never knows when the flood of imaging for a disease will start. A hospital nightmare scenario would be to have a large number of patients storming the emergency department without the capability to increase the number of reads during an emergency!

Increases Flexibility of The Workforce

When an epidemic strikes, some of the healthcare workers will inevitably become ill. And, radiologists are not immune. Especially with a disease like a coronavirus, most infected workers will have very mild symptoms. Why would you want to take them out of the workforce when they can read from home and help with the overwhelming increased burden of patients in the system. For others, it allows those with babies or school-age children at home to contribute as well. The last thing that the hospital needs is a shortage of radiologists during a time of need. Hospitals should be encouraging all able bodies to participate in a fully staffed department. Home teleradiology enables efficiency.

Coronavirus: A Call To Teleradiology Action

Sometimes you need a wake-up call to get you going. And, the coronavirus is doing just that. For practices without home teleradiology services (like ours), we need to mitigate exposure, increase efficiency, and augment flexibility for the best patient care. And, this pandemic has demanded that the hospital should be focusing their resources, so that home teleradiology is available to their radiologists. It’s the right thing to do.

 

 

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Technologists Can Make Or Break You: Three Sample Cases

technologists

Here is the real world: Technologists sometimes forget to report on or miss findings. Other times, they may perform a new protocol without checking it with a radiologist. And, this is just the tip of the iceberg. All sorts of technologist mistakes and judgment errors can happen that can affect our interpretations. And since most of us rely on them so heavily, these errors can make our jobs just a bit more complicated.

Why do these errors happen? Well, technologists are human. In some cases, just like some physicians, a few technologists want to do the least amount of work possible. But, that is the minority. More commonly, they may be exhausted from a tough night. Or, perhaps, it’s just an erroneous judgment call. The bottom line is that their work can be very subjective. And any of these errant cases can ruin your day (and the patient’s too!) if you miss the opportunity to correct it. It’s why we need to check and double-check. Recently, I had some cases that reminded me of the fallibility of the technologist. So, I am discussing them to reinforce my point: don’t accept all the information provided by a technologist at face value!

A New Fibroid In a 65-year Old

For those of you that have completed an ultrasound rotation, you probably have learned about the subjective nature of finding uterine fibroids. Some technologists need to see a very well-defined mass before calling them. And, others will measure almost anything with a slightly different echotexture.  Nevertheless, standards can vary widely. (One of the reasons it is better to have the same technologist to perform case after case)

So, in my situation, I had recently reported on a small intramural uterine mass that was not there in the prior study three years earlier.  And, I could not define a lesion in the previous study based on the images provided. So, I called it a “new” intramural uterine mass, most likely a fibroid. This time around, I received a phone call from an irate physician, saying that it is impossible to have a new fibroid crop up in a post-menopausal female. (Although not true) And for this reason, she said she was ready to take out the uterus.

Meanwhile, I had to calm her down by saying that the most common cause for a new lesion in the uterus is technical subjectivity. (Unless there was other clinical information that I was not aware of) Although, of course, weird lesions like leiomyosarcomas can occur. However, they are rare. And, it would be clinically appropriate to monitor the uterus for any significant changes closely. The clinician finally backed down. Who knew that an errant fibroid could cause such a problem? Just another example of how “minor” differences in the subjectivity of ultrasound technologists can have considerable ramifications!

A New Intussception- Get The Pediatric Surgeon Down Now!

A few weeks ago,  as I was packing my bags to leave at 10:01 pm as my shift had just ended, one of my residents runs into the reading room.  He yells, “Don’t leave! We have to reduce an intussception.”

So, I looked at the initial ultrasound images, and I saw bowel loops containing echogenic material. But, there was no significant bowel wall thickening or abnormal flow. It was almost a target sign, but it did not look quite right. Moreover, the technologist did not provide any real-time images to support her claim.

Therefore, like any half-way decent radiologist, I went back and looked at the priors. So, I checked a previous abdominal series performed right before the ultrasound. In it, you can see dense inspissated oral contrast through the colon, especially filling the entire cecum and a good majority of the large bowel. Well, there was my explanation for the appearance of hyperechoic material within the intestine on an ultrasound, not an intussception. Just because a technologist makes a diagnosis, doesn’t mean it is correct. Use all the information at hand!

New MRI Sequence Withdrawn

Finally, a while back, one day, we performed a brain MRI  to follow a patient with multiple sclerosis. And, the technologist called me after the patient had left, stating that they have a new protocol for multiple sclerosis patients, handed down from the administration. No one consulted me about this until this point. So, I look at the case, and I see that the typical most sensitive sequence for detecting plaques, the FLAIR sequence, is entirely missing. Additionally, I have no means to compare this study with his priors that had this same sequence. So, how can I say if the case is better, worse, or unchanged?

I consulted with my neuroradiologist colleague to confer about this situation because it didn’t make any sense. He agreed the patient needed to return and didn’t understand why the protocol was changed. Yet, the change in protocol forced a busy patient to return for additional imaging, wasting everyone’s time. A little bit of communication upfront could have resolved the situation. As you can see, protocol tweaks without communicating the change to the reading radiologist can have negative consequences!

Check And Double-Check- Technologists Can Make Or Break You!

Now, my primary goal is not to berate technologists. Instead, these examples show you that it is mission-critical to check and double-check their work, just like they should do the same for us. One wrong technical misstep can derail our ability to interpret images or provide quality patient care. Therefore, we need to catch them as best we can. We are all on the same team. So, remember that technologists, like radiologists, are fallible. Keep your eyes wide open and your head in the game!

 

 

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So, You Want To Become A Radiology Chair?

radiology chair

Maybe, you are ambitious and want to head a department. Or perhaps, your parents have high hopes for you and want you to become the boss. Although you think you may know, you probably have no idea about what goes into the radiology chair role. I know I didn’t until I started to practice. And, it can be challenging to find the truth about the job description (because they have too much bias!). So, what better venue than this blog to give you an accurate depiction of the position?

Of course, how much work you want to put into becoming a Radiology Chair is up to you. But, what does it entail to play the role of the Chair and do it well? And, is it worth the extra effort? First, I will discuss some of the personality traits that may be beneficial for the job. Then, let’s talk about the work, struggles, and benefits that you will need to think about before you start the process of working toward this goal. If you dare, go into this job pathway with your eyes wide open!

Personality Requirements For The Radiology Chair

Politically Savvy

Why is it critical to have a knack for politics? Well, invariably, there will be political factions that will push you towards different ends. And, you need to be strong enough to move the ship in a direction that is just and right for the practice. Therefore, you will need to deal with all sorts of personalities and points of view well.

Not Take All Criticisms To Heart

As a Chair, you will hear and field mostly complaints from colleagues, staff, and hospital administration. Very rarely, do folks get a compliment on a job well done. (Even if you are doing so!) So, you will need to let the upsetting criticisms slide off your back. Do not take it to heart. Or else, you will become a depressed and bitter radiologist!

Good Communicator

You need to let all parties know what you are doing with an open hand. One ingredient that gets employees more upset than anything else: finding out changes after the Chair has implemented them. Or, not letting anyone know about your intentions. Poor communication is a recipe for disaster in practice.

Strong Decision Maker

And, finally, this position entails making some hard choices that you will have to live with for the rest of your life. You will need to hire, fire, budget, and strategize. I would recommend that you have a strong stomach to make these decisions. Rarely, can you make everyone happy with all the decisions you make.

Job Requirements

Hiring and Firing

First of all, you will have the honor and privilege of hiring new employees. Not so bad, huh? But, that also comes with the painful task of firing ones that are not working out. If you have never experienced such a job, let me tell you, from my experience as a partner, that is certainly not fun. And, the Chair tends to be the leading player in this activity.

Fielding All Complaints- Radiologists And Other

Any practice of substantial size will receive complaints. And, if you are not getting them, you are probably not reading enough films to sustain a business. But with the territory of Radiology Chair comes fielding those complaints. And these can be from your practice, staff, hospital administration, or other clinicians. You will soon discover that many folks are not happy. And you have to deal with it all!

Attending Tons Of Meetings

If you like meetings, the chairman position is the job for you. Between partnership meetings, hospital staff meetings, galas, and more, you will soon become all too familiar with gatherings. You better have some tolerance for this activity!

Paperwork and Budgetary

As the head of a department, your signature needs to go onto lots of documents. It’s not official unless your name is on it. Moreover, you need to read those papers. Indeed, you don’t want your name going out on something you or your practice does not want.

Future Planning/Strategic Management- Mergers, Acquisitions, Contracts, Etc.

OK. I think that this part of the job is not so bad. Who doesn’t like planning the direction of your business? I believe it is the responsibility of all partners. But, the Chair should take a particular interest in these activities. They need to lead the business to better places!

Political Representation For Department- Parties, Etc.

The Radiology Chair is the figurehead of the practice. Think of the position as the President of the United States. If you don’t go to the hospital gala, who else will? And if you don’t show up on time for your work, everyone else will arrive late as well. Whatever you do makes a statement for better or worse.

Negotiations- Insurance and Other

Every hospital and private practice has times when you need to arbitrate to accomplish the goals of your department. Perhaps, you need to negotiate a salary or an insurance rate. Or, you need to get that great new CT scanner for the department. Regardless, you will be in charge of this process. Learn how to bargain with your peers!

Legal

Finally, your name will appear on lawsuits that strike the partners and employees. Since you are representative of the practice, there is a better chance that you will have to show up in court to defend the group’s position. Be prepared for this eventuality.

Advantages To The Role Of Radiology Chair

More Admin Time

Well, now you finally have what you want. You’ve got some more administrative time. Unfortunately, you will dedicate that time for all of those new responsibilities listed above (and probably a few more!). But, you may have a little bit more flexibility with your schedule. (If you are lucky!)

? Increased Pay

In some departments, the Chair makes a substantial amount more than her colleagues (especially in academics or massive private practices). For others, it does not move the needle that much. Regardless, there is usually some monetary bonus to being a chairman

? Respect

If you do an excellent job as a Radiology Chair, your colleagues and work alliances will respect you more. You will become a highly trusted member of the hospital and physician community. On the other hand, beware of becoming a poorly performing chair. You will have the active hostility of all!

Disadvantages

Time Away From Family

All these additional roles do not come without a price. You will most likely need to spend more time with your colleagues than with your family. It’s just the nature of the job.

Meeting After Meeting

The chairman’s role necessitates numerous meetings. To maintain communication with all parts of the practice, it becomes a necessary evil. The worst of the meetings are about when to decide the next meeting!

Less Clinical Time

The more you spend on administration, the less you spend on clinical work, That is just the nature of the beast. For some folks, this may seem enticing. And for others, not so much. In either case, know what you are getting into before you take this path!

Radiology Chair- Is It A Job Or A Lifestyle?

So there you have it. As you can see, becoming a chairman is not a road to a passive job with passive income. Instead, you most likely will work harder than you ever did before (unless you don’t care and want to do a bad job!) But, at the same time, it can come with a few rewards and prestige if approached in the right way. Just think about all the possibilities if you take this path. And, as I said at the beginning, go into this role with your eyes wide open!