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No Longer Practicing Radiology During The Covid Crisis? How To Keep Up!

practicing radiology

Many hospitals and imaging centers throughout the country have recruited radiology residents to help out with the Covid crisis. But that leaves many of these residents in a bind. Some residents may feel that they may be losing some of their hard-learned skills. And many have not had time practicing radiology, the main point of completing their residency. So, I am going to outline some steps to make the next several months more relevant to your training. I will do this by going through each residency year and what you should do to keep up your skills. And, I will divide what residents should into First Years, Second and Third Years, and Fourth Years as each of these groups are in different boats.

First Years

For many first years, you are probably not getting the same case experience as you did before. However, for those of you lucky to have some extra time outside of an ICU rotation, I would go through essential books in each subspecialty section. You will find some ideas for books that you may want to read through in my books and links section of this website. (as recommended by my residents) Make sure to read through some of the recommended reading materials at home, now that you may have more time (or even if you don’t!) The key to a successful first year is reading as a basis for the rest of your residency. Don’t squander this opportunity.

Also, if you are interested in interventional radiology, I would recommend participating in some of the procedures that a clinical rotation like the ICU may offer. Volunteer for lumbar punctures, central venous lines, and paracenteses, if possible. These are some procedures that overlap with radiology and will help to maintain what you have learned.

Second And Third Years

Second and third years are years to practice and learn the art of Radiology. So, in addition to reading like the first years.  I would make sure to emphasize radiology cases over only reading raw reading materials/textbooks. So, make sure to go through the case series. Also, when you have the chance, go to the PACS systems and review older cases from the year in different subspecialties, now that some of the regular imaging volumes have dried up. For instance, pick up some of the earlier MSK MRI and make your interpretations and match them up with the final dictations. This action will help to keep your skills and search patterns fresh in your mind since many elective sorts of cases have probably dried up a bit.

Also, even though the ABR has delayed the core examination, it is likely at the forefront of your mind. Make sure to continue to review test questions from sources like RadPrimer and others. (Check out a great post called Up To Date Book Reviews For The Radiology Core Examination from a former resident for some ideas) You certainly want to reinforce this information when you do take the test. Rinse and repeat as much as you can.

Fourth Years

Finally, we need to talk about the fourth year separately. Fourth-year is the best time to learn practical radiology. So, during this time, you should be reviewing areas of practice that you may feel less comfortable with. Especially now, more than ever, I would recommend doing this since the job market will most likely be changing. (Check out my recent post What’s In The Cards For The New Radiologist Job Market After Covid?). So, make sure to read cases in your weaker subspecialties to keep up or learn new imaging skills. (PACS is a godsend!) You may be using some of these skills at your next job!

Keep Practicing Radiology Skills: You Have Worked Too Hard To Lose Them!

Just because some of your radiology training has been canceled does not mean that you should stop practicing radiology. Now, more than ever, you should be making a concerted effort to hone your skills. Whether you are just starting as a first-year radiology resident and need the basics, or if you need more practical training in your final year, allowing your reading and procedural abilities to slip away would be a shame. Reading books and reviewing cases on PACS now is vital. Even though you may be busy outside of radiology with Covid patients, make a concerted effort to stay in the game. Don’t lose your hard-earned skills!

 

 

 

 

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Breast Imaging Versus MSK- What’s Better For Marketability And Lifestyle?

breast imaging versus MSK
Hi, Dr. Julius!
Been choosing between breast imaging versus MSK radiology fellowship, what do think is better in terms of marketability and lifestyle?
Yours truly,
Not quite sure
I find your choices of subspecialties of breast imaging versus MSK unusual because I almost consider them to be opposites in some senses. So, what are the particulars specifically about breast versus MSK radiology that you may find enticing or detract you from choosing them?

The Covid Crisis And Breast Imaging Versus MSK

Let’s start with current conditions. Many breast imagers that only perform breast imaging are currently out of jobs. Why? Because elective procedures have dried up entirely. So, you are subjecting yourself to a less diversified specialty in terms of outpatient versus inpatient imaging, that’s one negative for breast imaging. Today, MSK is more desirable in the Covid world because these subspecialists usually perform general radiology and inpatient imaging. But, times are atypical right now, and both specialties will likely return to a baseline (perhaps lower than before the pandemic- check out What’s In The Cards For The New Radiologist Job Market After Covid?).

The Traditional Job Market And Both Specialties

More traditionally, there have been fewer folks that have wanted to go into mammography for several reasons, such as more patient contact, lawsuits, and less diagnostic diversity. For these reasons,  the mammography job market has otherwise remained better than most subspecialties through other recessions. On the other hand, MSK is more conducive to practicing general radiology since it overlaps with other areas in radiology a bit more. So, you will find more cross-coverage, And, for this reason, this subspecialty tends to be more subject to the whims of the radiology job market in general.
In terms of lifestyle, both subspecialties tend to be primarily outpatient. And, both subspecialties can be procedural and usually non-emergent. Mammo folks do biopsies, and MSK folks perform facet injections and bone marrow biopsies/arthrograms. But that’s about where the overlap ends. Mammography is a specialty for those people that like patient interaction. MSK, on the other hand, in general, tends to be a more solitary subspecialty where you can work without having to see patients if you want. I find this to be the most substantial difference between the two subspecialties. You have to figure out if you are a people person or not to make this determination.
So, there you have it. Those are some of my thoughts about the comparison between the two subspecialties in a nutshell.
Thanks for the great question!
Barry Julius, MD
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What’s In The Cards For The New Radiologist Job Market After Covid?

radiology job market

In such a short time, a matter of weeks, the tenor of the radiologist job market has changed dramatically. Jobs in radiology were bountiful up until the beginning of March. Then, suddenly, elective procedures trickled down to almost nothing. And, practices began to fire their locum’s workers and furlough many part-time and full-time employees. But, this status will eventually end. And, the radiology job market will change and then establish a new baseline. But, what will that new baseline be? Can new graduates look forward to a booming job market once again? Well, let me give you a summary of what I think will happen as Covid-19 begins to wind down.

From Now To Three Months From Now

As we see a slight ramp up in elective studies, we will not yet see a brisk demand for radiologists. We will still have significantly fewer procedures, as many folks do not want to go to an imaging center for fear of contagion. However, many “elective” interventions, such as colon surgery for previously detected masses on colonoscopy, will need to begin again. But, don’t count on seeing many practices hiring just yet. Most practices will be more than adequately staffed during this time for the number of studies. Hiring freezes will remain.

Remember. You will continue to see advertisements for radiologists, but practices paid for these previous to the pandemic. These advertisements do not represent the current state of the job market!

Up To A Year From Now

Here, I will have to make a few more assumptions. But, I will postulate that a widely available vaccine is not yet available. And, I will conjecture that we have more widespread antibody testing (unlike now). Based on these premises, we will see more folks willing to come out to get their studies, especially those that tested positive for the antibody. However, fear will still prevent a lot of patients from getting the elective imaging that they want as not everyone will feel comfortable returning to hospitals and imaging centers. So, the patient load will not be back to the baseline. And, many practices will still be overstaffed based on the pre-Covid demand.  Therefore, new hires will have fewer job choices with lower salaries. Prospective new hires will face a tight job market.

The New Baseline Post- Covid Era Radiologist Job Market

The further you go out, of course, my predictions will become less accurate. And, we will assume that Covid infections go away from vaccinations and herd immunity. But, having seen other cycles, I believe that we will see several changes from the pre-Covid world. First of all, many patients will likely still be reluctant to return to imaging. Why? Unemployment will be much higher than what it once was before the pandemic.

Additionally, we will see a cultural shift of less imaging than before the crisis. Patients will more likely demand higher standards for cleanliness and sterilization. And, therefore, we may see fewer radiology procedures than in the pre-Covid world.

Also, many practices will have augmented their home teleradiology capabilities. So, reading efficiency will have increased dramatically.

Then, to add insult to injury, private equity firms and corporate radiology have become more significant players in the radiology space. These firms, formerly offering enticing salaries to new graduates, will now significantly lower the wages of new hires. Furthermore, we will see a decline in the salary of the contracts of the old hires since these firms renew these contracts on an annual basis. Why will this happen? Because profits rule their bottom line, and corporate radiology can cut with impunity. Corporate radiology will work radiologists to maximal efficiency, skimming any gains that they can from their radiologists. They will have no incentive to hire.

Finally, if we assume that the stock market remains lower than it was before March 2020, many prospective retirees will not retire. Why pack it in when your portfolio remains much less than what you planned at the time of retirement?

Between all these significant factors, the radiologist job market will not return to the pre-Covid era baseline. Instead, the market will most likely be more similar to the world five to ten years ago when good jobs were harder to come by.

What Are The Chances That I Am Wrong?

Of course, I can be wrong. However, I see the winds of change ahead based on what has happened in previous cycles. So, for those folks that are graduating soon, don’t expect the same radiology job market as the recent past. You will most likely have to work much harder to get the same position at a lower wage.

So my recommendations for you, as for years prior, take your training and residency seriously.  Be competitive. Step out of your comfort zone. Aggressively take charge of your education to become well versed in all areas of radiology. And, finally, expect to practice in locations and subspecialties that are not your primary area of interest. Although not for forever, we will see a return to a world more similar to the previous down cycle of the radiology job market. For those of you soon to find jobs, prepare accordingly!

 

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How To Mitigate The Next Pandemic: Encourage New Physicians To Get Business Training!

pandemic

Crises have a habit of magnifying gaps that we could not have imagined beforehand. And, this Covid pandemic reveals these large cracks in our healthcare system by the dozens. We have seen hospitals and imaging centers functioning without physicians receiving the appropriate personal protective equipment (PPE). We are witnessing a lack of ventilators for our sickest Covid patients. Moreover, we are beholding our healthcare system, reliant on lucrative elective procedures, go sour. Practices, hospitals, and imaging centers temporarily are almost empty (other than Covid patients) and dependent on our government to stay afloat. And, these issues are just the tip of the iceberg.

Did these misfires have to happen? Could leadership have prevented the dramatic shortfalls that we are experiencing now? How can we have known our future? Well, it’s a matter of ill-preparation.  And, this pandemic was not on the radar. But why? For years, many intelligent folks have been warning about preparations for pandemics. (check out this TED talk by Bill Gates) And, it is not just him. Other brilliant scientists and doctors have warned us about preparing for the next pandemic. No one listened.

Reason For Health Care’s Poor Preparation For The Current Pandemic

Why did hospitals and our healthcare system ignore prescient information sitting right in front of their noses? Well, it has to do with the model of healthcare that we follow in this country.  We have been treating healthcare as just a business for years.  And if you think about it only in these terms, the situation that we are in makes sense. Why would you prepare for calamity if it’s going to decrease your short-term and intermediate-term profits? Preparations reduce your bottom line.

But herein lies the crux of the problem. We can’t just think of healthcare as a business, but also as a way to protect and serve people. To accomplish this task, we have charged the wrong leaders with the responsibilities of running our healthcare system. Having only a JD or MBA, although helpful for understanding the business of medicine in the short term, is not enough. We need leaders in charge who have also been in the trenches and understand what our physicians and patients need in the long run. They need to understand the science and art of medicine. For these reasons, I would argue that we need more MDs and MD/MBA types in administrative leadership positions. With physicians in charge, hospitals could have prevented many of these issues.

Examples Of Why Physician-Hospital Administrators Would Make Better Health Care Administrators/Leaders

Let’s take some of the examples I provided above. PPE and ventilators are examples of two expenses that make no sense for a hospital to buy if you are thinking only about the business of medicine. First of all, buying such equipment would attract patients with infectious diseases to your institution because you have the equipment to manage only the sickest of patients. These patients cost more to the hospital. Additionally, why buy ventilators or PPE if you don’t need them now?. For-profit and non-profit institutions lose money off of their balance sheets, thereby decreasing bonuses given to their leaders. We can no longer think in these terms.

Or, let’s think about elective procedures as a way for hospitals to make money. Does it make sense? No. In a pandemic, the profit centers of a hospital shut down, causing the government to have to bail them out. Instead, healthcare profits should be made based on treating patients for sickness and making them well. Who better than a physician with some business sense to change this system so that we begin to treat patients and not just increase short term hospital cash flow?

The Answer: Encourage More Physicians/Radiologists To Receive Business Training

I want to underscore that we do need folks with business minds in charge of our healthcare institutions. However, these folks should be the doctors as leaders who can understand both business and medicine. To know how to run a healthcare system, you need experience in the trenches, both in the corporate world and medicine.

So, we, as program directors, mentors, and faculty, should encourage our residents to learn more about hospital administration. Instead of dismissing those residents that are not following our clinical footsteps, we should guide these new physicians on how they can begin this new pathway. Business courses should not be just an afterthought or tack-on to the radiology curriculum.

We need to start thinking differently about what and how we teach about the business of medicine. Let’s start taking more seriously some of the excellent curricula that the ACR or other physician societies offer and create mandatory externships to learn more about healthcare administration. Or maybe, just like informatics or MSK, all specialties should have fellowships dedicated to hospital administration. Now is the time to create easy-to-follow health care administrative pathways for our residents. It’s more than just creating another silly specialty pathway; it’s the future and viability of the entire healthcare system at stake!

 

 

 

 

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Should Hospitals Force Radiology Residents To Work In The ICU During The Covid Crisis?

ICU

Radiology residents are working in the ICU or the wards to meet the increasing demands of an influx of Covid-19 patients, sometimes having little to do with their training. And, most residents have graciously accepted their new duties, in the name of helping a higher cause. But why must residents comply with these demands? Are hospitals treating these physicians fairly? Is it ethical for h0spitals to require residents to participate and forego training in their desired subspecialty? And, what must the hospital ethically provide in return? Let’s answer some of these burning questions as it reveals some underlying issues about residents and residencies themselves.

The Government Indirectly Hires Residents

Once you sign your residency contract on the dotted line (or solid line!), you are receiving a salary from not just the healthcare system that employs you, but also indirectly from a pool of money provided to the hospitals by Medicare. And, most residents receive these government funds in one way or another. Therefore, you are indirectly working as the Government’s servant. In this setting, residents must comply with the Government and the hospital to receive a salary. So, hospitals do have the right to set aside educational objectives for the moment (even though it may not be what you bargained for!)

Residency Has Service And Educational Obligations

It’s not all about take, take, take! There are two components to any residency, educational and service obligations. Not too long ago, in an attempt to get back Social Security taxes from the Federal Government, residents sued the IRS because they claimed that medical residents were students and not employees. (Check out this article) In the end, the Government returned taxes to residents because the Government never clarified the definition of a resident. However, nowadays, the definition of residency changed. Today, the Government/IRS considers residents to be employees, not just students. And, for that reason, all current residents pay Social Security taxes as well as need to comply with government/hospital demands for service. (That includes time in the ICU!)

What Do Hospitals/Government Need To Provide In Return?

Hospitals have a moral and ethical obligation to provide a safe environment for resident trainees. Any institution that does not offer such a setting violates the spirit of a resident’s contract with the institution. What does that mean? Well, hospitals should treat residents like any other employee. In the case of this epidemic, hospitals should provide residents with the protective equipment they need to stay safe. No resident should risk life and limb without the appropriate accommodations of the institution in return.

And, hospitals should continue to pay their residents at their negotiated salary. Understandably, hospitals are struggling with the lack of revenue from canceled elective procedures. However, the amount that they receive for maintaining residency programs remains fixed by the Government. Therefore, it is only fair that residencies should continue to receive their salaries without furlough or pay cut. They are not the same as general employees whose wages can be subject to market forces.

A New World Order For Radiology Residents: Time In The ICU

No. ICU work is not what most residents signed up for when they began their radiology residencies. However, radiology trainees are still, first and foremost, physicians with service obligations. Part of these requirements is a duty to do no harm and help patients. Moreover, hospitals also have ethical and moral responsibilities toward their residents. Therefore, when both the resident and hospital meet these conditions, radiology residents can and should play a role in meeting the new needs of the healthcare system. Hey, when did you ever sign up for something that was as you exactly expected?

 

 

 

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Danger Of Using Case Studies To Dictate Imaging Policy: The Initial Covid-19 Study

case studies

Rumors abounded at the beginning of March 2020 about Covid-19. And, no one quite knew how Covid-19 would play out. All sorts of physicians were on edge to try to figure out what to do. But then a new case study about the role of CT scan arrived at the scene. And, clinicians began to read or hear about this “seminal paper” in Radiology that came out from China, called Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. This paper claimed a high sensitivity for the detection of the diagnosis coronavirus compared to PCR. Admitting physicians quoted it and demanded to get CT scans on their patients with presumed Covid-19. ER doctors were ordering Chest CT scans left and right.

What happened next? The throughput of patients slowed down to a crawl because the CT scanner needed special cleaning for potential Covid-19 contamination. Subsequently, this thorough cleaning delayed the treatment of patients. And, the CT scanner was out of commission for other patients that needed the CT scan for emergency workups.

Was it the right to use this paper to dictate the workup of patients? In hindsight, no. And, it brings up an all too common issue, the usage of case studies to dictate health care policy. So, what are the other factors that we need to evaluate before we decide to take a paper and apply it to patient care? Well, I will use this incident as a way to show you what you need to think about before using case studies to guide patient imaging. Let’s divide it into the following categories: practicality, throughput, exposure, and change in management.

Practicality- It’s Not All About Sensitivity Or Specificity

I don’t know about you. But, whenever I hear a test is highly sensitive or specific for a disease entity, I get excited. My first thought is usually, maybe we can use this exam to diagnosis patients? However, before arriving at that conclusion, we need to take a step back. Does the test make sense in the context of patients coming into the emergency department? Many clinicians did not think about these issues when they decided to utilize a CT scan to image presumptive Covid-19 patients. Just because you can make a diagnosis does not mean that you should complete a test.

Throughput is Important

A test is only useful when it can rapidly diagnose patients. In the case of CT scans for the diagnosis of Covid-19 patients, regardless of any other factor, our throughput for patient care significantly slowed down. And, this had a dramatic effect upon the patients that came into the Emergency Department for many other reasons. Always, physicians need to take this factor into account before jumping into ordering a test.

Exposure To Health Care Workers And Patients

We need to take care of all the folks that are providing services for the sick and infirm. If we do not perform this duty, we will have no health care workers to treat patients. In this situation, deep cleaning the CT scanner after each patient added undue risk to the technologists and nurses that completed these functions. Not to mention, you are also increasing the possibility of exposure to the next patient in the CT scanner. The upshot was a tremendous cost to the patients and employees.

Does It Change Management?

And, then finally, the most critical question that we need to ask ourselves is how does the test change management? In the case of Covid-19, a negative test did not preclude the possibility of the disease. So, regardless of the test outcome, the clinicians would need to use their clinical intuition to decide if they need to ventilate the patient or other invasive measures. Moreover, the treatment of the patient would remain the same, whether the CT was positive or negative. Why submit a patient to such a test?

Beware The Dangers of Using Small Case Studies To Dictate Policy!

We all need to take a step back when we hear the claims of physicians that we should be imaging a patient based on a paper. Instead, you should be answering the following questions: Is it practical? Will it prevent other patients from receiving appropriate testing? Will it endanger my staff and patients? And, does it change the management of the patient’s case? If the case studies can pass these tests, consider using it as a tool. If not, beware of imaging the patient based on a paper, the test may do more harm than good!

 

 

 

 

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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!