Nonradiologists as second readers for intraluminal findings at CT colonography

RATIONALE AND OBJECTIVES: Multiple trials have documented wide interobserver variability between radiologists interpreting computed tomography colonography (CTC) exams. We sought to determine if nonradiologists could learn to interpret intraluminal findings at CTC with a high degree of sensitivity to determine if they could play a role as second readers in interpreting CTC exams. MATERIALS AND METHODS: Seven nonradiologists (five medical students, two radiologic technologists) undertook self-directed CTC training using a teaching file of 50 cases; thereafter, each reader blindly interpreted 50 cases with colonoscopic correlation (30 positive, 20 negative). Results were compared with a previously studied cohort of radiologists. The two technologists additionally repeated the exam after 6 weeks of clinical experience. RESULTS: The sensitivity of nonradiologists for small (5-9 mm) polyps, large (>9 mm) lesions, and cancers was similar to that of radiologists (0.45 versus 0.63, 0.74 versus 0.71, and 0.80 versus 0.88, respectively). After 6 weeks of clinical experience as second readers, the accuracy of one technologist significantly improved (from 74% to 90%, P = .008), whereas accuracy of the other tended toward improvement (from 74% to 86%%, P = .25). Nonradiologists detected, on average, 6/36 additional polyps (17%) missed by any radiologist, and the sensitivity of 5/7 nonradiologists was significantly greater than at least one of the radiologists (P = .05). CONCLUSION: Nonradiologists can perform similarly to radiologists in interpreting intraluminal findings at CTC, with nonradiologist performance improving even after experience with more than 100 cases. Skilled nonradiologists may play a vital role as a second reader of intraluminal findings or by performing quality control of examinations before patient dismissal.     

Improving the adherence of urban women to mammography guidelines: strategies for radiologists

Only 16% of women over 40 years of age are being screened regularly with mammography. To learn what radiologists and technologists can do to increase patient adherence to the screening guidelines of the American Cancer Society, especially by poor, urban women, the authors surveyed patients at a county facility immediately after mammography to document the patients' experiences with technologists and the procedure. Analysis of these data led to the conclusion that the radiologist should encourage an expanded role for the technologist as a breast health educator. By incorporating the use of a well-designed patient brochure, technologists can greatly enhance their effectiveness by decreasing the patient's anxiety and increasing her understanding of the procedure and of the importance of screening. Radiologists need to appreciate the potential of an expanded technologist's role for increasing future referrals.     

Increasing radiographer productivity by an incentive point system

Because of a very low technologist productivity in their Radiology Department, the authors describe a Productive Point System they developed and implemented to solve this personnel problem. After establishing the average time required to perform all exams, point credits (one point for every ten minutes utilized) were assigned to each exam performed, thereby determining an index of production. A Productive Index of 80% was considered realistic and was the equivalent of 192 points for a 40-hour work week. From 1975 to 1978 personal productivity increased from 79% to 113%. This resulted in an average yearly fiscal savings of over $20,000.00 for this three-year period. There was also a significant improvement in exam efficiency and quality, job attitude, personnel morale, and public relations. This program was highly successful because technologist acceptance and cooperation was complete, and this occurred mainly because the system supports the normal occupational goals and expectations of technologists.     

The voice of the radiologist: Enabling patients to speak directly to radiologists

Patients and patient advocates express a desire to speak directly with radiologists, who are ideally suited to answer imaging-related questions and recommend for further imaging or testing. While web-based patient portals have improved patient access to reports of radiology examinations, they do little to help patients understand the report, and rarely facilitate contact with their radiologists.We implemented an alias phone number that forwarded to the smartphone of each participating radiologist and embedded it in 3896 reports over 8 months. It was embedded as an invitation to the individual viewing the report to call with questions. For each call received, we logged parameters such as call duration, call reason, and required radiologist time/resources. Finally, the call was documented in the electronic medical record.Radiologists received 27 calls exclusively about cross-sectional exams: 22 from patients or caregivers, and 5 from physicians. The reasons for the calls included term definitions, correction of dictation errors, findings not specifically mentioned, and clinical impact of findings.Time spent on the phone with patients averaged 8.6 min. When including the time spent reviewing the images, patient chart, and/or literature; the total radiologist time per call was approximately 13.9 min. Averaged over all of the exams in the study, this service added 5 s to each exam.While the total call rate was low, implementation of this program required minimal effort. The aliased phone number masked the radiologist's phone number and allowed scheduled consultation hours. Even when called, the time to address questions appears to be minimal.     

Feasibility of instructing radiology technologists in the performance of gastrointestinal fluoroscopy

OBJECTIVE: We sought to determine if dedicated gastrointestinal technologists could be trained to properly perform esophagography and double-contrast barium enema examinations. SUBJECTS AND METHODS: Ninety-four patients undergoing double-contrast barium enema examinations and 123 patients undergoing esophagographic examinations were included in the study. The study was conducted over a 4-month period, with examinations performed by eight gastrointestinal technologists, 10 radiology residents, and four staff radiologists. Four random lists were generated for each set of examinations. Each staff gastrointestinal radiologist, who was unaware of who had performed the examination, independently scored the representative radiographs. RESULTS: For the double-contrast barium enema examinations, no statistically significant differences were found between the technologists and residents for amount of barium used, degree of distention, cecal opacification, and quality of spot radiographs. The technologist-performed examinations had a statistically significant lower mean fluoroscopy time (3.2 min, compared with 4.0 min for staff radiologists and 5.7 min for residents). For the esophagrams, no statistically significant differences between technologists and residents were found for single-contrast esophagrams; radiographs of the gastric cardia; assessment of motility, reflux, and transit of a solid bolus; and fluoroscopy time. Double-contrast esophagrams obtained by technologists received a better mean score than did those of the residents. CONCLUSION: Radiology technologists can be trained to perform high-quality esophagography and double-contrast barium enema examinations without an unacceptably high radiation dose.     

Implementing a Software Solution Across Multiple Ultrasound Vendors to Auto-fill Reports with Measurement Values

Reliable transmission of ultrasound measurements into radiology reports is fraught with potential sources of error. In a conventional workflow, measurements are either written by hand on worksheets and/or dictated from worksheets or the images themselves into the radiology report. Valuable physician time is spent dictating, checking, and editing these values and this process is error-prone. Our approach was to use a transfer-software application to auto-populate measurements, with a goal of achieving >90% utilization rate by both technologists and radiologists. Implementation involved creating measurement fields for each measurement on each ultrasound unit of our multisite academic department. These fields were then mapped in both the transfer-software and the dictation software, to set up a 1:1:1 correspondence for each field. As a result, each measurement acquired by the technologist would automatically populate the radiology report within the dictation software. We created and mapped 128 fields for 39 exam templates. After implementation, technologist utilization rate was 86%-96% and overall radiologist utilization rate was 92%-93%. Radiology resident utilization rate was highest, at 95%-96%. We provide a guide for implementation and lessons learned.     

The Patient Experience in Radiology: Observations From Over 3,500 Patient Feedback Reports in a Single Institution

PurposeTo identify factors associated with the patient experience in radiology based on patient feedback reports from a single institution.MethodsIn a departmental patient experience committee initiative, all imaging outpatients are provided names and roles of all departmental employees with whom they interact, along with contact information for providing feedback after their appointment. All resulting feedback was recorded in a web-based database. A total of 3,675 patient comments over a 3-year period were assessed in terms of major themes. Roles of employees recognized within the patient comments were also assessed.ResultsPatient feedback comments most commonly related to professional staff behavior (74.5%) and wait times (11.9%), and less commonly related to a spectrum of other issues (comfort during the exam, quality of the facilities, access to information regarding the exam, patient privacy, medical records, the radiology report, billing). The most common attributes relating to staff behavior involved patients’ perceptions of staff caring, professionalism, pleasantness, helpfulness, and efficiency. Employees most commonly recognized by the comments were the technologist (50.2%) and receptionist (31.6%) and much less often the radiologist (2.2%). No radiologist was in the top 10% of employees in terms of the number of comments received.ConclusionPatients' comments regarding their experiences in undergoing radiologic imaging were largely influenced by staff behavior and communication (particularly relating to technologists and receptionists), as well as wait times, with radiologists having a far lesser immediate impact. Radiologists are encouraged to engage in activities that promote direct visibility to their patients and thereby combat risks of the perceived “invisible” radiologist.     

Medical radiologic technologist review: effects on a population-based breast cancer screening program

PURPOSE: To evaluate the effects of medical radiologic technologist review of mammograms in a population-based breast cancer screening program. MATERIALS AND METHODS: A technologist review pilot project was incorporated into the Regina, Saskatchewan, Canada, reading center. Technologists received special training in mammographic interpretation. They reviewed all 27,863 mammograms obtained at the center from July 1995 to September 1996 that were reviewed by a radiologist and selected cases for second blind reading by another radiologist. When the two radiologists' readings were in agreement, the report was sent. When the readings differed, a third opinion was obtained from the program's consulting radiologist. Changes in the number of mammograms interpreted as abnormal and the number of cancers detected were assessed. RESULTS: The technologist review was responsible for the detection of nine cancers missed at the first radiologist's interpretation. Technologists were very discriminating; only 391 cases (1.4%) were sent for double reading. The positive predictive value of screening did not change significantly (7.5% without review, 8.1% with review; P > .20). CONCLUSION: A substantial number of cancers were found with the technologist review. The number of mammograms interpreted as abnormal was reduced slightly. The technologist review proved to be a cost-effective alternative to double reading by two radiologists.     

The role of the GI radiographer: a United Kingdom perspective

CONTEXT: Since the 1990s radiographers in the United Kingdom have expanded their role in gastrointestinal (GI) radiology, first by performing double-contrast barium enema (DCBE) examinations independently and later by interpreting and reporting the results of these exams. OBJECTIVE: This article will trace the evolution of GI radiographers in the United Kingdom, evaluate their success and explore how the U.K. experience could apply to American radiologist assistants. METHODS: The authors surveyed the professional literature to determine the historical context in which GI radiographers emerged and assess how their performance on DCBE exams compares with radiologists' performance. RESULTS: DCBE exams performed by GI radiographers have been shown to be efficient, cost effective and safe. In addition, GI radiographers have helped reduce waiting and turnaround times for DCBE exams. SUMMARY: The success of GI radiographers in the United Kingdom offers assurance that radiologist assistants can benefit American patients, radiologists and radiologic technologists.     

A review of ethics for the radiologic technologist

Radiologic technology students learn ethical theory, ethical principles and the Code of Ethics. However, over time, the concepts may fade from the radiologic technologist's memory. Periodic review of the ethical concepts and the American Registry of Radiologic Technologists Standards of Ethics are important to maintain a clear understanding of ethical expectations of the radiologic technologist. This article provides examples of potential ethical violations to illustrate each principle in the Code of Ethics and each tenet in the Rules of Ethics. The examples are intended to help readers think about and relate to situations they may encounter. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your CE preference. For access to other quizzes, go to www.asrt.org/store.     

Monitoring the Use of Extra Images on Chest Radiography Examinations

BackgroundA large number of chest radiography studies in our department include extra images due to incompletely imaged anatomy (eg, extra frontal view to include a truncated costophrenic angle). Negative impacts include: increased radiologist review time due to disruption of search pattern and the need to review additional films in slightly different obliquities, additional radiation exposure, and increased technologist time expenditure.PurposeTo determine the chest radiograph repeat rate, collaborate with technologists on a process to decrease the frequency, and incorporate the process into our quality control program.MethodsData collection was performed by using coded dictation macros to indicate the type of extra view (frontal, lateral) and whether the extra image was necessary due to patient habitus. Twelve weeks after the macro was instituted, baseline data were collected by querying the macro codes with a search engine (MONTAGE Search and Analytics). Intervention consisted of in-person tutorials of basic radiographic positioning principles with x-ray technologists and posting of checklists in all diagnostic radiology exam rooms. Twelve weeks of postintervention data were collected.ResultsBaseline data included 5645 examinations, of which 335 (5.9%) included extra images. Postintervention, 5943 examinations were performed and 295 (5.0%) included extra images. A significant decrease in the frontal view repeat rate was noted, decreasing from 4.6%-3.3% (P = 0.001). The repeat rate of lateral images did not change significantly (3.1%-3.2%).Conclusions and ImplicationsData monitoring and interprofessional collaboration led to a significant decrease in unnecessary extra radiographs. Ongoing monitoring may lead to sustained improvement and further reductions.     

Economic challenges in breast imaging. A survivor's guide to success

Most breast imaging centers today operate under financial strain. Among strategies designed to improve their bottom line, more efficient use of the radiologist's time is the most fundamental strategy and the one most likely to succeed in all breast imaging centers. Tasks performed by the radiologist that are not directly related to interpretation and consultation should be shifted to other personnel. Other strategies that may help some breast imaging centers include accepting only self-paying patients, renegotiating the hospital contract, performing more interventional procedures, and extending the hours of operation. Measures that can improve the economic efficiency of screening mammography include batch interpretation of mammograms; paperwork reduction; brief automated reports; limiting requests for previous films from other facilities to only potentially necessary cases; dedicated screening mammography examination rooms; reduction in recall rates; and, in certain circumstances, extension of breast center hours. Measures that can improve the economic efficiency of diagnostic mammography performance and interpretation include dedicated diagnostic mammography examination rooms, automated film rotators, improved scheduling, and efficient work-flow patterns for examination performance. Measures that can improve the economic efficiency of both screening and diagnostic mammography include improved triage of screening and diagnostic patients, reminder telephone calls to confirm mammography appointments, greater use of medical assistants to help the radiologists and technologists, and streamlined film library procedures and operations. Measures that can improve the economic efficiency of breast interventional procedures include preprocedure work-up, establishment of scheduling protocols, and greater involvement of technologists and medical assistants in assisting the radiologist who performs the interventional procedures. All of these methods are intended to create a breast imaging center that is cost efficient while maintaining a patient-friendly atmosphere and diagnostic accuracy.     

Radiologists' reading times using PACS and using films: one practice's experience

RATIONALE AND OBJECTIVES: To measure the change in radiologists' productivity in terms of interpretation time per examination when using picture archiving and communication system (PACS) workstations in a particular private practice, Valley Radiologists, Ltd, as part of a feasibility study and subsequent business plan to implement a digital enterprise. MATERIALS AND METHODS: Time to process a series of exams was measured for 18 radiologists during an uninterrupted period of a working day. Radiologists in the practice served in multiple locations. The data were analyzed in aggregate and by modality (plain film, ultrasound, computed tomography, and magnetic resonance imaging). Average time per exam, with and without PACS, was measured for each modality. Regression analysis was used to determine the independent effect of PACS on radiologist productivity. RESULTS: The mean time to process an exam was 1.4 minutes (SE = 0.04) for plain film, 1.96 minutes (SE = 0.14) for ultrasound, 5.08 minutes (SE = 0.44) for computed tomography, and 6.83 minutes (SE = 0.31) for magnetic resonance imaging. Regression results indicate that PACS had no effect on the time taken to read a series of exams. CONCLUSIONS: When considering a PACS purchase or implementation, decrease in radiologists' time to process an examination may not be realized. In this specific practice setting, we did not find evidence that PACS workstations alone, without any other changes in workflow design, improved radiologists' interpretation time.     

The Lung Image Database Consortium (LIDC): ensuring the integrity of expert-defined "truth"

RATIONALE AND OBJECTIVES: Computer-aided diagnostic (CAD) systems fundamentally require the opinions of expert human observers to establish "truth" for algorithm development, training, and testing. The integrity of this "truth," however, must be established before investigators commit to this "gold standard" as the basis for their research. The purpose of this study was to develop a quality assurance (QA) model as an integral component of the "truth" collection process concerning the location and spatial extent of lung nodules observed on computed tomography (CT) scans to be included in the Lung Image Database Consortium (LIDC) public database. MATERIALS AND METHODS: One hundred CT scans were interpreted by four radiologists through a two-phase process. For the first of these reads (the "blinded read phase"), radiologists independently identified and annotated lesions, assigning each to one of three categories: "nodule >or=3 mm," "nodule <3 mm," or "non-nodule >or=3 mm." For the second read (the "unblinded read phase"), the same radiologists independently evaluated the same CT scans, but with all of the annotations from the previously performed blinded reads presented; each radiologist could add to, edit, or delete their own marks; change the lesion category of their own marks; or leave their marks unchanged. The post-unblinded read set of marks was grouped into discrete nodules and subjected to the QA process, which consisted of identification of potential errors introduced during the complete image annotation process and correction of those errors. Seven categories of potential error were defined; any nodule with a mark that satisfied the criterion for one of these categories was referred to the radiologist who assigned that mark for either correction or confirmation that the mark was intentional. RESULTS: A total of 105 QA issues were identified across 45 (45.0%) of the 100 CT scans. Radiologist review resulted in modifications to 101 (96.2%) of these potential errors. Twenty-one lesions erroneously marked as lung nodules after the unblinded reads had this designation removed through the QA process. CONCLUSIONS: The establishment of "truth" must incorporate a QA process to guarantee the integrity of the datasets that will provide the basis for the development, training, and testing of CAD systems.     

ACR and ASRT development of the radiologist assistant: concept, roles, and responsibilities

ACR and ASRT joined forces to address the workforce shortages of radiologists and radiological technologists with the development of a radiologist assistant. This paper discusses the rationale for the evolution and development of the radiologist assistant as designed by ACR and ASRT.With the profession of radiology experiencing workforce shortages among radiologists and radiological technologists many radiological groups were beginning to hire ancillary personnel to fill efficiency gaps in practices. Many academic institutions were in the process of considering programs to initiate advanced practice status for radiologic technologists. Several state legislatures were considering laws that would provide extended scope of practice technology with additional training. The ACR and ASRT entered into discussions to address these concerns in order to: (1) assure patient safety by allowing only properly trained personnel to provide radiological service to patients; (2) assure that these ancillary personnel are not allowed to practice without appropriate physician supervision; (3) assure that there are not 50 different state scope of practice laws based more on political expediency than quality patient care; (4) alleviate workforce shortages for radiological technologists by creating a professionally satisfying career path; (5) alleviate some of the time pressures placed on radiologists as a result of their workforce shortages. The ACR had a choice to lead on the development of the roles and responsibilities of the radiologist assistant or continue to allow the process to evolve as market and political pressures warranted. As a leader in the profession, the ACR believed that it was in the best interest of its members and the profession to be at the table with the development of the roles and responsibilities of the radiologist assistant to assure the best for our patients. The roles and responsibilities of the RA as approved by the ACR Council are presented.     

The role of the radiology nurse

The radiology nurse's role requires a high level of knowledge, expertise and independence because the department provides services to a wide variety of patients with diverse needs and about whom information may be limited. Radiology nurses routinely start or check peripheral i.v.s, assess infusaports, administer medications, monitor vital signs, suction patients, insert foleys and help patients with their personal needs. The nurse also informs the technologist or radiologist of any unusual patient needs and performs specialized nursing duties, such as administering i.v. sedation or analgesia during special procedures and closely monitoring patients with cardiac/pulse oximeters. Radiology departments call on nurses to care for patients transported from intensive care, patients in emergency situations and pediatric patients and others needing sedation. Teaching is another duty radiology nurses assume, instructing patients and their families, students, technologists, other nurses, radiologists and physicians about patient care. They also teach the radiology staff new nursing policies and national standards as such changes occur. Radiology nurses devote a lot of time to quality improvement and infection control programs: collecting data, keeping records and reporting results. Because radiology nursing is relatively new, the nurse may be called upon to help write patient care policies, design flowsheets or patient instruction sheets and develop protocols or care plans. Radiology nurses utilize skills employed in many other nursing specialties and incorporate them in the radiology setting. They must provide quality nursing care to a large, transient group of patients of all ages, be a spokesperson for patient care and a teacher to other radiology staff members on patient care issues.     

Imaging professionals' beliefs on overutilization of CT and MRI exams

The intent of an independent study was to see if radiologists, administrators, and technologists would agree that there is a problem with CT and MRI overutilization. Another goal was to see if they are doing anything about this issue, to determine if there are best practices in place, and to set the basis for future studies. A literature review uncovered United States utilization rates compared to the global community. It also revealed economic concerns and relevance to an increase in healthcare costs. The recognition of overutilization exists; however, many still have not put a program in place to help with mitigation.     

Radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies

RATIONALE AND OBJECTIVES: To determine the incidence of radiology resident preliminary interpretation errors for plain film, body computed tomography, and neuroradiology (neuro)computed tomographic examinations read on call. MATERIALS AND METHODS: We retrospectively reviewed the data in a prospectively acquired resident quality assurance (QA) database dating between January 2000 and March 2007. The database comprises all imaging studies initially interpreted by an on-call resident and later reviewed by a board-certified attending radiologist who determined the level of discrepancy between the two interpretations according to a graded scale from 0 (no discrepancy) to 3 (major discrepancy). We reviewed the data with respect to resident training level, imaging modality, and variance level. Statistical analysis was performed with chi(2) test, alpha = 0.05. We compared our results with other published series studying resident and attending accuracy. RESULTS: A total of 141,381 cases were entered into the database during the review period. Of all examinations, 95.7% had zero variance, 3.3% minor variance, and 1.0% major variance. There was a slight, statistically significant increase in overall accuracy with increased resident year from 95.4% of examinations read by first-year residents (R1s) to 96.1% by fourth-year resident (R4s) (P < .0001). Overall percentages of exams with major discrepancies were 1.0% for R1s, 1.1% for second-year residents, 1.0% for third-year residents, and 0.98% for R4s. CONCLUSIONS: The majority of preliminary resident interpretations are highly accurate. The incidence of major discrepancies is extremely low and similar, even with R1s, to that of attending radiologists published in other studies. A slight, statistically significant decrease in the error rate is detectable as residents gain experience throughout the 4 years of residency.     

Comparing the Diagnostic Yields of Technologists and Radiologists in an Invitational Colorectal Cancer Screening Program Performed with CT Colonography

Purpose: To compare the diagnostic yields of a radiologist and trained technologists in the detection of advanced neoplasia within a population-based computed tomographic (CT) colonography screening program. Materials and Methods: Ethical approval was obtained from the Dutch Health Council, and written informed consent was obtained from all participants. Nine hundred eighty-two participants (507 men, 475 women) underwent low-dose CT colonography after noncathartic bowel preparation (iodine tagging) between July 13, 2009, and January 21, 2011. Each scan was evaluated by one of three experienced radiologists (≥800 examinations) by using primary two-dimensional (2D) reading followed by secondary computer-aided detection (CAD) and by two of four trained technologists (≥200 examinations, with colonoscopic verification) by using primary 2D reading followed by three-dimensional analysis and CAD. Immediate colonoscopy was recommended for participants with lesions measuring at least 10 mm, and surveillance was recommended for participants with lesions measuring 6-9 mm. Consensus between technologists was achieved in case of discordant recommendations. Detection of advanced neoplasia (classified by a pathologist) was defined as a true-positive (TP) finding. Relative TP and false-positive (FP) fractions were calculated along with 95% confidence intervals (CIs). Results: Overall, 96 of the 982 participants were referred for colonoscopy and 104 were scheduled for surveillance. Sixty of 84 participants (71%) referred for colonoscopy by the radiologist had advanced neoplasia, compared with 55 of 64 participants (86%) referred by two technologists. Both the radiologist and technologists detected all colorectal cancers (n = 5). The relative TP fraction (for technologists vs radiologist) for advanced neoplasia was 0.92 (95% CI: 0.78, 1.07), and the relative FP fraction was 0.38 (95% CI: 0.21, 0.67). Conclusion: Two technologists serving as a primary reader of CT colonographic images can achieve a comparable sensitivity to that of a radiologist for the detection of advanced neoplasia, with far fewer FP referrals for colonoscopy. ? RSNA, 2012 Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112486/-/DC1.     

Delayed growth in the development of the radiologist assistant's role

The physician extender model has been established for many years (e.g., NP, PA) and radiology departments would benefit by fully adopting this model, as well, through the hiring of radiologist assistants (RAs). Potential benefits of this role are facility cost reductions and increased customer satisfaction. An RA is an advanced level radiologic technologist who works under the supervision of a radiologist to promote high standards of patient care by assisting radiologists in the diagnostic imaging environment. Agreements by stakeholders such as the ASRT, ARRT, and the ACR have to convene and regulatory hurdles involving the CMS have to be resolved in order for this physician extender position to thrive.