Current State of Private Practice and Academic Interventional Radiology: Differences in Practice Structure,Case Mix,and Productivity

PurposeTo investigate whether private practice interventional radiology (IR) groups self-report higher overall productivity given differing case mix and more diagnostic radiology interpretation.Materials and MethodsA 60-question survey was distributed to 3,159 self-identified US IR physicians via the Society of Interventional Radiologists member search engine, with 357 responses (11.3% response rate). Of these responses, there were 258 unique practices from 34 US states.ResultsOut of 84 IR group responses, private practice IR (PPIR) physicians reported a minimal trend for higher annual work relative value units (wRVUs) per clinical full-time equivalent compared with academic IR physicians (8,000 versus 7,140, P = .202), but this did not reach statistical significance. PPIR groups reported fewer median weekly hours (50 versus 52), more frequent call (every 6 versus every 5 days), and significantly higher median tenured compensation ($573,000 versus $451,000, P = .000). Out of 179 responses, academic practices reported significantly higher case percentages of interventional oncology and complex hepatobiliary intervention (P <.001), and private practices reported significantly higher percentages of musculoskeletal intervention (P < .001) with a nonsignificant trend for stroke or neurologic intervention (P = .010). Private practices reported more wRVUs from the interpretation of diagnostic imaging, at 26% of total wRVU production compared with 7% of total wRVU production for academic practices (P < .001; n = 131).ConclusionsSelf-reported data from private and academic IR groups suggest minimally higher wRVUs per clinical full-time equivalent among PPIRs with lower weekly work hours, more frequent call, differing case mix, and significantly higher tenured compensation among PPIR groups.     

Invasive Procedural Versus Diagnostic Imaging and Clinical Services Rendered by Radiology Trainees Over Two Decades

PurposeTo characterize evolving radiology trainee exposure to invasive procedures.MethodsUsing Physician/Supplier Procedure Summary Master Files from 1997 to 2016, we identified Medicare services performed by radiology trainees in approved programs by extracting information on services billed by diagnostic and interventional radiologists reported with “GC” modifiers. Services were categorized as (1) invasive procedures, (2) noninvasive diagnostic imaging services, or (3) clinical evaluation and management (E&M) services. Relative category trainee work effort was estimated using service-level work relative value units.ResultsNationally from 1997 to 2016, invasive procedures declined from 34.2% to 14.3% of relative work effort for all Medicare-billed radiology trainee services. Radiology trainees’ noninvasive diagnostic imaging services increased from 65.1% to 85.4%. Clinical E&M services remained uniformly low (0.7%-0.3%). Diagnostic radiology (DR) and interventional radiology (IR) faculty supervised 81.0% and 19.0%, respectively, of all trainee invasive procedures in 1997, versus 68.3% and 31.7%, respectively, in 2016. Despite declining relative procedural work, trainees were exposed to a wide range of both basic and complex invasive procedures in both 1997 and 2016. Over this period, trainee noninvasive diagnostic imaging services shifted away from radiography to CT and MRI.ConclusionRadiology trainees’ relative invasive procedural work effort has declined over time as their work increasingly focuses on CT and MRI. As DR and IR-DR residency curricula begin to diverge, it is critical that both DR and IR residents receive robust training in basic image-guided procedures to ensure broad patient access to these services.     

Practice Management and Health Policy Education in Radiology: An Emerging Imperative

As society places increased responsibility on practicing physicians for addressing accelerating health care costs and delivery system inefficiencies, traditional education and training programs have left most physicians ill equipped to assume this responsibility. A variety of new initiatives are underway that dramatically change how radiology training programs address these issues. We review the emerging need for better physician education in health policy and practice management, detail the history and requirements of the ACGME and the ABR Healthcare Economics Milestone Project, and outline mechanisms by which radiology residency programs can comply with these requirements. We describe our own new comprehensive pilot curriculum, Practice Management, Health Policy, and Professionalism for Radiology Residents (P³R²), which may serve as a potential model for other training programs seeking to develop targeted curricula in these newly required areas.     

24/7/365 Neuroradiologist Coverage Improves Resident Perception of Educational Experience,Referring Physician Satisfaction,and Turnaround Time

PurposeTo quantitatively and qualitatively assess the impact of attending neuroradiology coverage on radiology resident perceptions of the on-call experience, referring physician satisfaction, and final report turnaround times.Materials and Methods24/7/365 attending neuroradiologist coverage began in October 2016 at our institution. In March 2017, an online survey of referring physicians, (emergency medicine, neurosurgery, and stroke neurology) and radiology residents was administered at a large academic medical center. Referring physicians were queried regarding their perceptions of patient care, report accuracy, timeliness, and availability of attending radiologists before and after the implementation of overnight neuroradiology coverage. Radiology residents were asked about their level of independence, workload, and education while on-call. Turnaround time (TAT) was measured over a 5-month period before and after the implementation of overnight neuroradiology coverage.ResultsA total of 28 of 64 referring physicians surveyed responded, for a response rate of 67%. Specifically, 19 of 23 second (junior resident on-call) and third year radiology residents (senior resident on-call) replied, 4 of 4 stroke neurology fellows replied, 8 of 21 neurosurgery residents, and 16 of 39 emergency medicine residents replied. Ninety-five percent of radiology residents stated they had adequate independence on call, 100% felt they have enough faculty support while on call, and 84% reported that overnight attending coverage has improved the educational value of their on-call experience. Residents who were present both before and after the implementation of TAT metrics thought their education, and independence had been positively affected. After overnight neuroradiology coverage, 85% of emergency physicians perceived improved accuracy of reports, 69% noted improved timeliness, and 77% found that attending radiologists were more accessible for consultation. The surveyed stroke neurology fellows and neurosurgery residents reported positive perception of the TAT, report quality, and availability of accessibility of attending radiologist.ConclusionsIn concordance with prior results, overnight attending coverage significantly reduced turnaround time. As expected, referring physicians report increased satisfaction with overnight attending coverage, particularly with respect to patient care and report accuracy. In contrast to some prior studies, radiology residents reported both improved educational value of the on-call shifts and preserved independence. This may be due to the tasking the overnight neuroradiology attending with dual goals of optimized TAT, and trainee growth. Unique implementation including subspecialty trained attendings may facilitate radiology resident independence and educational experience with improved finalized report turnaround.     

Influences of Radiology Trainees on Screening Mammography Interpretation

PurposeParticipation of radiology trainees in screening mammographic interpretation is a critical component of radiology residency and fellowship training. The aim of this study was to investigate and quantify the effects of trainee involvement on screening mammographic interpretation and diagnostic outcomes.MethodsScreening mammograms interpreted at an academic medical center by six dedicated breast imagers over a three-year period were identified, with cases interpreted by an attending radiologist alone or in conjunction with a trainee. Trainees included radiology residents, breast imaging fellows, and fellows from other radiology subspecialties during breast imaging rotations. Trainee participation, patient variables, results of diagnostic evaluations, and pathology were recorded.ResultsA total of 47,914 mammograms from 34,867 patients were included, with an overall recall rate for attending radiologists reading alone of 14.7% compared with 18.0% when involving a trainee (P < .0001). Overall cancer detection rate for attending radiologists reading alone was 5.7 per 1,000 compared with 5.2 per 1,000 when reading with a trainee (P = .517). When reading with a trainee, dense breasts represented a greater portion of recalls (P = .0001), and more frequently, greater than one abnormality was described in the breast (P = .013). Detection of ductal carcinoma in situ versus invasive carcinoma or invasive cancer type was not significantly different. The mean size of cancers in patients recalled by attending radiologists alone was smaller, and nodal involvement was less frequent, though not statistically significantly.ConclusionsThese results demonstrate a significant overall increase in recall rate when interpreting screening mammograms with radiology trainees, with no change in cancer detection rate. Radiology faculty members should be aware of this potentiality and mitigate tendencies toward greater false positives.     

Knowledge of the Costs of Diagnostic Imaging: A Survey of Physician Trainees at a Large Academic Medical Center

PurposeTo study the awareness of postgraduate physician trainees across a variety of specialties regarding the costs of common imaging examinations.MethodsDuring early 2016, we conducted an online survey of all 1,238 physicians enrolled in internships, residencies, and fellowships at a large academic medical center. Respondents were asked to estimate Medicare national average total allowable fees for five commonly performed examinations: two-view chest radiograph, contrast-enhanced CT abdomen and pelvis, unenhanced MRI lumbar spine, complete abdominal ultrasound, and unenhanced CT brain. Responses within ±25% of published amounts were deemed correct. Respondents were also asked about specialty, postgraduate year of training, previous radiology education, and estimated number of imaging examinations ordered per week.ResultsA total of 381 of 1,238 trainees returned complete surveys (30.8%). Across all five examinations, only 5.7% (109/1,905) of responses were within the correct ±25% range. A total of 76.4% (291/381) of all respondents incorrectly estimated every examination’s cost. Estimation accuracy was not associated with number of imaging examinations ordered per week or year of training. There was no significant difference in cost estimation accuracy between those who participated in medical school radiology electives and those who did not (P = .14). Only 17.5% of trainees considered their imaging cost knowledge adequate. Overall, 75.3% desire integration of cost data into clinical decision support and/or computerized physician order entry systems.ConclusionsPostgraduate physician trainees across all disciplines demonstrate limited awareness of the costs of commonly ordered imaging examinations. Targeted medical school education and integration of imaging cost information into clinical decision support / computerized physician order entry systems seems indicated.     

Trainee and Faculty Perceptions of Remote PACS Workstations and Next Steps in a Large US Academic Medical Institution

ObjectiveRemote workstations were rapidly deployed in our academic radiology practice in late March 2020 in response to the COVID-19 pandemic. Although well-received by faculty, there were concerns for the impact on resident education.Materials and MethodsSurveys of the radiology trainees and faculty were conducted online seven- and thirteen-months following workstation deployment as a part of a quality improvement project to assess the impact on radiology education and faculty wellness, as well as assess the desired trajectory of remote work in an academic setting.ResultsThe majority of trainees (52%) reported the implementation had negatively impacted resident education, greatest among lower level residents (p < .001). This perception did not change despite interventions and perceived improvement in teleconferencing.Greater than 75% of radiologists with remote workstations reported improved wellness and lower stress levels compared to the onsite radiologists. The majority of all respondents voted to continue or expand remote work following the COVID-19 pandemic in both surveys.ConclusionsOnsite teaching is important for the education of residents, particularly for lower-level residents. However, the adoption of a hybrid model in an academic setting may prove beneficial for faculty wellness and recruitment of the next generation.     

Interventional Radiology Peer,a Newly Developed Peer-Review Scoring System Designed for Interventional Radiology Practice

PurposeExisting diagnostic radiology peer-review systems do not address the specificities of interventional radiology (IR) practice. The purpose of this study was to assess the feasibility of a specifically developed interventional peer review method, IR Peer.Materials and MethodsRetrospective review of a prospectively encoded pilot database aimed at demonstrating the feasibility of IR Peer in a multiphysician practice was performed. This scoring system used morning peer review of selected IR cases from the previous day in the form of a five-item questionnaire and an ordinal answer scale that grades reviewers’ agreement with imaging findings, procedural/technical management, early outcomes, and follow-up plan. Patient lists from IR Peer and morbidity and mortality (M&M) conferences were compared to evaluate the amount of overlap and capability of IR Peer to help detect adverse events (AEs).ResultsA total of 417 consecutive reviews of IR attending physician cases by peers were performed in 163 consecutive patients over 18 months, and 94% of cases were reviewed by two or three IR attending physicians. Each question was answered 99%–100% of the time. Answers showed disagreement in 10% of cases (2% by a single reviewer, 8% by several), most related to procedural technique. Overall AE incidence was 1.8%. IR Peer contributed 10.7% of cases to the M&M list.ConclusionsIR Peer is feasible, relevant, and easy to implement in a multiphysician IR practice. When used along with other quality-assurance processes, it might help in the detection of AEs for M&M; the latter will require further confirmatory research.     

Characteristics of musculoskeletal radiology job postings to guide radiology trainees

ObjectiveTo review current musculoskeletal (MSK) job market postings to define the listed requirements for practice in order to provide insight to guide residents pursuing fellowship training in MSK radiology to best meet the needs of potential future employers.MethodsUtilizing the ACR (American College of Radiology) Career Center, a review of the ACR job postings began 6/1/2018 focusing on jobs labeled as musculoskeletal (MSK) subspecialty. E-mail notifications from the career center were reviewed, and jobs were tracked prospectively for 1 year. Data was collected regarding the number of positions, the location, the practice type, and required skills both within musculoskeletal radiology and within the remainder of the radiology subspecialties.Results456 postings met the inclusion criteria. Approximately 19% were for a dedicated MSK radiologist, 25% sought a combination of MSK and a general skill set, and 56% were specifically for a general radiologist position. Approximately 29% of jobs require some combination of mammography and/or light interventional radiology (IR).DiscussionOur results indicate that majority of job postings for musculoskeletal radiology require a practice that is not specifically limited to MSK, mirroring trends in other radiology subspecialties. Radiology trainees and program directors should be aware of the needs being demanded by the job market to help guide trainees to individualize their training to best meet the needs of their future employment.     

The State of Medical Student Teaching of Interventional Radiology: Implications for the Future

IntroductionThe formation of integrated interventional radiology (IR) residency programs has changed the training paradigm. This change mandates the need to provide adequate exposure to allow students to explore IR as a career option and to allow programs to sufficiently evaluate students. This study aims to highlight the availability of medical student education in IR and proposes a basic framework for clinical rotations.Materials and MethodsThe Liaison Committee on Medical Education (LCME) website was utilized to generate a list of accredited medical schools in the United States. School websites and course listings were searched for availability of IR and diagnostic radiology rotations. The curricula of several well-established IR rotations were examined to identify and categorize course content.ResultsIn all, 140 LCME-accredited medical schools had course information available. Of those schools, 70.5% offered an IR rotation; 84.6% were only available to senior medical students and only 2% were offered for preclinical students; and 8.1% of courses were listed as subinternships. Well-established IR clerkships included a variety of clinical settings, including preprocedure evaluation, experience performing procedures, postprocedure management, and discharge planning.ConclusionMedical student exposure to IR is crucial to the success of integrated IR residency programs. Current research shows few institutions with formal IR subinternship rotations. Although 70.5% of institutions have some form of nonstandardized IR course, 84.6% are available only to fourth-year students, and 2% are offered to preclinical students. This suggests there is a significant opportunity for additional formal exposure to IR through increasing availability of IR rotations and exposure during the clinical and preclinical years.     

Unique Medicare Beneficiaries Served: A Radiologist-Focused Specialty-Level Analysis

PurposeThe aims of this study were to compare the number of unique Medicare fee-for-service beneficiaries served by radiologists and other physicians and to identify characteristics of radiologists serving the most number of unique patients.MethodsMedicare Physician and Other Supplier Public Use Files were used to identify all physicians who provided services to Medicare fee-for-service beneficiaries for the entirety of 2013. The average number of unique beneficiaries served was computed per specialty. The number of unique beneficiaries served was further stratified among radiologists in terms of physician and practice characteristics.ResultsAmong 56 unique physician specialties, diagnostic radiologists on average served the most unique beneficiaries (3,150 ± 2,344). Among radiologists, the number of unique beneficiaries varied in association with numerous characteristics and was larger for male (3,214) versus female (2,521) radiologists, rural (3,551) versus urban (3,092) radiologists, nonacademic (3,427) versus academic (1,932) radiologists, generalist (3,866) versus subspecialist (1,981) radiologists, and radiologists in the South (3,716) versus other geographic regions (range, 2,432-3,217). The number of unique beneficiaries served increased significantly with smaller group practice size (2,218 for ≥100 group members versus 3,669 for ≤9 members). Among subspecialists, the number of unique beneficiaries was largest for breast imagers (2,594).ConclusionsThe large number of unique beneficiaries served by radiologists highlights their important role in orchestrating patient care and their immense opportunities to expand the face of the specialty. An understanding of which radiologists serve the largest numbers of unique patients may help radiology practices target patient engagement and other Imaging 3.0™ efforts.     

Demographic Trends in Female Interventional Radiology Trainees With the Advent of the Integrated Interventional Radiology Residency

ObjectiveExamine changes in gender representation in the interventional radiology (IR) training pool since the advent of the integrated IR residency in 2015 to 2020.MethodsElectronic Residency Application Service and ACGME Data Resource Book records from 2015 to 2020 were reviewed for integrated IR residency and vascular and interventional radiology (VIR) fellowship applicant data and active IR resident and VIR fellow data, respectively. The Society of Interventional Radiology (SIR) 2018 registry data were reviewed for SIR membership data. Two-tailed Fisher’s exact tests and χ² analyses were used to compare trainees between application cycles.ResultsIn the 2017 application cycle, 23% (247 of 1,062) of integrated IR residency applicants were female, with similar interest in the 2018, 2019, and 2020 cycles (χ²[3, n = 2,863] = 5.1, P = .17). In comparison, female VIR fellowship applicants were 12% from 2017 to 2020. Female integrated IR residents represented 13% to 18% of all integrated IR residents in the 2016 to 2020 academic years compared with the period before the integrated IR residency when female IR trainees represented 8% (23 of 275) of all IR trainees in 2015 to 2016 (P = .0002). Although in 2018, the total active SIR female membership was 9% (319 of 3,622), the female resident membership was 17% (131 of 793), and the female medical student membership was 25% (389 of 1,573).DiscussionWith the advent of the integrated IR residency, there is an increasing female constituency, at the medical student, IR applicant, and IR resident levels, with more than a doubling of female IR trainees, portending a continued reduction in the IR gender disparity in the future.     

Face-to-Face: Resident-led Radiology Medicine Rounds Facilitate Evidence-based Processes for Clinical Decision Support

BackgroundThe transition toward value-based payment models increases focus on the radiologist's direct impact on hospital-provided patient care. Radiology trainees understand inpatient hospital workflows and decision-making paradigms and are well positioned to interface directly with hospital physicians regarding clinical decision making related to diagnostic imaging and/or image guided interventions. A radiology resident-led project with internal medicine residents focused on Clinical Decision Support was designed, implemented, and reviewed, with the objectives of educating clinical teams and positively impacting patient care.Materials and MethodsDuring the 2017-2018 academic year, senior radiology residents (PGY-5) led weekly rounds with medicine residents rotating through inpatient floor units. During these rounds, they discussed indications for and types of hospital inpatient imaging studies, exchanged clinical information, directed further imaging workup, and taught the essentials of image interpretation. Participating medical residents’ degree of radiology-awareness and opinions were systematically surveyed at the conclusion of the academic year. Thirty-four out of a total of 161 (21%) Internal Medicine residents responded to the survey. Thirty one percent of these residents could identify an instance where radiology-led rounds altered patient management and 94% acknowledged an increase in medical knowledge. Sixty-one percent believed evidence-based choice for imaging orders was enhanced by attending radiology-led rounds and 64% developed a better understanding of resources available to guide image ordering. Forty-nine percent of residents made suggestions to their Internal Medicine attending physician or more senior trainee or otherwise applied something learned during radiology-led rounds and 42% cancelled or ordered a study based on what they learned or discussed in radiology rounds. Thirty-nine percent of medicine residents stated that these rounds changed their perception of the role of the radiologist and 75% expressed the desire to see increased participation by radiologists in their daily workflow. Radiology resident-led educational medicine rounds promote cross-specialty collaboration, further educate trainees, and directly affect patient management. It is therefore valuable for radiology trainees to directly engage in the teaching of other medical providers, to enhance their own consultative skill set, promote face-to-face interactions with other physicians, and to directly impact patient care.     

Canadian and American Emergency Radiology Fellowship Websites: An Evaluation of Content

PurposeThe internet is commonly employed by Radiology trainees to investigate and learn about potential fellowship programs. As a new and emerging subspecialty, Emergency Radiology requires strong internet presence and training program website content. This is vital to ensure good exposure of the fellowship programs to inform medical students, radiology trainees, and program directors, highlight unique aspects of a fellowship and raise awareness of the discipline at large.MethodsTo assess the standard and depth of information available online, Canadian and American Radiology fellowship websites were evaluated for content. Thirty-six criteria related to application process and recruitment, departmental structure, incentives, education, and research and clinical training were evaluated for presence or absence.ResultsSixteen Emergency Radiology fellowship program websites were assessed from the United States and Canada for 36 criteria across 5 individual areas; application process and recruitment, departmental structure, incentives, education and research, and clinical training. Overall there was an absence of information found across all 5 areas. In particular areas for improvement were identified in education and research, and incentives both with median values of 12.5% of criteria present.ConclusionMost Emergency Radiology fellowship program websites demonstrate several information deficiencies. This relative lack of comprehensive information represents an actionable opportunity for individual programs and the field to better educate trainees, program directors and the public about the unique training of Emergency Radiologists.     

Mentorship of junior radiologists in nonacademic radiology

Junior radiologists in nonacademic settings currently face multiple challenges, including clinical productivity, climbing the ladder to partnership, maintenance of certification, and administrative requirements. Mentorship of junior radiologists in nonacademic settings can ease their transition into nonacademic practice, foster comradery, increase radiologist retention, and support career growth. Strategies to implement and sustain effective mentorship in nonacademic radiology practice settings are described.SummaryStrategies to implement and sustain mentorship in nonacademic radiology practice settings are described.     

Radiology trainees in the UK and Ireland: academic background,publication rates and research plans

To assess the level of achievement of current trainees, we investigated the academic qualifications, publication rates and future research plans of 240 radiology trainees in the UK and Ireland. All radiology trainees in the UK and Ireland were surveyed by a questionnaire enquiring about academic record and career ambitions. Our study shows that the level of academic achievement of radiology trainees is high, and provides interesting information concerning the current group of radiology trainees in these regions. It will be of interest both to radiology trainers and to doctors hoping to pursue a career in radiology. It also demonstrates that a potential recruitment crisis in academic radiology exists.To assess the level of achievement of current trainees, we investigated the academic qualifications, publication rates and future research plans of 240 radiology trainees in the UK and Ireland. Trainees interested in academia typically have experience of research, medical education or academic success. These factors were analysed in relation to radiology and the Walport report on future training of clinical academics.     

Primary Care Provider Awareness of IR: A Single-Center Analysis

PurposeTo evaluate primary care provider awareness of interventional radiology (IR) services at a tertiary care academic medical center to identify areas of IR practice that require additional education and awareness initiatives.Material and MethodsAn internet-based survey was distributed via email to primary care providers, including internal medicine (IM), family medicine (FM), obstetrics and gynecology (OBGYN), and hospital medicine (HM) physicians in the region. The survey consisted of 17 questions regarding provider demographics, experiences with IR in their practice, awareness of IR training, and awareness of IR procedures and services.ResultsA total of 234 of 533 invited physicians completed the survey (40% IM, 22% FM, 22% HM, and 16% OBGYN). Providers rated their knowledge of IR as poor (49, 20.3%), adequate (137, 56.9%), good (49, 20.3%), and excellent (6, 2.5%). Although 235 (97.5%) had consulted IR previously, only 141 (58.5%) had referred a patient directly to IR for an elective procedure. IR was offered as an alternative to surgical procedures never (42, 17.6%), a quarter of the time (101, 42.3%), half of the time (61, 25.5%), three-quarters of the time (27, 11.3%), and every time (8, 3.35%). Most respondents (161, 67.4%) learned the most about IR procedures during residency. Most (180, 75.3%) indicated that they would like to learn more about IR.ConclusionsThese findings indicate that more can be done to educate providers about the potential role of IR in patient care. Provider awareness is limited regarding procedures that are increasingly popular in the IR community. This study helps to identify specific areas of IR in which awareness of can be increased.     

Beyond business as usual: Radiology residency educational response to the COVID-2019 pandemic

The COVID-19 pandemic has disrupted standard hospital operations and diagnostic radiology resident education at academic medical centers across the country. Deferment of elective surgeries and procedures coupled with a shift of resources toward increased inpatient clinical needs for the care of COVID-19 patients has resulted in substantially decreased imaging examinations at many institutions. Additionally, both infection control and risk mitigation measures have resulted in minimal on-site staffing of both trainees and staff radiologists at many institutions. As a result, residents have been placed in nonstandard learning environments, including working from home, engaging in a virtual curriculum, and participating in training sessions in preparation for potential reassignment to other patient care settings. Typically, for residents to gain the necessary knowledge, skills, and experience to practice independently upon graduation, radiology training programs must provide an optimal balance between resident education and clinical obligations. We describe our experience adapting to the challenges in educational interruptions and clinical work reassignments of 41 interventional and diagnostic radiology residents at a large academic center. We highlight opportunities for collaboration and teamwork in creatively adjusting and planning for the short and long-term impact of the pandemic on resident education. This experience shows how the residency educational paradigm was shifted during a pandemic and can serve as a template to address future disruptions.