Volume and impact of second-opinion consultations by radiologists at a tertiary care cancer center: data

RATIONALE AND OBJECTIVES: Patients with cancer who are referred to a dedicated oncology center usually have undergone previous imaging studies that the oncologists typically desire to have reviewed by radiologists. Such reinterpretations can be complex and time-consuming, yet many institutions do not systematically account for them as part of the total workload. The purpose of this study was to ascertain the numbers and types of second-opinion consultations performed by radiologists at a tertiary care cancer center, and to assess their effect on work volume. MATERIALS AND METHODS: A survey of referring clinicians was undertaken to evaluate the numbers and types of second-opinion consultations requested of radiologists at the Dana Farber Cancer Institute during a 12-month period. Consultations included review of studies from outside institutions, and cases from Dana Farber in which further comparison was needed. The number of consultations requiring additional tumor size measurements was tallied. The mean daily number of new studies interpreted by radiologists was used as a benchmark of work volume. RESULTS: Radiologists performed 4,664 consultations during 254 workdays, interpreting a mean of 18 additional studies (range, 4-42) per day as a result of referrals for second opinion. These included 3,638 (78%) cross-sectional studies (ie, computed tomographic [CT], magnetic resonance [MR], and ultrasound [US] studies), 674 (14%) mammograms, 220 (5%) plain radiographs, 132 (3%) nuclear medicine scans, and one galactogram. Of the 4,664 consultations, 1,306 (28%) were performed to obtain tumor measurements, many of these involving five to 10 bidimensional calculations per study. A mean of 101 new examinations per day was performed by radiologists during the same 12-month period, including cross-sectional studies (CT and US scans) (56%), plain radiographs (34%), and mammograms (11%). MR imaging was not performed. CONCLUSION: Second-opinion consultations increased the average daily work volume by 18%. This has implications for workforce, as well as for compensation in terms of relative value units and finances for this previously unquantified service.     

Routine editing of trainee-generated radiology reports: effect on style quality

RATIONALE AND OBJECTIVES: The authors performed this study to determine the effect of routine editing on the style quality of trainee-generated radiology reports. MATERIALS AND METHODS: Trainee-generated reports of 50 body computed tomographic scans obtained at a tertiary care cancer center were edited in a routine fashion by one of two attending radiologists. Three physicians and four radiologists each independently evaluated the randomized unedited and edited reports (n = 100) and rated each report for clarity, brevity, readability, and quality of the impression by using a five-point scale. RESULTS: Editing significantly improved mean ratings for clarity (4.6 after editing vs 4.2 before editing, P < .007), brevity (4.6 vs 4.2, P < .007), readability (4.4 vs 4.1, P < .007), and quality of the impression (4.5 vs 4.3, P < .007). CONCLUSION: Routine editing of trainee-generated reports significantly improves the perceived report quality. This finding suggests that greater emphasis should be placed on stylistic aspects of reporting during training to improve report style quality at dictation.     

Career advancement of men and women in academic radiology: is the playing field level?

RATIONALE AND OBJECTIVES: The authors' purposes were to determine if there are gender differences in the speed of promotion and/or academic productivity in academic radiology and if this situation had changed since a previous study was performed in 1987. MATERIALS AND METHODS: Surveys were distributed to faculty members of academic radiology departments in May 1997. A total of 707 surveys were analyzed according to gender for time at rank for assistant and associate professor levels, in relation to publication rate, grant funding rate, and distribution of professional time. RESULTS: There was no difference between genders in the time at assistant professor rank. Among all current professors, women had been associate professors longer than men, but there was no difference between genders for those who had been in academic radiology for less than 15 years. There was no gender difference at any rank in the rate of publishing original articles. There was no difference in funding rates, although men had more total grant support. Male associate professors reported spending more time in administration and slightly more time in total hours at work than did their female colleagues, and male professors spent slightly more time teaching residents. Otherwise, there is no difference in how men and women at any rank spend their professional time. There are, however, lower percentages of women in tenured positions and in the uppermost levels of departmental administration. CONCLUSION: The time at rank for men and women and their rate of publication appear to have equalized. Women still are underrepresented at the uppermost levels of departmental administration, however, and are less likely than men to hold tenured positions.     

Radiology Resident Experience in a Community-Based Residency Program

RATIONALE AND OBJECTIVES: The authors performed this study to examine the educational experience of radiology residents by evaluating exposure to total number and variety of examinations. They examined this exposure in relation to current concepts of resident education regarding exposure to difference radiologic examinations, preparation for private practice, and 4th-year resident experience. MATERIALS AND METHODS: The number of examinations performed by radiology residents and the number classified as general versus cross-sectional radiology were analyzed by calculating the average number of studies performed per academic year during the past 6 years. RESULTS: In general, there was in increase in the total number of examinations performed per resident during the past 6 years. There was no statistically significant difference in the experience with general versus cross-sectional radiologic examinations. The data support the contention that 4th-year residents perform fewer examinations. CONCLUSION: Experience with all radiologic examinations is increasing as the overall utilization of radiology services increases. Fourth-year residents read fewer images; further studies are necessary to determine whether this finding reflects a planned decrease in workload or an increase in the complexity of the workload. It may be necessary to establish a minimum number and mixture of examinations to prepare residents for private practice.     

Results of and comments on the 2000 survey of the American Association of Academic Chief Residents in Radiology

RATIONALE AND OBJECTIVES: The American Association of Academic Chief Residents in Radiology (A3CR2) annually surveys radiology residency programs on issues related to training. The objective is to highlight national similarities, differences, and trends to help programs establish standards and improve residency training. MATERIALS AND METHODS: Questionnaires were mailed to 180 accredited diagnostic radiology residency training programs in the United States. The survey covered the usual general topics and more specific topics considered every 4 years; for 2000 the latter were on-call issues and the chief residency year. RESULTS: Completed surveys were returned from 63 programs (35%). Important findings included increased caseload and call commitments, especially for smaller programs. Resident salaries appear to have increased more than the consumer price index. Nonemergent after-hour coverage and teleradiology are now a large part of the resident work practice. Women continue to be underrepresented, with a trend downward. Chief residents are more involved in organizing preparation for board examinations and have greater office facilities and more administrative duties. CONCLUSION: This survey provided useful insights. All levels of residency face increased workloads. On-call hours have not changed, but the work has intensified and the use of teleradiology has increased. Many programs have adopted a "night-float" system, and nonemergent after-hours coverage should be considered in any program evaluation. Continued vigilance and sustained efforts are required to ensure that radiology is considered as a specialty by both men and women. With increased demands on attending physicians' time, chief residents may need to take on more administrative responsibilities.     

Distributed Web-supported radiology clerkship for the required clinical clerkship year of medical school: development,implementation, and evaluation

RATIONALE AND OBJECTIVES: The authors performed this study to develop, implement, and evaluate a new radiology clerkship for the required clinical clerkship year of medical school. MATERIALS AND METHODS: A mandatory radiology clerkship experience was added to the required clinical clerkships as a series of 10 independent half-day teaching sessions. These sessions were distributed as one session per existing clerkship throughout the year. To provide continuity and organization, Web-based curriculum materials were designed and implemented as a component of the radiology clerkship. The new clerkship was evaluated with observations, pretest and posttest measures with a control group, structured and unstructured student and faculty surveys, and individual and small group interviews. RESULTS: The clerkship was successfully developed and implemented. Ninety-five students have completed the clerkship. Their mean posttest score (84.8) was significantly higher than their mean pretest score (58.8, P < .001) and the mean control group score (59.7, P < .001). Students rarely used the Web site. Disadvantages of the distributed clerkship were identified. CONCLUSION: A radiology clerkship distributed among existing clerkships is feasible but has many disadvantages. Students greatly prefer live instruction, and Web-based educational materials are more valuable to faculty and administrators than to students.     

Agreement and reproducibility of subjective methods of measuring faculty time distribution

RATIONALE AND OBJECTIVES: The authors performed this study to compare self-reported estimates of the time radiology members spend performing various activities between reporting methods and academic years. MATERIALS AND METHODS: For 3 consecutive academic years, the percentage of time each faculty member reported spending on clinical, teaching, research, and service and/or administrative activities was noted on each of three separate reports: a quarterly report to department administration, an annual report to university administration, and the annual review with his or her department supervisor. For each activity, the means were compared between methods and between years. RESULTS: In general, the year-to-year changes in mean percentage for each activity and method were not statistically significant (34 of 36 comparisons). Nineteen of 36 comparisons, however, showed significant differences between reporting methods for a particular activity. For example, the mean percentages obtained with the three methods from 1999 to 2000 varied from 49% to 66% (clinical), 14% to 34% (teaching), 8% to 15% (research), and 3% to 11% (service and/or administrative). CONCLUSION: Current methods used to quantify faculty time distribution yield significantly different results despite internal consistency from year to year for each method. New and clearer methods for determining faculty time distribution are needed.     

Changing roles: the radiologist in management

RATIONALE AND OBJECTIVES: Radiologists have rarely had direct administrative control of the hospital departments in which they practice. Several years ago, the administration of the medical school at the University of Texas Health Science Center at San Antonio and its county-owned principal teaching hospital agreed to integrate the physician and administrative management of the radiology department in an attempt to improve operations and reduce expenses. This integration is a pilot plan that will eventually be extended to most departments. MATERIALS AND METHODS: The authors have collected data that measure department function for the seven quarters of physician management and compared these data with those of the previous four quarters prior to physician management. RESULTS: There are substantial increases in department activity, together with reductions in expenses and waiting time for procedures. These changes have occurred while overall hospital activity has decreased. Bench-marking studies show favorable comparison with comparable radiology departments. CONCLUSION: Radiologists can have an important effect on department operations when given the responsibility and authority for managing these affairs.     

Factors affecting patient enrollment in radiology clinical trials: a case study of the American College of Radiology Imaging Network

RATIONALE AND OBJECTIVES: This study was designed to identify factors that affect the enrollment of patients into American College of Radiology Imaging Network clinical trials. MATERIALS AND METHODS: A quality improvement study was performed. Brainstorming produced an exhaustive list of factors that could affect the interest of sites in participating in American College of Radiology Imaging Network trials, as well as factors that could influence patient recruitment. Surveys, structured interviews, and benchmarking were used to validate and rank the importance of these factors. RESULTS: Site participation was influenced mainly by the support of the department chair and the interest of the investigator. Patient recruitment was affected primarily by the ease of identifying candidates and the perceived experience level and skill of the support staff. CONCLUSION: Because radiologists do not control patient referrals for imaging tests, a premium must be placed on developing systems to maximize the identification and enrollment of candidates for clinical trials. Other factors considered critical to success in patient enrollment include the supportiveness of the departmental leadership, the experience and skill level of study personnel, and the availability of site-specific infrastructure to support the study.     

Measuring the academic radiologist's clinical productivity: survey results for subspecialty sections

RATIONALE AND OBJECTIVES: The purpose of this project was to understand better the academic radiologist's clinical workload in order to determine faculty staffing requirements more accurately. MATERIALS AND METHODS: Surveys performed by the Society of Chairmen of Academic Radiology Departments (SCARD) collected data for radiologists in 20 departments in 1996 and 1998; the data included work relative value units (RVUs) per full-time equivalent (FTE). Radiologists in each subspecialty were compared with their counterparts in other departments. The data were collected for each radiologist. Summary statistics showing averages, medians, and quartiles were used to describe workload (in RVUs per FTE) for each department and each subspecialty. RESULTS: Overall, the average clinical workload was 4,458 RVU/FTE, with 0.62 RVU per procedure. In those sections for which the faculty performed similar types of procedures across departments, the results were useful. The workload data, however, proved inadequate to compare across subspecialty sections. Between 1996 and 1998, the workload increased from 3,790 to 4,458 RVU/FTE. CONCLUSION: The SCARD survey provided very useful clinical workload data, measured in work RVUs per FTE for specific subspecialty sections. At practically all surveyed institutions, increasing clinical workload is competing with academic activities.     

Evaluation of clinical experience in a radiology residency program with quantitative profiling: rationale,methods, and application

RATIONALE AND OBJECTIVES: The author developed a technique for residency program evaluation, called "quantitative profiling," that is based on computer retrieval of radiologic reports. The hypothesis was that it would provide insights into the contributions of residents to clinical service, measures of resident experience and productivity for program evaluation, and benchmarks for comparison. MATERIALS AND METHODS: The radiology residency program of a major teaching hospital was studied retrospectively from 1989 to 1997. The number of radiologic reports signed by individual residents and faculty members was retrieved. The clinical experience of the 1993-1997 cohort of residents was described according to subspecialty area and modality. RESULTS: Residents signed 46.5% of all reports, with a mean total of 14,445 reports +/- 1,292 per resident during the entire residency. The distribution of examinations was as follows: thoracic, 42.1%; musculoskeletal, 26.1%; abdominal, 13.4%; sonography, 8.7%; neuroradiology, 4.3%; nuclear, 2.4%; breast, 1.6%; and vascular, 1.4%. The most frequently reported results were for one-view chest radiography. CONCLUSION: Quantitative profiling can help track the range and progress of resident experience, help determine the deployment of residents, and provide empirical data upon which decisions to modify residency programs may be based.     

Is terminology used effectively to convey diagnostic certainty in radiology reports?

RATIONALE AND OBJECTIVES: This study was performed to assess the extent of agreement among radiologists and nonradiologists in perception of diagnostic certainty conveyed by words and phrases commonly used in radiology reports. MATERIALS AND METHODS: The study was performed in a large academic radiology department. To determine the commonly used terminology for conveying diagnostic certainty in radiology reports, 12 randomly selected radiologists from six different subspecialties were interviewed. The authors identified the 15 most commonly used words and phrases and included these in random order in a questionnaire sent to all staff radiologists (n = 45) and to 158 referring physicians. Physicians were asked to rank the 15 phrases in order of the diagnostic certainty conveyed by each, from 1 (most certain) to 15 (least certain), using each number only once. The kappa statistic was used to assess agreement in rank order among physicians. RESULTS: The questionnaire response rate was 76% (n = 34) for radiologists and 49% (n = 78) for nonradiologists. There was excellent agreement among radiologists (kappa = 0.95) and nonradiologists (kappa = 0.93) in the rank order for the phrase diagnostic of. Although there was good agreement (kappa = 0.45) among radiologists for the word unlikely, agreement among nonradiologists was poor (kappa = 0.27). There was very poor agreement among all physicians for the rank order of the other 13 phrases. CONCLUSION: Among radiologists and nonradiologists, concordance was poor regarding the diagnostic certainty associated with phrases commonly used in radiology reports. Because poor agreement could lead to suboptimal quality of care, the standardization of terminology would benefit all parties.     

Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit?

AIM: The purpose of our study was to investigate whether reporting of plain chest radiographs affects immediate management of patients admitted to a medical assessment unit. MATERIALS AND METHODS: During a 3 month period we prospectively evaluated 200 patients who had a plain chest radiograph on admission. After the post on-call ward round, an independent medical specialist registrar reviewed the notes, retrieving relevant clinical details. The plain chest films were reported independently by a trainee radiologist and consultant, reaching a consensus report. RESULTS: There was 93% agreement between trainee and consultant radiologists (95% CI=89-96%). Seventy percent had documented reports by the on-call medical team. There was disagreement between radiology and medical reports in 49% of reported films (95% CI=40-57%). The radiologist's report led to a direct change in the immediate management of 22 patients (11%). CONCLUSION: Only 70% of films had documented reports in the clinical notes despite this being a legal requirement. Radiology reporting does cause a direct change in patient management. Chest radiographs of patients admitted to a medical admissions unit should be reported by a radiologist with the minimum of delay.     

Radiology quality and performance metrics on the Web: a management information and communications tool

RATIONALE AND OBJECTIVES: The purpose of this study was to demonstrate the feasibility of using the World Wide Web to communicate critical radiology quality and performance metrics to departmental and hospital management staff. MATERIALS AND METHODS: Data on report turnaround, appointment access, patient and physician satisfaction, and financial performance were harvested from a variety of sources. These were then standardized and condensed so they could be displayed electronically in a concise, information-dense fashion. RESULTS: The final product was a series of graphic materials on a single Web site. The most informative was a summary "spiderweb chart" that indicated the percentage of specified performance goals achieved for 12 operational parameters. These graphic materials were distributed to management staff monthly by means of e-mail. CONCLUSION: The use of simple Web-based technology facilitates the collection of key departmental performance data and the dissemination of these data to a wide audience.     

The academic radiologist's clinical productivity: an update

RATIONALE AND OBJECTIVES: The purpose of this project was to further understand the academic radiologist's clinical workload with comparison to the prior studies in the past decade. This updated data is very important in determining faculty staffing requirements. MATERIALS AND METHODS: A survey performed by the Society of Chairmen of Academic Radiology Departments (SCARD) collected data in 2003 for radiologists in 23 departments. This data included Current Procedure Terminology (CPT) codes by radiologist. The CPT codes were converted into relative value units (RVUs) per full-time equivalent (FTE) faculty. By grouping the CPT codes into similar examination categories, adjustment factors were created for the RVU values for each CPT in order to compensate for workload variations. These adjustment factors are identical to the adjustments made in 2001 except for a new factor for nuclear medicine. RESULTS: Overall, the average clinical workload in 2003 was 5,872 RVU/FTE, a 32% increase compared to 4,458 RVU/FTE in 1998 and 55% increase compared to 3,790 RVU/FTE in 1996. The average number of examinations per FTE had a smaller (17%) increase since 1998. The adjustment factors remain very similar to those presented in 2001. The only change was a new adjustment factor of 1.3 for nuclear medicine. CONCLUSIONS: Clinical workload as measured by RVU/FTE and adjusted RVU/FTE are very useful for determining optimal staffing in subspecialty sections and in the department as a whole. The workload continues to increase, but more in examination complexity than in numbers of procedures overall.     

Assessing the potential versus the actual earnings of academic radiologists: effects of unequal duty service assignments

RATIONALE AND OBJECTIVES: The purpose of this study was to determine if annual total work relative value units (RVUs) can be used to accurately compare physician productivity and effort among a small group of similarly trained radiologists. MATERIALS AND METHODS: The annual procedures for nine abdominal imaging radiologists were obtained. The work RVU was assigned to each procedure and summed for each radiologist. The daily work RVU mean earnings by duty service (eg, ultrasound [US], gastrointestinal radiology) were calculated for each radiologist and for the entire group. RESULTS: Annual total work RVUs earned by the six full-time radiologists ranged widely (5,000 to >9,000). Mean work RVUs earned per day by all the radiologists for each duty service also ranged widely (74 for US vs 23 for gastrointestinal radiology). The range of mean work RVUs earned per day by the radiologists within each duty service was narrower, however, and had almost no statistical significance. The wider range of annual total work RVUs earned by the radiologists resulted primarily from unequal distribution of duty service assignments. For example, radiologists with more days spent performing gastrointestinal radiology had lower annual total RVUs compared to radiologists with more days spent performing computed tomography or US. CONCLUSION: The RVU is an accurate measure of income production but may be an inaccurate measure of effort and individual productivity because of differences in duty assignments. In a relatively homogeneous group of radiologists/practitioners, such a comparison should be done within a duty service, or a correcting methodology should be used, because assignment to duty services rarely is equalized across physicians.