The radiologist assistant: the solution to radiology workforce needs

Since 2003 the radiologist assistant (RA) was introduced in response to the severe shortage of radiologists and the increased demand for medical imaging services. Other non-physician clinicians, such as PAs, currently play an important role in the medical imaging environment. The article discusses the reasons physician assistants have found favor with interventional radiologists, and advocates an increased role for physician extenders in Radiology. It refutes the skeptics who question whether the new profession will alleviate the manpower crisis in Radiology. The authors suggest that RAs are the ideal complement to radiologists; and based on their radiologic technology background, have a vested interest in the field.     

ACR intersociety conference 2003: radiologist assistants and other radiologist extenders

Improvements in imaging technologies are contributing to increases in the demand for radiology services. Efforts to match this rising demand are limited by the Centers for Medicare & Medicaid Services cap on resident positions and the challenges in obtaining appropriate visas and medical licenses for international medical graduates. This rising gap in the demand for and capacity to deliver radiology services has created a need for radiologist extenders. A variety of roles have been developed for these radiologist extenders, depending on the skills of the individuals and the subspecialty areas in which they work. Prominent among these are radiologist assistants, physician assistants, nurse practitioners, dosimetrists, and advanced-practice nuclear medicine technologists. Quality patient care is best accomplished when radiologist extenders function under the guidance of qualified radiologists, nuclear physicians, or radiation oncologists.     

Physician assistants in academic radiology: the harborview experience

We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.     

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.     

Reimbursement risks with radiologist extenders: there is no free lunch!

There is great allure in the concept of using qualified health care providers to assist radiologists and radiation oncologists, increasing efficiency and possibly even improving patient care delivery. However, physician services are most commonly reimbursed under a system that is resource based, and the physician work and practice expense components of reimbursement for existing procedure codes are periodically reexamined to ensure their appropriate rank in this “relative value system.” Also, as new codes are developed, demonstrable physician work and practice expenses will determine the relative values for the new procedures. In both cases, the type of individual who actually performs different portions of a procedure will determine the reimbursement level. In addition, the total reimbursement must be appropriately apportioned between the physician involved and the facility where the service is delivered. This article examines some of the potential impacts on procedure coding and radiologist and radiation oncologist reimbursement schedules if physician extenders perform work previously performed by physicians. It also examines possible shifts in reimbursement from physician to facility if an extender is employed by a facility.     

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.     

Wellness Program Implementation in an Academic Radiology Department: Determination of Need,Organizational Buy-in,and Outcomes

ObjectiveTo implement a multifaceted wellness program in an academic radiology department to prevent burnout and to assess initial outcomes with special focus on the challenges related to the coronavirus disease 2019 (COVID-19) pandemic.MethodsA wellness program was established to address institutional and personal factors of burnout. The program focused on interventions to improve efficiency of practice, provide personal and career support, and create a culture of wellness. The components of the program were designed with input from radiology faculty, and the program was financially supported by the hospital’s physician organization. A survey was performed 6 months after the initiation of the program to determine radiologist engagement and satisfaction. With the onset of the COVID-19 pandemic, a new survey was administered to identify needs of faculty and adjust initiatives. This study was exempt from institutional review board approval.ResultsThe majority of radiologists (79%) agreed or strongly agreed that the wellness program provided opportunities to connect with coworkers. All radiologists agreed that the program was helpful and should be continued. During the COVID-19 pandemic, 49% of physicians requested initiatives focused on well-being, emotional health, and mindfulness to support them during the crisis.ConclusionsThe implementation of a faculty wellness program in an academic radiology department addressed institutional and personal factors of burnout, allowed faculty to connect with coworkers, and was found to be helpful by all radiologists. The COVID-19 pandemic shifted needs to well-being and emotional health initiatives. Follow-up data are necessary to assess its effect on burnout reduction.     

Physician assistants in interventional radiology practice

Interventional radiology (IR) is a clinical subspecialty; as such, there is a large amount of direct patient care. However, until recently, this topic has not been a major focus in radiology training programs. Additionally, as interventional radiologists develop busier and busier practices, there is less time to spend with individual patients. Physician extenders such as physician assistants (PAs) represent an excellent way to improve clinical patient care. This article describes what PAs are and how they work together with physicians. It illustrates differences between PAs and other physician extenders and describes the duties that may be delegated to PAs in the IR setting.     

Who is more accurate in the diagnosis of neck of femur fractures, radiologists or orthopaedic trainees?

Objective

Our study aims to compare the sensitivity and specificity between orthopaedic trainees and radiologists in diagnosing occult hip fractures from pelvic radiographs.

Methods

All patients undergoing computed tomography (CT) of the hip for a suspected occult hip fracture at our two centres between November 1, 2010 and October 31, 2011 were retrospectively identified. Two orthopaedic trainees (RJ and ED) independently reviewed the initial radiographs, and if both agreed a fracture was present this was recorded. The reports from the radiologist of the initial radiograph and subsequent CT were recorded, with the CT report used as the standard of reference for comparison of performance.

Results

239 CTs were performed for suspected neck of femur fractures during the study period, compared to only 20 in 2006–07, reflecting a 1,095 % increase. The interpretation of radiographs by the orthopaedic trainees showed a sensitivity of 55.4 % and specificity of 96.6 %. In comparison, the radiologists had a sensitivity of 60.7 % and specificity of 92.9 %; this difference was shown not to be statistically significant. Radiologists and orthopaedic trainees agreed when interpreting the majority of radiographs with a Kappa co-efficient of 0.77 (a statistical measure of inter-rater agreement). In 20 of the 174 cases (11.5 %) where the radiologist and orthopaedic trainees agreed no fracture was present, the subsequent CT revealed a fracture.

Conclusion

Orthopaedic trainees and radiologists have similar accuracy at interpreting pelvic radiographs for suspected hip fractures, so the trainee’s opinion can be relied upon. If uncertainty exists, then either the orthopaedic trainee or radiologist should request further imaging urgently as we believe this will expedite diagnosis and treatment of hip fractures, and ensure judicious use of CT.     

Measuring and Teaching Confidence Calibration Among Radiologists: A Multi-Institution Study

ObjectiveOur purpose was to assess the calibration of resident, fellow, and attending radiologists on a simple image classification task (presence or absence of an anterior cruciate ligament [ACL] tear based on interpretation of sagittal proton density, fat-saturated MR images) and to assess whether teaching residents could improve their calibration.MethodsWe created a test containing 30 randomized, sagittal, proton density, fat-saturated MR images of the ACL (15 normal, 15 torn). This test was administered in person to 20 trainees and 3 attendings at one medical center in one state. An online version of the test was given to 23 trainees and 14 attendings from 11 other medical centers in nine other states. Subjects were asked to give their confidence level (0%-100%) that each ACL was torn.ResultsCross-sectional data were collected from 60 radiologists (mean time after medical school = 9.3 years, minimum = 1 year, maximum = 36 years). This demonstrated a statistically significant improvement in calibration as a function of increasing experience (P = .020). Longitudinal data were collected from 12 trainees at the start and end of their musculoskeletal radiology rotation, with an intervening review of the primary and secondary signs of ACL tear on MR. A statistically significant improvement in calibration was noted during the rotation (P = .028).ConclusionsConfidence calibration is a promising tool for quality improvement and radiologist self-assessment. Our study showed that calibration loss improves with experience in radiologists tested on a common and clinically important image classification task. We also demonstrated that calibration can be successfully taught to residents over a relatively short period (2-4 weeks).     

The new radiology workforce: Changing expectations

The zeitgeist of the new radiology workforce can best be described by a Bob Dylan song title: “The Times They Are A-Changin’.” The new generation of physicians, although embracing the same foundations of medical practice as previous generations, places greater emphasis on personal satisfaction than its predecessors. Gone are the days when physicians operated as sole practitioners; today’s workforce member is content to function in the role of “employee” in a trade-off for more lifestyle flexibility. This change has occurred not because of one specific factor but because of a change in the profession of medicine coupled with a combination of factors; familial responsibilities, avocational activities, and personal satisfaction have surfaced as motivating factors in choosing a profession. Today’s workforce has a personal perception of success that may not be fulfilled solely by the contemporary practice of medicine. With the radiologist shortages that are now occurring and anticipated increased demand for staff radiologists, today’s radiology workforce has helped shape the specialty into one that is altering its structure to attract and retain its workforce.     

Relationship between radiologist training level and radiation exposure for therapeutic hip injections

ObjectiveThe aim of this study was to determine the relationship between the level of training of the performing radiologist and patient radiation exposure, as measured by fluoroscopy time (FT) and dose area product (DAP), during fluoroscopic guided hip injections.Materials and methodsThis IRB-approved retrospective review of our institutional radiology report database identified all fluoroscopic guided hip injections performed between August 1st, 2012 and May 30th, 2015. Performing radiologists were divided into groups based on their level of training at the time of the procedure: first-year residents (R1), second-year residents (R2), third-year residents (R3), fourth-year residents (R4), staff fellowship trained musculoskeletal radiologists, and non-musculoskeletal radiologists. A mixed effects model was applied, using level of training as an independent predictor to model FT and DAP separately.ResultsThere were 20, 19, 18 and 20 residents in the R1, R2, R3 and R4 groups, respectively. There were 5 performers in the non-MSK radiologist group, and 7 in the MSK radiologist group. A total of 1362 hip injection procedures met the inclusion criteria and were included in the analysis. The overall average FT was 26 s (±17 SD) and overall average DAP was 20.4 uGy*m² (±22.3 SD). The mixed effects model showed no statistically significant difference between the groups, for FT (p = 0.31) and for DAP (p = 0.82).ConclusionThere is no association between radiologist level of training and patient radiation exposure for fluoroscopic hip injections. Resident trainees maintain radiation exposure to patients at levels comparable to their more experienced colleagues.     

The value of the internship year for radiologists: a retrospective analysis as assessed by current residents and fellows

RATIONALE AND OBJECTIVES: The purposes of the study were to determine (a) if radiology residents and fellows view their internship year as a valued prerequisite for their career as a radiologist and as a physician, (b) how their postgraduate year (PGY)-1 was perceived with regard to a specific type of internship (i.e., internal medicine, transitional year, or surgery), and (c) how their internship is considered from the vantage point of their current year of training and subspecialty career choice. MATERIALS AND METHODS: A survey was sent to all current U.S. radiology residents and fellows from a list derived from the American College of Radiology database. They were polled regarding their experiences in their preliminary year (PGY-1). Responses were coded on a 5-point Likert scale. RESULTS: Response rate for the study was 35%. Although 70% of respondents maintained that their internship year was necessary for their development as a physician, only 49% indicated that it was necessary for their development as a radiologist. Of respondents who graduated from surgical internships, 72% claimed that their PGY-1 was important for their development as a radiologist, compared to 44% of former transitional year interns and 49% of internal medicine interns (P < .001). When disaggregated by subspecialty career choice, participants were evenly divided about their perceptions of their intern year. However, among those considering interventional radiology, 67% of respondents considered their internship important to their development as a radiologist (P < .001). CONCLUSION: Overall, these data suggest that although the internship year was believed to have merit, the transitional year was least liked by radiology trainees. Efforts should be made to determine why the transitional year does not fare so well in the hope that structural improvements in it can be undertaken to make the year seem more worthwhile and more highly regarded.     

Radiology Practices Employing Nurse Practitioners and Physician Assistants: Characteristics and Trends From 2017 Through 2019

PurposeThe number and roles of US nonphysician practitioners (NPPs) have expanded considerably, but little is known about their use by radiology practices. The authors assessed characteristics and trends of radiology practices employing Medicare-recognized NPPs.MethodsUsing Medicare databases from 2017 through 2019, the authors mapped all nurse practitioners and physician assistants (together “NPPs”) to employer groups for which all physicians were radiologists (“radiology practices”). Practices were characterized by size, geography, and radiologist characteristics. Temporal changes were assessed, and NPP employment likelihood was estimated using multivariate logistic regression modeling.ResultsAs the number of US radiology practices declined by 36.5% (from 2,643 to 1,679) between 2017 and 2019, the number employing NPPs increased by 10.5% (from 228 [8.6%] to 252 [15.0%]). The number of radiologists in NPP-employing practices increased by 10.4% (from 6,596 [35.1%] to 7,282 [40.0%]) as the number of radiology-employed NPPs increased by 17.5% (from 588 to 691). Practices were more likely to employ NPPs when medium (odds ratio [OR], 1.31) or large (OR, 1.25) in size, when urban located (OR, 1.35), and as their percentages of interventional radiologists increased (OR, 5.53 per percentage point) (P < .01 for all). Practices were less likely to employ NPPs as mean radiologist years since completing training increased (OR, 0.99 per year; P < .01).ConclusionsEmployment of NPPs by radiology practices has grown considerably in recent years, particularly in larger and urban practices and in those that employ more interventional and early-career radiologists. More work is necessary to better understand how this expanding use of NPPs affects the specialty.     

Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations

PurposeThe aim of this study was to temporally characterize radiologist participation in Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs).MethodsUsing CMS Physician and Other Supplier Public Use Files, ACO provider-level Research Identifiable Files, and Shared Savings Program ACO Public-Use Files for 2013 through 2018, characteristics of radiologist ACO participation were assessed over time.ResultsBetween 2013 and 2018, the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, and the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. The number of physicians in MSSP ACOs with radiologists was substantially larger than those without radiologists (mean range across years, 573-945 versus 107-179). Primary care physicians constituted a larger percentage of the physician population for ACOs without radiologists (average across years, 66.3% versus 38.5%), and ACOs with radiologists had a higher rate of specialist representation (56.0% versus 33.7%). Beneficiary age, race, and sex demographics were similar among radiologist-participating versus nonparticipating ACOs.ConclusionsIn recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. Nonparticipating radiologists should prepare accordingly.     

Productivity of radiologists in 1997: estimates based on analysis of resource-based relative value units

OBJECTIVE: Productivity of radiologists was quantified using the resource-based relative value scale for examining trends in workload. MATERIALS AND METHODS: Staffing and workload data for 1997 were collected in a survey of radiology departments in multispecialty clinics. Workload ratios were calculated and were compared with prior surveys of the same clinics and with published data. RESULTS: Fifteen clinics reported 3,234,730 examinations and 1,860,729 resource-based relative value units (RBRVUs) performed by 284 radiologists and 28 fellows serving 6305 providers. Productivity ratios were as follows: physician index, 19 physicians per radiologist; provider index, 23 providers per radiologist; availability index, 0.78; difficulty index, 0.54 RBRVUs per examination; examination index, 11,559 examinations per year per radiologist; RBRVU index, 6090 RBRVUs per year per radiologist. Each index had roughly a twofold range of variation from lowest to highest ratio observed. Among diagnostic and interventional procedures, 37% of the supervision and interpretation RBRVUs were in general radiography, 41% in sectional imaging, and 22% in special procedures. Since 1973, the percentages of sectional imaging and special procedure examinations and RBRVUs have increased, and the difficulty index has increased. The physician index has been relatively stable. Non-supervision and interpretation codes constitute approximately 18% of the reported RBRVUs. RBRVU valuation of total radiology services has held steady or slightly increased between 1993 and 1997. CONCLUSION: RBRVU workload of radiologists in the clinics appears to be increasing primarily because of an increase in the percentages of highly valued sectional imaging and interventional and angiographic studies, which constituted 63% of the diagnostic imaging RBRVU workload. The ranges of the indexes among the clinics varies greatly.     

The radiologist and the patient: breaking bad news.

Radiologists may be asked to disclose results directly to patients. Studies of radiologist-patient communication show that radiologists have a direct responsibility to their patients, that many patients wish to learn the results of imaging tests from the radiologist at the time of the examination, and that many referring physicians support the principle of radiologists disclosing results when patients ask for them. In some areas, such as breast imaging and interventional radiology, disclosure by radiologists is very common. The authors, who work in a perinatology unit in which obstetrical ultrasonography is performed, have developed a template to help them with the often-emotional interactions associated with pregnancy failure. They recommend that radiologists inform the patient clearly of the examination results, choosing everyday words such as "miscarriage" and "pregnancy." They also recommend that physicians show compassion, acknowledge patients' grief and inform the referring physician as soon as possible. These steps should be part of a policy of direct, honest communication with patients.     

The impaired radiologist

The concept of the “impaired physician” is an oxymoron. Physicians are by definition bearers of health, which can lead to overlooking the possibility of them contracting an illness that reduces their diagnostic and therapeutic abilities, with a consequent danger to their patients’ health. The clinical reasons for which a radiologist may constitute a danger to patients can be divided into two categories: infectious blood-borne diseases, which can be transmitted to the patient during interventional radiology procedures; and neurodegenerative and psychiatric disorders, including alcohol and drug abuse, which temporarily or permanently impair the faculty of judgement. All radiologists have a duty to periodically verify their own state of health and seek help as soon as possible when they fear it may be a danger. This individual responsibility towards one’s own patients is flanked by the health and safety requirements provided by European regulations for radiologists who are employers, directors or department heads. The occupational health physician plays a key role in identifying and managing the impaired radiologist.     

Enhancing communication in radiology using a hybrid computer-human based system

IntroductionCommunication and physician burn out are major issues within Radiology. This study is designed to determine the utilization and cost benefit of a hybrid computer/human communication tool to aid in relay of clinically important imaging findings.Material and methodsAnalysis of the total number of tickets, (requests for assistance) placed, the type of ticket and the turn-around time was performed. Cost analysis of a hybrid computer/human communication tool over a one-year period was based on human costs as a multiple of the time to close the ticket. Additionally, we surveyed a cohort of radiologists to determine their use of and satisfaction with this system.Results14,911 tickets were placed in the 6-month period, of which 11,401 (76.4%) were requests to “Get the Referring clinician on the phone.” The mean time to resolution (TTR) of these tickets was 35.3 (±17.4) minutes.Ninety percent (72/80) of radiologists reported being able to interpret a new imaging study instead of waiting to communicate results for the earlier study, compared to 50% previously. 87.5% of radiologists reported being able to read more cases after this system was introduced.The cost analysis showed a cost savings of up to $101.12 per ticket based on the length of time that the ticket took to close and the total number of placed tickets.ConclusionsA computer/human communication tool can be translated to significant time savings and potentially increasing productivity of radiologists. Additionally, the system may have a cost savings by freeing the radiologist from tracking down referring clinicians prior to communicating findings.