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.     

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.     

How do training, education, and experience affect quality in radiology?

The quality of care is attracting increasing attention from payers, regulators, and consumers. The assumption that training, education, and experience are major determinants of quality and safety permeates the health care delivery system. However, the relationship between quality and training, education, and experience is neither straightforward nor well documented, particularly for the practice of radiology. A recent Institute of Medicine report questioned the effectiveness of the existing system for the education and training of health care professionals. In this article, “quality” in radiology is defined, and evidence for a relationship between quality care and experience and traditional continuing medical education is reviewed. Alternative approaches to education and training, with an emphasis on systems rather than individuals, are elucidated. The nature of radiologist training, education, and experience should be reexamined and adjusted to meet the changing demands of the health care delivery system.     

The development of radiology guidelines in Canada, Part 2.

In the second part of a two-part article on the development of Canadian clinical practice guidelines in radiology, the author discusses the implementation of guidelines. The aim is to translate guidelines into practice policies, but nation-wide implementation is difficult because of the regional circumstances and constraints in Canadian health care. One approach to making guidelines more effective tools and preventing conflict is to distinguish between effectiveness (benefit of an intervention under average conditions of use) and efficiency (value of an intervention compared with other things that could be done with the same resources). Clinical practice guidelines are based on effectiveness criteria alone, whereas practice policies can be based on efficiency criteria and are made by those responsible for allocating resources. From an ethical point of view, guidelines have an important feature in common with applied ethics: neither can give the right answer in a situation, but both can indicate the right decision-making process, including who should decide, on what basis, using which process and for what purpose. From a legal standpoint, if the medical community views guidelines as constituting reasonable medical care and jurists see them as a medical and legal norm, they can have significant influence in malpractice litigation. At the last annual meeting of the CAR, the executive committee decided that an integrated national approach to guidelines is needed because of the considerable confusion in this field. It supports the National Framework Development Committee's efforts to set national principles and operating rules for development and implementation. This necessitates an organizational structure consisting of a coordinating group representing consumers, service providers, regulators and funding agencies; multidisciplinary guidelines-development groups; and methodology resource groups.     

Sideline preparedness for the team physician: consensus statement

The objective of the Sideline Preparedness Statement is to provide physicians who are responsible for making decisions regarding the medical care of athletes with guidelines for identifying and planning for medical care and services at the site of practice or competition. It is not intended as a standard of care and should not be interpreted as such. The Sideline Preparedness Statement is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the health care professional. Individual treatment will turn on the specific facts and circumstances presented to the physician at the event. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. The Sideline Preparedness Statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.     

Development of a core curriculum in professional growth: practice management military model

Military medicine has faced some big challenges in recent years. Military treatment facilities have not been exempt from these alterations, as the American public has sought to reinvent government practices with regard to medicine. Until recently, professional education consisted almost entirely of emphasis in the particular content of the chosen field. Obstetrics and gynecology was one of the first medical specialties to recognize the importance of practice management, professional growth and development, and to require exposure to it as part of the residency process. The Department of Obstetrics and Gynecology's instructional objectives dealing with professional growth and development originated as part of the military-unique curriculum for physicians implemented at Tripler Army Medical Center in Hawaii. Later, these objectives were used at Madigan Army Medical Center in Tacoma, Washington. Recent changes in the health care environment, coupled with an increasing awareness of professional liability and the newer specter of managed care, force physicians to learn the cost of each health encounter and to be more familiar with the business aspects of health care. As medicine in general is changing, the curricula have been revised and tailored to the needs of our physicians with the addition of ethics, managed care, utilization, and practice management.     

2011 recommendations for the diagnosis and management of gout and hyperuricemia

Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care practices; thus, primary care physicians have a significant opportunity to improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant new evidence has accumulated, and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading the strength of recommendation formulated for use in clinical practice. A total of 26 key recommendations, 10 for diagnosis and 16 for management, of patients with gout were evaluated, resulting in important updates for patient care. The presence of monosodium urate crystals and/or tophus and response to colchicine have the highest clinical diagnostic value. The key aspect of effective management of an acute gout attack is initiation of treatment within hours of symptom onset. Low-dose colchicine is better tolerated and is as effective as a high dose. When urate-lowering therapy (ULT) is indicated, the xanthine oxidase inhibitors allopurinol and febuxostat are the options of choice. Febuxostat can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. The target of ULT should be a serum uric acid level that is ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option. This article is a summary of the 2011 clinical guidelines published in Postgraduate Medicine. This article provides a streamlined, accessible overview intended for quick review by primary care physicians, with the full guidelines being a resource for those seeking additional background information and expanded discussion.     

2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI)

Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.     

Tactical medicine training for SEAL mission commanders

The Tactical Combat Casualty Care (TCCC) project initiated by the Naval Special Warfare Command and continued by the U.S. Special Operations Command has developed a new set of combat trauma care guidelines that seek to combine good medical care with good small-unit tactics. The principles of care recommended in TCCC have gained increasing acceptance throughout the Department of Defense in the 4 years since their publication, and increasing numbers of combat medical personnel and military physicians have been trained in this concept. Because casualty scenarios in small-unit operations typically present tactical as well as medical problems, however, it has become apparent that a customized version of this course suitable for small-unit mission commanders is a necessary addition to the program. This paper describes the development of a course in tactical medicine for SEAL mission commanders and its transition into use in the Naval Special Warfare community.     

Promoting the online use of radiology appropriateness criteria.

Radiology appropriateness criteria and practice guidelines seek to promote the cost-effective use of radiology procedures and interventions and can be most useful when integrated with electronic patient records and order-entry systems. The task of translating practice guidelines into computer-based formats can highlight deficiencies and lead to revisions that make them more useful. Computer-based practice guidelines can include additional didactic material, such as images, videos, sounds, simulations, and links to bibliographic databases. Given patient data, information systems can select the most appropriate intervention automatically; some systems can function autonomously. Knowledge representation schemes can make appropriateness criteria available across a wide variety of computer platforms. Internet-based tools can allow developers to collaborate across an institution or around the globe. Information systems can bring appropriateness criteria to physicians at the point of care. The use of standardized approaches is important to ensure that appropriateness criteria reach the broadest possible audience and that such efforts can be incorporated easily into automated systems.     

Common medical ethics dilemmas: Few reflections from a Saudi perspective

Medical ethics plays a crucial role in physicians’ daily practice, as it reflects on themselves, their institution, and, most importantly, the outcome of the treatment they provide to their patients. Common medical ethics dilemmas faced in Saudi Arabia include: end-of-life care, patient rights, which comprise autonomy, informed consent, and confidentiality, reproductive ethics, and equity of resources. The identification of flaws within the healthcare system and the implementation of clear guidelines are important to overcome the risk of malpractice and flawed judgment, and ensure the delivery of the best possible care to patients.     

Medical education research: challenges and opportunities

Medical education research is not as well understood or established as is basic science or clinical research. The reasons for this are many, but most importantly, there is insufficient funding for medical education research and a dearth of skilled and experienced medical education researchers. There is no nationally centralized force to build and sustain a medical education research enterprise. Yet faculty and training programs are held accountable for the quality of patient care rendered by those that they train. New regulatory requirements at all levels of physician training demand assurance that physicians are competent to practice in the current health care environment and provide optimal patient care. Documenting the relationship between education and patient outcomes represents one of the biggest challenges and greatest opportunities in medical education research. There is no research infrastructure in place to support such outcomes studies. The majority of medical education research that is currently being done is supported by volunteer faculty time and resources. This is not a viable model to sustain a medical education research mission. Compared with medicine in general, these challenges are multiplied in radiology, where there are relatively fewer extramural research dollars available and skilled investigators to carry out radiology education research. Building a critical mass of radiology education researchers through education fellowship programs specific to radiology and mobilizing the existing radiology education researchers into one group with a shared vision are opportunities for elevating the status of radiology education research.     

The Availability and Delivery of Health Care to High School Athletes in Alabama

In brief: A sports medicine survey of 119 public high schools in Alabama showed that the smaller schools are farther from medical facilities and have less space and equipment for injury management than larger schools. Primary care or family physicians are used most often as team physicians, but the availability of physicians at practice and at sports events other than football is limited. Many schools have no team physician, most lack athletic trainers, and about half of the coaches do not feel prepared to handle a medical emergency. Many of the schools rated the delivery and quality of medical care to their athletes as fair to very poor.     

Seventh Annual Mario S. Verani,MD Memorial Lecture: “ASNC and integrating cardiac imaging”

Although cardiovascular mortality is decreasing over the last two decades, the cost of such care is escalating at a pace that is not sustainable for Medicare. Over this same time period, cardiac imaging has grown at an extremely rapid rate and is a leading contributor to this escalation in expense. It is now incumbent on both profession medical societies and individual physicians to demonstrate that cardiovascular care and the imaging growth lead to better patient outcomes and that the level of competent performance in these areas is documented. The development of physician certification and laboratory accreditation are key components to this effort and need to be supported and updated in a timely manner. The recent introduction of appropriateness criteria for patient imaging and treatment, especially in concert with the more established national clinical guidelines, appears to offer the best mechanism to deal with all the clinical and economic factors that we will need to address to continue our efforts to improve cardiovascular healthcare. Physicians can best serve their patients by practicing best standards of practice as well as being advocates for high-quality medical care in the setting of responsible healthcare funding. The article is the text of the author’s presentation at the 2008 ASNC national meeting for the Verani Lecture.     

Value added radiology: using existing radiology services to improve cancer screening

Consumers, clinicians, and health care payers accept the clinical and economic benefits of cancer prevention/early detection and encourage their use. It is clearly evident that radiologists will remain at the forefront of innovation in screening technologies. Because nearly all Americans undergo at least one imaging test, radiologists should give strong consideration to using these existing diagnostic tests as “teachable moments” to educate and motivate their patients to increase participation in underused yet potentially life-saving interventions. The opportunities for radiologists to adopt this approach can be considered for several reasons. From a basic point of view, acceptance of the “teachable moment” concept will increase the use of evidence-based diagnostic interventions. From a more idealistic standpoint, the adoption will foster more interdisciplinary collaboration with radiologists that will likely demonstrate an important “added value” of radiographic services.     

The polity of academic medicine: Status of faculty governance

How should academic medical departments be governed? Models of governance span a wide spectrum between autocracies, in which important decisions are made by a single individual, to democracies, in which each member enjoys a voice in decision making. Despite the fact that more participatory governance models are the norm in practice settings outside of academia, many academic physicians seem to take an autocratic model more or less for granted. In fact, however, most medical schools and universities do not mandate a governance system that vests authority in a powerful chairperson, and departments frequently enjoy more latitude than they suppose in determining how to govern themselves. Because an organization’s effectiveness is powerfully influenced by its governance structure, academic physicians should give serious consideration to this subject, to ensure that academic medicine is well prepared to meet the many challenges now before it     

Imaging Appropriateness for Neck Pain

Imaging of neck pain contributes to a significant proportion of health care costs and is expected to increase with current practices that heavily use radiologic studies as a diagnostic tool. Though consensus guidelines are available to assist physicians in selection of appropriate imaging examinations for neck pain, it is unclear if current ordering practices reflect their use and understanding. To investigate this, we analyzed the number and types of imaging examinations performed for neck pain at a university medical center over the past year. Current trends at our institution suggest that clinicians use consensus imaging guidelines, but there is still controversy in the cervical spine for when not to image. To promote appropriate imaging utilization, we developed an algorithm to guide imaging of neck pain, based upon clinical presentation, referral patterns for neck pain, and a review of the literature.     

Lifelong learning and the maintenance of certification

Lifelong learning is critical to radiology and the method by which, as professionals, we have kept up to date on new knowledge and developments. The American Board of Medical Specialists and the American Board of Radiology, along with other professional societies such as the Council of Medical Specialty Societies and the ACR, identified a need and an opportunity to serve the public and our profession through the Maintenance of Certification (MOC) initiative. These issues of lifelong learning, public concern, and MOC—and their interrelationship—are discussed. Lifelong learning is defined as a continuation of medical education with an ongoing process of professional development along with self-assessment, which enables physicians to maintain the requisite knowledge, skills, and professional standards.Continuing professional development can be grouped into three categories: formal, nonformal, and informal learning. Examples from the author’s career illustrate key points. Future technologies and scientific discoveries affect radiology and make the commitment to lifelong learning even more critical. The challenge will be the maintenance of specialty certification and its components and competencies, along with the attainment of knowledge and the skills necessary in our unique practices for quality patient care in the evolving health care environment. These are important challenges to our boards, professional societies, specialty societies, institutions, and practicing community. It is critical to participate actively in these organizations and processes to continue development of the MOC initiative, because it is beneficial to patients, applicable to practicing physicians, and credible to public interests.     

The added value of screening mammography in improved screening for other cancers

As part of day-to-day practice, the most frequent role of the radiologist is to provide diagnostic information derived from imaging that will help the clinician better manage patient care. In essence, radiologists are reimbursed for the information we provide. The value of diagnostic information, however, extends beyond strict clinical and monetary value.The objectives of this paper are to provide the framework for understanding the “value” of diagnostic imaging. The article focuses on the application of these concepts using examples from the literature with particular emphasis on screening and suggests using a screening test experience as a means of improving health behavior.