Spectrum of Cognitive Biases in Diagnostic Radiology.

Cognitive biases are systematic thought processes involving the use of a filter of personal experiences and preferences arising from the tendency of the human brain to simplify information processing, especially when taking in vast amounts of data such as from imaging studies. These biases encompass a wide spectrum of thought processes and frequently overlap in their concepts, with multiple biases usually in operation when interpretive and perceptual errors occur in radiology. The authors review the gamut of cognitive biases that occur in radiology. These biases are organized according to their expected stage of occurrence while the radiologist reads and interprets an imaging study. In addition, the authors propose several additional cognitive biases that have not yet, to their knowledge, been defined in the radiologic literature but are applicable to diagnostic radiology. Case examples are used to illustrate potential biases and their impact, with emergency radiology serving as the clinical paradigm, given the associated high imaging volumes, wide diversity of imaging examinations, and rapid pace, which can further increase a radiologist's reliance on biases and heuristics. Potential strategies to recognize and overcome one's personal biases at each stage of image interpretation are also discussed. Awareness of such biases and their unintended effects on imaging interpretations and patient outcomes may help make radiologists cognizant of their own biases that can result in diagnostic errors. Identification of cognitive bias in departmental and systematic quality improvement practices may represent another tool to prevent diagnostic errors in radiology. ©RSNA, 2024 See the invited commentary by Larson in this issue.

Radiologist and Radiology Practice Wellbeing: A Report of the 2023 ARRS Wellness Summit.

In April 2023, the first American Roentgen Ray Society (ARRS) Wellness Summit was held in Honolulu, Hawaii. The Summit was a communal call to action bringing together professionals from the field of radiology to critically review our current state of wellness and reimagine the role of radiology and radiologists to further wellbeing. The in-person and virtual Summit was available free-of-cost to all meeting registrants and included 12 sessions with 44 invited moderators and panelists. The Summit aimed to move beyond simply rehashing the repeated issues and offering theoretical solutions, and instead focus on intentional practice evolution, identifying implementable strategies so that we as a field can start to walk our wellness talk. Here, we first summarize the thematic discussions from the 2023 ARRS Wellness Summit, and second, share several strategic action items that emerged.

Peer learning in abdominal radiology: iterative process improvements over a 20-year experience.

PURPOSE: After a slow and challenging transition period, peer learning and improvement (PLI) is now being more widely adopted by practices as an option for continuous personal and practice performance improvement. In addition to gaps that exist in the understanding of what PLI is and how it should be practiced, wide variation exists in how the process is implemented, administered, how outcomes are measured, and what strategies are employed to engage radiologists. This report aims to describe lessons learned from our 20-year experience with the design, implementation, and continuous improvements of a PLI program in a large academic program. METHODS: Since initial implementation in 2004, an oversight team prospectively documented iterative process improvements and data submission trends in our PLI process. Process data included strategies for engaging radiologists in the PLI process (fostering case submission, PLI meeting participation), steps for achieving regulatory compliance, and template content for facilitating the value and impact of PLI meetings (case analysis, review of contributing factors, identification of improvement opportunities). RESULTS: Submission trends, submitted case content, and improvement opportunities varied by clinical section. Process improvements that fostered engagement included closing the loop with participants, expanding criteria for case submission beyond interpretive disagreements (e.g., great pickups, near misses), minimizing impacts to workflow, and using evidence-based templates for case and contributor categorization, bias analysis, and identification of improvement opportunities. CONCLUSION: Implementing an effective PLI program requires sustained communication, education, and continuous process improvement. While PLI can certainly lead to process and individual performance improvement, the program requires trained champions, designated time, effort, resources, education, and patience to be effectively implemented.

The Society of Abdominal Radiology at 10 years: Reflections, status report, and look to the future.

In 2012, the Society of Abdominal Radiology (SAR) was formed by the merger of the Society of Gastrointestinal Radiologists (SGR) and the Society of Uroradiology (SUR). On the occasion of SAR's ten year anniversary, this commentary describes important changes in society structure, the growth and diversity of society membership, new educational and research initiatives, intersociety and international outreach, and plans for the future.

Outcomes of Postprocedural Closeout Checklist Implementation to Prevent Adverse Events during Interventional Radiology Procedures: An Initiative to Improve Outcomes.

PURPOSE: To assess whether adherence to a postprocedural closeout (PPC) checklist decreases adverse events during image-guided procedures. MATERIALS AND METHODS: Based on the analysis of prior adverse events related to image-guided procedures, the Radiology Quality Committee developed a PPC checklist. The rates of serious reportable events related to image-guided procedures performed in the radiology department were recorded annually from 2015 to 2021. The rate of adverse events was normalized to the procedure volume in the corresponding periods. The number of patients requiring repeat procedures was recorded. The severity of impact was classified according to the Society of Interventional Radiology Adverse Event Classification System. The annual rates before (2015 and 2016) and after (2017-2021) the implementation of PPC were compared. RESULTS: Seventy-seven safety reports were identified in image-guided procedures over the study period, of which 43 cases were not related to the PPC, leaving 34 cases for the analysis. Radiology adverse events decreased from 0.069% (14/20,218, 7/y) before PPC implementation to 0.034% (20/58,793, 4/y) after implementation (P = .05, 43% decrease). Radiology repeat procedures decreased from 0.040% (8/20,218, 4/y) before PPC implementation to 0.007% (4/58,793, 0.8/y) after implementation (P = .0033, 80% decrease). Moreover, severity of adverse events decreased (P = .009). CONCLUSIONS: Implementation of a PPC checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the end of image-guided procedures by 43%, need for repeat procedures by 80%, and severity of impact of errors.

Emotional Harm in the Radiology Department: Analysis of an Underrecognized Preventable Error.

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.

Radiologist Well-Being and Professional Fulfillment in the COVID-19 Era: Fostering Posttraumatic Growth.

The acute consequences of the COVID-19 pandemic have impacted wellness strategies aimed at mitigating the pre-existing epidemic of burnout in radiology. Specifically, safety measures including social distancing requirements, effective communications, supporting remote and distributed work teams, and newly exposed employment and treatment inequities have challenged many major efforts at fostering professional fulfillment. To get our wellness efforts back on track and to achieve a new and perhaps even a better "normal" will require refocusing and reconsidering ways to foster and build a culture of wellness, implementing practices that improve work efficiencies, and supporting personal health, wellness behaviors, and resilience. Optimizing meaning in work is also critical for well-being and professional fulfillment. In addition to these earlier approaches, organizations and leaders will need to reprioritize efforts to build high-functioning cohesive and connected teams; to train, implement, and manage peer-support practices; and to support posttraumatic growth. This growth represents the positive psychological changes that can occur after highly challenging life circumstances and, when successful, allows individuals to achieve a higher level of functioning by addressing and learning from the precipitating event. Our practices can support this growth through education, emotional regulation, and disclosure, by developing a narrative that reimagines a hoped-for better future and by finding meaning through services that benefit others.

Enabling Your Radiology Business to Thrive Strategic Lessons Learned During the Initial and Subsequent Surges of the Covid-19 Pandemic.

The Covid-19 pandemic surges of 2020 resulted in major operational, personal, and financial impacts on US radiology practices. In response, a series of strategic and intentional operational changes were implemented, varying by practice size, structure and model. In reviewing the many business lessons that we learned during the pandemic, it became clear that for a business to be successful, a host of additional supportive factors are necessary. In addition to timely expense reductions, optimizing revenue capture and close monitoring and management of cash and reserves available for use, we also consider effective leadership and communication strategies, maintenance of a healthy and adequately staffed team, support for a remote work environment and flexible staffing models. Other ingredients include effectively embracing digital media for communications, careful attention to current and new stakeholders and the service delivered to them, understanding federal and state regulatory changes issued in response to the pandemic, close collaboration with the Human Resources office, and an early focus on redesigning your future practice structure and function, including disaster and downtime planning. This review aims to share lessons to enable leaders of an imaging enterprise to be better prepared for similar and future surges.

Procedure-specific Training for Robot-assisted Distal Pancreatectomy.

OBJECTIVE: To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. BACKGROUND: RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. METHODS: A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. RESULTS: After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. CONCLUSION: Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit.

Since its introduction nearly 20 years ago, score-based peer review has not been shown to have meaningful impact on or be a valid measurement instrument of radiologist performance. A new paradigm has emerged, peer learning, which is a group activity in which expert professionals review one another's work, actively give and receive feedback in a constructive manner, teach and learn from one another, and mutually commit to improving performance as individuals, as a group, and as a system. Many radiology practices are beginning to transition from score-based peer review to peer learning. To address challenges faced by these practices, a 1-day summit was convened at Harvard Medical School in January 2020, sponsored by the ACR. Several important themes emerged. Elements considered key to a peer-learning program include broad group participation, active identification of learning opportunities, individual feedback, peer-learning conferences, link with process and system improvement activities, preservation of organizational culture, sequestration of peer-learning activities from evaluation mechanisms, and program management. Radiologists and practice leaders are encouraged to develop peer-learning programs tailored to their local practice environment and foster a positive organizational culture. Health system administrators should support active peer-learning programs in the place of score-based peer review. Accrediting organizations should formally recognize peer learning as an acceptable form of peer review and specify minimum criteria for peer-learning programs. IT system vendors should actively collaborate with radiology organizations to develop solutions that support the efficient and effective management of local peer-learning programs.

A Road Map to Foster Wellness and Engagement in Our Workplace-A Report of the 2018 Summer Intersociety Meeting.

The 2018 radiology Intersociety Committee reviewed the current state of stress and burnout in our workplaces and identified approaches for fostering engagement, wellness, and job satisfaction. In addition to emphasizing the importance of personal wellness (the fourth aim of health care), the major focus of the meeting was to identify strategies and themes to mitigate the frequency, manifestations, and impact of stress. Strategies include reducing the stigma of burnout, minimizing isolation through community building and fostering connectivity, utilizing data and benchmarking to guide effectiveness of improvement efforts, resourcing and training "wellness" committees, acknowledging value contributions of team members, and improving efficiency in the workplace. Four themes were identified to prioritize organizational efforts: (1) collecting, analyzing, and benchmarking data; (2) developing effective leadership; (3) building high-functioning teams; and (4) amplifying our voice to increase our influence.

Improving Imaging Care for Diverse, Marginalized, and Vulnerable Patient Populations.

Although much attention has been paid to the reduction of disparities in health care within the United States, these issues continue to exist. Such efforts include increased focus on patient centeredness and cultural responsivity. These concepts are based on the recognition that diverse, marginalized, and vulnerable patients may possess different physical, psychologic, or social characteristics that contribute to their diversity and susceptibility. Such patients may face numerous obstacles and barriers when seeking medical care, including financial constraints, difficulties with communication, a limited understanding of how to navigate the health care system, and not feeling welcomed, respected, or safe. It is essential that the radiologist and members of the radiology care team understand and embrace patients' unique characteristics to provide effective and appropriate care to all patients. This article illustrates the spectrum of knowledge that benefits radiologists and members of the radiology care team when interacting with and providing care for the growing pool of diverse, marginalized, and vulnerable patients. ©RSNA, 2018.

The Road to Wellness: Engagement Strategies to Help Radiologists Achieve Joy at Work.

Physician wellness is recognized as a critical component of enhancing the quality of health care. An epidemic of symptoms related to stress and burnout among medical professionals, including radiologists, in the workplace is threatening not only health care providers at a personal level but also the entire health care system. In this review, the authors highlight recognized stressors in the contemporary radiology workplace and offer practical suggestions for mitigating burnout, improving professional engagement, and promoting wellness. Thematic goals to focus on include fostering an integrated and harmonious community at work, diminishing workplace detractors, creating opportunities to cultivate positive attitudes and intellect, and implementing effective leadership practices. ©RSNA, 2018.

Ongoing Professional Practice Evaluation of Radiologists: Strategies and Tools for Simplifying a Complex Process.

The Joint Commission, our major accreditation organization, requires that all physicians who have been granted privileges at an organization must undergo evaluation of and collect data relating to their performance, to make the decisions of privileging more objective and continuous by that organization. For radiologists, this so-called ongoing professional practice evaluation (OPPE) can be assessed by using the six general core competencies. These competencies were initially developed for graduate medical education and defined by the Accreditation Council for Graduate Medical Education and have now been expanded to provide a general framework for defining categories of data to be collected in assessing the performance of practicing radiologists. Within each core competency, various radiology-relevant metrics exist that can be measured to fulfill the OPPE requirements. Each radiology department can determine the specific type of data to be collected, including determining what items are defined as acceptable performance metrics, what data or outcomes require further monitoring, and what specific data or data trends would trigger the need for an additional focused and more thorough professional practice evaluation, also known as a focused professional practice evaluation (FPPE). ©RSNA, 2018.

Fostering Diversity and Inclusion: A Summary of the 2017 Intersociety Summer Conference.

The 39th radiology Intersociety Committee reviewed the current state of diversity among trainees and in our workplaces and addressed future strategies for fostering diversity through inclusion. The assembled participants addressed the imperatives and drivers for diversity and developed a road map to foster diversity. Themes included the need to be proactive in increasing awareness of our own biases and their potential impact on workplace decisions, overcoming blind spots, and being culturally sensitive. The need to identify and eliminate barriers to diversity was discussed at both the organizational and practice level and included efforts to break down structural and clinical barriers, such as training in multicultural awareness. Additional strategies that were addressed included building inclusive work environments; facilitating debate, conversations, and community building; and pipelining medical students through mentoring pathways. The conference ended with a call to action to develop toolkits with effective resources to support the necessary diversity and inclusion initiatives we must all undertake.

Practical Suggestions on How to Move From Peer Review to Peer Learning.

OBJECTIVE: The purpose of this article is to outline practical steps that a department can take to transition to a peer learning model. CONCLUSION: The 2015 Institute of Medicine report on improving diagnosis emphasized that organizations and industries that embrace error as an opportunity to learn tend to outperform those that do not. To meet this charge, radiology must transition from a peer review to a peer learning approach.

Radiologists' Experience With Patient Interactions in the Era of Open Access of Patients to Radiology Reports.

PURPOSE: The aim of this study was to evaluate radiologists' experiences with patient interactions in the era of open access of patients to radiology reports. METHODS: This prospective, nonrandom survey of staff and trainee radiologists (n = 128) at a single large academic institution was performed with approval from the institutional review board with a waiver of the requirement to obtain informed consent. A multiple-choice questionnaire with optional free-text comments was constructed with an online secure platform (REDCap) and distributed via departmental e-mail between June 1 and July 31, 2016. Participation in the survey was voluntary and anonymous, and responses were collected and aggregated via REDCap. Statistical analysis of categorical responses was performed with the χ2 test, with statistical significance defined as P < .05. RESULTS: Almost three-quarters of surveys (73.4% [94 of 128]) were completed. Staff radiologists represented 54.3% of survey respondents (51 of 94) and trainees 45.7% (43 of 94). Most respondents (78.7% [74 of 94]) found interactions with patients to be a satisfying experience. More than half of radiologists (54.3% [51 of 94]) desired more opportunities for patient interaction, with no significant difference in the proportion of staff and trainee radiologists who desired more patient interaction (56.9% [29 of 51] versus 51.2% [22 of 43], P = .58). Staff radiologists who specialized in vascular and interventional radiology and mammography were significantly more likely to desire more patient interaction compared with other specialists (77.8% [14 of 18] versus 45.5% [15 of 33], P = .03). Only 4.2% of radiologists (4 of 94) found patient interactions to be detrimental to normal workflow, with 19.1% of radiologists (18 of 94) reporting having to spend more than 15 min per patient interaction. CONCLUSIONS: Most academic staff and trainee radiologists would like to have more opportunities for patient interaction and consider patient interaction rarely detrimental to workflow.