The Late-Career Radiologist: Options and Opportunities.

More than 25% of the present radiology workforce, or nearly 8300 radiologists, are actively practicing late-career radiologists. While these individuals could decide to retire from active practice, their continued presence in the workforce helps to maintain adequate and appropriate patient imaging services. To ensure their continued participation, issues important to all late-career radiologists need to be appreciated, discussed, and addressed. These issues include call-duty requirements, compensation, physical and cognitive health, and organized phase-out programs. The gamut of these issues is addressed in this review article. ©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.

Potential Radiation-Related Effects on Radiologists.

OBJECTIVE: The risk of injury associated with long-term occupational exposure to ionizing radiation is low for radiologists. The purpose of this article is to systematically review and inform radiologists about radiation-related effects to which they are potentially susceptible. CONCLUSION: Formal education and training on radiation safety and management, careful attention to good radiation protection habits, and continued emphasis on radiation management and the as low as reasonably achievable principle are recommended for all radiologists.

Evaluation of Posttreatment Follow-Up of Patients With Prostate Cancer Relative to the American College of Radiology's Appropriateness Criteria.

OBJECTIVE: The American College of Radiology (ACR) Appropriateness Criteria panel has recommended that patients with prostate cancer who have received treatment undergo imaging only after suspected cancer recurrence. We examined whether local physicians followed this recommendation and what types of imaging examinations were ordered in a cohort of patients with local prostate cancer. MATERIALS AND METHODS: The Rochester Epidemiology Project, a research consortium that collects, links, and stores medical record information of Olmsted County, Minnesota, residents, was used to capture the complete medical history of treated patients with prostate cancer from 2000 through 2011. Clinical information and imaging examinations performed were retrieved by chart review. Suspected recurrence was defined as treatment-specific prostate-specific antigen level elevations, bone pain, or abnormal digital rectal examination findings. RESULTS: Of the 670 treated patients with prostate cancer who were included in the final analysis, 129 (19%) underwent posttreatment imaging. After excluding imaging related to retreatment or another cancer, 13 patients (i.e., 2% of the entire cohort and 10% of imaged patients) underwent imaging in the absence of suspected recurrence. A total of 90 patients (70% of imaged patients) underwent imaging after suspected recurrence. Of these 90 patients, 62 (69%) underwent a bone scan as their first imaging modality either alone or in combination with other imaging modalities. Of the providers who ordered a bone scan first, 27% were urologists, 23% were radiation oncologists, and 24% were primary care physicians. CONCLUSION: Most patients in this study did not undergo imaging in the absence of suspected recurrence. Various types of imaging examinations were ordered for patients with suspected recurrence.

How to set up a departmental comparative effectiveness research unit: one department's experience.

OBJECTIVE: Comparative effectiveness research (CER) is the comparison of clinical interventions in real-world settings. The purpose of this article is to discuss the experiences of a CER unit created within the radiology department of one medical institution to provide an example of how to pursue CER within the field of radiology. CONCLUSION: Medical institutions would benefit from investing in CER by creating research groups specifically devoted to this evolving field.

Gas-containing gallstones as a cause of the "effervescent gallbladder" sign and pneumobilia.

The "effervescent gallbladder" sign, the sonographic finding of tiny echogenic foci rising from the dependent portion of the gallbladder, reminiscent of bubbles rising in a glass of champagne, has been reported previously as a finding of emphysematous cholecystitis. We report two additional cases of this unusual finding in an asymptomatic patient and in a patient with acute, gangrenous cholecystitis, confirmed in both cases by CT, to be secondary to the release of gas from gallstones. These two cases cast doubt on the sonographic sign as a pathognomonic finding of emphysematous cholecystitis.

Monitoring the initial delivery of an oncolytic measles virus encoding the human sodium iodide symporter to solid tumors using contrast-enhanced computed tomography.

BACKGROUND: We aimed to determine the feasibility of monitoring viral delivery and initial distribution to solid tumors using iodinated contrast agent and micro-computed tomography (CT). METHODS: Human BxPC-3 pancreatic tumor xenografts were established in nude mice. An oncolytic measles virus with an additional transcriptional unit encoding the sodium iodide symporter (NIS), as a reporter for viral infection, was mixed with a 1:10 dilution of Omnipaque 300 (GE Healthcare, Milwaukee, WI, USA) contrast agent and injected directly into tumors. Mice were imaged with micro-CT immediately before and after injection to determine the location of contrast agent/virus mixture. Mice were imaged again on day 3 after injection with micro-single-photon emission CT/CT to determine the location of NIS-mediated (99m) TcO(4) transport. RESULTS: A 1:10 dilution of Omnipaque had no effect on viral infectivity or cell viability in vitro and was more than adequate for CT imaging of the intratumoral injectate distribution. The volume of tumor coverage with initial CT contrast agent and the 3-day postinfection measurement of virally infected tumor volume were significantly correlated. Additionally, regions of the tumor that did not receive contrast agent from the initial injection were largely devoid of viral infection at early time points. CONCLUSIONS: Contrast-enhanced viral delivery enables a rapid and accurate prediction of the initial viral distribution within a solid tumor. This technique should enable real-time monitoring of viral propagation from initially infected tumor regions to adjacent tumor regions.

How Radiology Leaders Can Address Burnout.

The 2018 Annual Workforce Survey conducted by the ACR Commission on Human Resources demonstrated that, although the majority of radiology practice leaders acknowledge radiologist burnout as a significant problem, only about one in five leaders responded that their practices were either extremely or very effective at addressing physician burnout. Moving forward, leaders will be increasingly held accountable and expected to describe to their teams their reasons for not addressing burnout. In this article, common misperceptions that may contribute to radiology practice leaders not addressing burnout are described, followed by outlining practical skills that leaders should develop to effectively address burnout.

Sodium iodide symporter (NIS)-mediated radiovirotherapy for pancreatic cancer.

OBJECTIVE: We have previously shown the therapeutic efficacy of an engineered oncolytic measles virus expressing the sodium iodide symporter reporter gene (MV-NIS) in mice with human pancreatic cancer xenografts. The goal of this study was to determine the synergy between MV-NIS-induced oncolysis and NIS-mediated (131)I radiotherapy in this tumor model. MATERIALS AND METHODS: Subcutaneous human BxPC-3 pancreatic tumors were injected twice with MV-NIS. Viral infection, NIS expression, and intratumoral iodide uptake were quantitated with (123)I micro-SPECT/CT. Mice with MV-NIS-infected tumors were treated with 0, 37, or 74 MBq (131)I and monitored for tumor progression and survival. Additional studies were performed with stable NIS-expressing tumors (BxPC-3-NIS) treated with 0, 3.7, 18.5, 37, or 74 MBq of (131)I. RESULTS: Mice treated with intratumoral MV-NIS exhibited significant tumor growth delay (p < 0.01) and prolonged survival (p = 0.02) compared with untreated mice. Synergy between MV-NIS-induced oncolysis and NIS-mediated (131)I ablation was not seen; however, a significant correlation was observed between NIS-mediated intratumoral iodide localization (% ID/g) and peak tumor volume reduction (p = 0.04) with combination MV-NIS and (131)I therapy. Stably transduced NIS-expressing BxPC-3 tumors exhibited rapid regression with > or = 18.5 MBq (131)I. CONCLUSION: Delivery of (131)I radiotherapy to NIS-expressing tumors can be optimized using micro-SPECT/CT imaging guidance. Significant hurdles exist for NIS as a therapeutic gene for combined radiovirotherapy in this human pancreatic cancer model. The lack of synergy observed with MV-NIS and (131)I in this model was not due to a lack of radiosensitivity but rather to a nonuniform intratumoral distribution of MV-NIS infection.

Radiologist Burnout According to Surveyed Radiology Practice Leaders.

Overall, 55% of surveyed radiology practice leaders reported that burnout was a very significant problem, and 22% reported that burnout was a significant problem. Burnout did not vary by geographical region but did vary by practice size. Overall, 71% of respondents reported stress from workplace factors, and 36% reported stress from personal or social factors very significantly affected radiologist employee wellness; both sets of factors varied by geographical region, practice size, and practice type. Only 19% of practice leader respondents reported mechanisms to assess burnout, which varied by region and practice type.

Characteristics of Radiologists' Clinical Practice Patterns by Career Stage.

PURPOSE: To assess characteristics of radiologists' clinical practice patterns by career stage. METHODS: Radiologists' 2016 billed services were extracted from the Medicare Physician and Other Supplier Public Use File. Billed clinical work was weighted using work relative value units. Medical school graduation years were obtained from Medicare Physician Compare. Practice patterns were summarized by decades after residency. RESULTS: Among 28,463 included radiologists, 32.7% were ≤10 years postresidency, 29.3% 11-20 years, 25.0% 21-30 years, 10.5% 31-40 years, 2.4% 41-50 years, 0.1% ≥51 years. Billed clinical work (normalized to a mean of 1.00 among all radiologists) ranged 0.92-1.07 from 1 to 40 years, decreasing to 0.64 for 41-50 years and 0.43 for ≥51 years. Computed tomography represented 34.7%-38.6% of billed clinical work from 1 to 30 years, decreasing slightly to 31.5% for 31-40 years. Magnetic resonance imaging represented 13.9%-14.3% from 1 to 30 years, decreasing slightly to 11.2% for 31-40 years. Ultrasonography represented 6.2%-11.6% across career stages. Nuclear medicine increased steadily from 1.7% for ≤10 years to 7.0% for 41-50 years. Mammography represented 9.9%-12.9% from 1 to 50 years. Radiography/fluoroscopy represented 15.1%-29.8% from 1 to 50 years, but 65.9% for ≥51 years. CONCLUSION: The national radiologist workforce declines abruptly by more than half approximately 30 years after residency. Radiologists still working at 31-40 years, however, contribute similar billed clinical work, both overall and across modalities, as earlier career radiologists. Strategies to retain later-career radiologists in the workforce could help the specialty meet growing clinical demands, mitigate burnout in earlier career colleagues, and expand robust patient access to both basic and advanced imaging services.

Radiology Practice Consolidation: Fewer but Bigger Groups Over Time.

PURPOSE: The aim of this study was to assess recent trends in US radiology practice consolidation. METHODS: Radiologist practice characteristics were obtained from the Medicare Physician Compare database for 2014 and 2018. Radiologists were classified on the basis of their largest identifiable practice affiliations. Single-specialty radiology practices were identified using practice names. Temporal trends in practice sizes were assessed. RESULTS: At the individual radiologist level from 2014 to 2018, the fraction of all radiologists in groups with 1 or 2 members declined from 3.2% to 2.1%, 3 to 9 members from 10.2% to 6.7%, 10 to 24 members from 18.2% to 14.1%, 25 to 49 members from 16.6% to 15.1%, and 50 to 99 members from 13.3% to 11.5%. In contrast, the fraction in groups with 100 to 499 members increased from 15.7% to 21.8% and with ≥500 members from 22.9% to 28.7%. At the practice level, the fraction of all radiologists' practices with 1 or 2 members decreased from 26.9% to 22.8%, whereas the fraction with 100 to 499 members increased from 7.6% to 10.2% and with ≥500 members from 2.5% to 4.1%. Similar shifts were present for single-specialty radiology practices and all geographic regions nationally. The 30,492 radiologists identified in 2014 were affiliated with 4,908 group practices, including 2,812 single-specialty practices. In comparison, the 32,096 radiologists identified in 2018 were affiliated with 4,193 group practices (a 14.6% decline), including 2,216 single-specialty practices (a 21.2% decline). CONCLUSIONS: In very recent years, the US radiologist workforce has consolidated, leading to increased practice sizes and a substantial decline in the number of distinct practices, disproportionately affecting single-specialty radiology practices. The impact of this consolidation on cost, quality, and patient access merits further attention.

Quantitative molecular imaging of viral therapy for pancreatic cancer using an engineered measles virus expressing the sodium-iodide symporter reporter gene.

OBJECTIVE: Our objectives were to, first, determine the oncolytic potential of an engineered measles virus expressing the sodium-iodide symporter gene (MV-NIS) for intratumoral (i.t.) therapy of pancreatic cancer and, second, evaluate NIS as a reporter gene for in vivo monitoring and quantitation of MV-NIS delivery, viral spread, and gene expression in this tumor model. MATERIALS AND METHODS: Cultured human pancreatic cancer cells were infected with MV-NIS. Light microscopy, cell viability, and iodide uptake assays were used to confirm viral infection and NIS gene expression and function in vitro. Human pancreatic tumor xenografts were established in mice and infected via i.t. MV-NIS injections. NIS-mediated i.t. iodide uptake was quantitated by (123)I micro-SPECT/CT. i.t. MV-NIS infection was confirmed by immunohistochemistry of excised pancreatic xenografts. The oncolytic efficacy of MV-NIS was determined by measurement of tumor growth and mouse survival. RESULTS: Infection of human pancreatic cancer cell lines with MV-NIS in vitro resulted in syncytia formation, marked iodide uptake, and ultimately cell death. Tumor xenografts infected with MV-NIS concentrated radioiodine, allowing serial quantitative imaging with (123)I micro-SPECT/CT. i.t. MV-NIS therapy of human pancreatic cancer xenografts resulted in a significant reduction in tumor volume and increased survival time of the treated mice compared with the control mice. CONCLUSION: MV-NIS efficiently infects human pancreatic tumor cells and results in sufficient radioiodine uptake to enable noninvasive serial imaging and quantitation of the intensity, distribution, and time course of NIS gene expression. MV-NIS also shows oncolytic activity in human pancreatic cancer xenografts: Tumor growth is reduced and survival is increased in mice treated with the virus.

2018 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual workforce survey to determine the makeup of the radiology workforce and to identify potential plans for hiring new staff in an attempt to better understand our profession. METHODS: The Practice of Radiology Environment Database group leaders were asked to complete an electronic survey regarding the makeup of their present workforce by subspecialty as well as the numbers and types of subspecialists hired in 2017 and the numbers and types of subspecialists expected to be hired in 2018 and 2019. They were also asked about midlevel practitioner employment. RESULTS: Twenty-three percent of practice leaders (367) represente 10,179 radiologists, 30% of all practicing radiologists in the United States, responded to the survey. The number of radiology groups represented in this survey decreased from 1,811 in the 2017 survey to 1,588 groups in the 2018 survey. The current makeup of radiology workforce remains similar to 2016 and 2017. The workforce distribution by practice type and radiologists' ages has been relatively stable since 2012. Practice leaders report they plan to hire between 1,393 to 1,808 radiologists in 2018 (similar to 2017 reported hires between 1,434 to 1,861) with the greatest number of hires to be in breast imaging, neuroradiology, and interventional radiology. The study represented 549 midlevel practitioners and 693 medical physicists. CONCLUSION: The 2018 ACR workforce survey continues to show a positive picture and outlook for those seeking jobs as practicing radiologists in 2018.

Small animal absorbed radiation dose from serial micro-computed tomography imaging.

PURPOSE: To determine the radiation dose to mouse cancer xenografts from serial micro-computed tomography (CT) examinations. PROCEDURES: A nude mouse with a 15-mm subcutaneous pancreatic cancer xenograft in the rightflank was used. Radiation exposure to the subcutaneous tumor and the mouse pancreas (to simulate an orthotopic pancreatic tumor model) was measured using lithium fluoride thermoluminescent dosimeters. Ultrafast micro-CT was performed using 80 kVp, 0.26 mA, 0.156 mm slice thickness, 256 slices, 0.7 mm Al filtration, and 60-second image acquisition time (15 mA second). Micro-CT imaging acquisitions were repeated four times. RESULTS: We measured consistently low tumor doses (0.014 to 0.02 Gy; average=0.017 Gy) per scan. Orthotopic doses in the region of the pancreas were also consistently low (0.014 to 0.018 Gy; average=0.016 Gy) per scan. CONCLUSIONS: Radiation doses delivered during ultrafast micro-CT serial imaging in the mouse are low and are likely below the threshold to affect tumor growth.

The 2017 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual workforce survey to determine the makeup of the radiology workforce and to identify potential plans for hiring new staff in an attempt to understand our profession better. METHODS: The Practice of Radiology Environment Database group leaders were asked to complete an electronic survey regarding the makeup of their present workforce by subspecialty, as well as the numbers and types of subspecialists hired in 2016 and the numbers and types of subspecialists expected to be hired in 2017 and 2020. They were also asked about midlevel practitioners. RESULTS: Twenty-six percent of practice leaders (477) representing 11,056 radiologists, 33% of all practicing radiologists in the United States, responded to the survey. The workforce distribution by practice type and radiologists' ages has been relatively stable since 2012. Six percent of the practicing workforce is over the age of 65 years. Sixteen percent of radiologists work part-time, and 21.5% of radiologists are female. The survey results indicate that 1,569 to 2,037 radiologists were hired in 2016. In 2017, 1,826 to 2,370 new job opportunities are anticipated, a 14.1% increase compared with 2016. For 2017, the subspecialists most recruited will be neuroradiologists, general interventionalists, after-hours radiologists, and body imagers. Approximately 2,156 midlevel practitioners are presently working and supervised by radiologists. CONCLUSIONS: The 2017 ACR workforce study shows an optimistic picture and outlook for those seeking jobs as practicing radiologists in 2017. For practice leaders, the market will be much more competitive than it has been in past years.

Work-Related Injuries of Radiologists and Possible Ergonomic Solutions: Recommendations From the ACR Commission on Human Resources.

Increasingly, radiologists' workplaces revolve around PACS and digital imaging. Use of these technologies can lead to repetitive strain injuries, many of which can be exacerbated by specific features of a radiology practice environment. Ergonomic approaches, such as proper reading room structure, lighting, temperature, noise, and equipment setup, can help decrease the frequency and severity of repetitive strain injuries and improve radiologist productivity. However, ergonomic approaches are complex, include all aspects of the radiology practice environment, and are best implemented along with proper training of the practicing radiologists. The ergonomic approaches considered most important by members of the ACR Commission on Human Resources are presented in this report, and this information may serve as an aid in departmental planning.

Addition of the Fleischner Society Guidelines to Chest CT Examination Interpretive Reports Improves Adherence to Recommended Follow-up Care for Incidental Pulmonary Nodules.

RATIONALE AND OBJECTIVES: The study aimed to determine whether the addition of the Fleischner Society guidelines to chest computed tomography (CT) reports identifying incidental pulmonary nodules affects follow-up care. PATIENTS AND METHODS: Beginning in 2008, a template containing the Fleischner Society guidelines was added at the interpreting radiologist's discretion to chest CT reports describing incidental solid pulmonary nodules at our institution. The records of all medical centers in Olmsted county were used to capture the complete medical history of local patients >35 years old diagnosed with a pulmonary nodule from April 1, 2008 to October 1, 2011. Patients with a history of cancer or previously diagnosed nodule, or who died before follow-up, were excluded. Patients were categorized according to whether they did ("template group") or did not ("control group") have the template added. Nodule size and smoking history were used to determine recommended follow-up care. Differences in follow-up were compared between groups using Pearson's chi-square test. RESULTS: A total of 510 patients (276 in the template group, 234 in the control group) were included in the study. Only 198 patients (39%) received their recommended follow-up care. Template group patients were significantly more likely to receive recommended follow-up care compared to control group patients (45% vs 31%, P = .0014). Most patients whose management did not adhere to Fleischner Society guidelines did not receive a recommended follow-up chest CT (210 out of 312, 67%). CONCLUSIONS: The addition of the Fleischner Society guidelines to chest CT reports significantly increases the likelihood of receiving recommended follow-up care for patients with incidental pulmonary nodules. Additional education is needed to improve appropriate guideline utilization by radiologists and adherence by ordering providers.

In vivo quantitation of intratumoral radioisotope uptake using micro-single photon emission computed tomography/computed tomography.

PURPOSE: This study was undertaken to determine the ability of micro-single photon emission computed tomography (micro-SPECT)/computed tomography (CT) to accurately quantitate intratumoral radioisotope uptake in vivo and to compare these measurements with planar imaging and micro-SPECT imaging alone. PROCEDURES: Human pancreatic cancer xenografts were established in 10 mice. Intratumoral radioisotope uptake was achieved via intratumoral injection of an attenuated measles virus vector expressing the NIS gene (MV-NIS). On various days after MV-NIS injection, (123)I planar and micro-SPECT/CT imaging was performed. Tumor activity was determined by dose calibrator measurements and region-of-interest (ROI) image analysis. Agreement and reproducibility of tumor activity measurements were assessed by Bland-Altman plots and Lin's concordance correlation coefficient (CCC). RESULTS: Intratumoral radioisotope uptake was detected in all mice. Scatterplots demonstrate strong agreement (CCC = 0.93) between micro-SPECT/CT ROI image analysis and dose calibrator tumor activity measurements. The differences between dose calibrator activity measurements and those obtained with ROI image analysis of micro-SPECT alone and planar imaging are less accurate and more variable (CCC = 0.84 and 0.78, respectively). CONCLUSIONS: Micro-SPECT/CT can be used to accurately quantify intratumoral radioisotope uptake in vivo and is more reliable than planar or micro-SPECT imaging alone.

The Radiologist and Depression.

Clinical depression affects physicians, including radiologists. Medical professionals, including radiologists, may be more comfortable treating a patient than being one, and psychiatric issues may be regarded as taboo for discussion, so the issue of clinical depression in the specialty and subspecialty has not received widespread attention. Specifically, a review of the national and international literature in PubMed, Scopus, and Google reveals few publications dedicated to the issue of clinical depression in radiology; although statistically, they must exist. The purpose of this report is to define the terms and describe the manifestations and scope of the issues related to clinical depression, with special attention given to risk factors unique to radiologists, such as working in low ambient light or near different fields of magnetic strength. By the end of the article, it is the authors' hope that the reading radiologist will be aware of, and open to, the possibility of clinical depression in a colleague or within his or herself because clinical depression is common and it is important to get help.