New Job, New Challenges: Life After Radiology Training.

OBJECTIVE: Beginning a new job after radiology training is exciting but can also be nerve-racking. The key challenge remains making the strange familiar and assimilating with the new practice as soon as possible. This process is complicated and may require learning new policies, getting to know new colleagues, adapting to new surroundings, and learning new skills. CONCLUSION: This article provides strategies to navigate professionally and adapt to a new environment.

ACR TI-RADS: Pitfalls, Solutions, and Future Directions.

The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. Risk classification models based on US features have been created by multiple professional societies, including the American College of Radiology (ACR), which published the Thyroid Imaging Reporting and Data System (TI-RADS) in 2017. ACR TI-RADS uses a standardized lexicon for assessment of thyroid nodules to generate a numeric scoring of features, designate categories of relative probability of benignity or malignancy, and provide management recommendations, with the aim of reducing unnecessary biopsies and excessive surveillance. Adopting ACR TI-RADS may require practice-level changes involving image acquisition and workflow, interpretation, and reporting. Significant resources should be devoted to educating sonographers and radiologists to accurately recognize features that contribute to the scoring of a nodule. Following a system that uses approved terminology generates reproducible and relevant reports while providing clarity of language and preventing misinterpretation. Comprehensive documentation facilitates quality improvement efforts. It also creates opportunities for outcome data and other performance metrics to be integrated with research. The authors review ACR TI-RADS, describe challenges and potential solutions related to its implementation based on their experiences, and highlight possible future directions in its evolution. ©RSNA, 2019 See discussion on this article by Hoang.

Heuristics and Cognitive Error in Medical Imaging.

OBJECTIVE: The field of cognitive science has provided important insights into mental processes underlying the interpretation of imaging examinations. Despite these insights, diagnostic error remains a major obstacle in the goal to improve quality in radiology. In this article, we describe several types of cognitive bias that lead to diagnostic errors in imaging and discuss approaches to mitigate cognitive biases and diagnostic error. CONCLUSION: Radiologists rely on heuristic principles to reduce complex tasks of assessing probabilities and predicting values into simpler judgmental operations. These mental shortcuts allow rapid problem solving based on assumptions and past experiences. Heuristics used in the interpretation of imaging studies are generally helpful but can sometimes result in cognitive biases that lead to significant errors. An understanding of the causes of cognitive biases can lead to the development of educational content and systematic improvements that mitigate errors and improve the quality of care provided by radiologists.

Fundamentals of Diagnostic Error in Imaging.

Imaging plays a pivotal role in the diagnostic process for many patients. With estimates of average diagnostic error rates ranging from 3% to 5%, there are approximately 40 million diagnostic errors involving imaging annually worldwide. The potential to improve diagnostic performance and reduce patient harm by identifying and learning from these errors is substantial. Yet these relatively high diagnostic error rates have persisted in our field despite decades of research and interventions. It may often seem as if diagnostic errors in radiology occur in a haphazard fashion. However, diagnostic problem solving in radiology is not a mysterious black box, and diagnostic errors are not random occurrences. Rather, diagnostic errors are predictable events with readily identifiable contributing factors, many of which are driven by how we think or related to the external environment. These contributing factors lead to both perceptual and interpretive errors. Identifying contributing factors is one of the keys to developing interventions that reduce or mitigate diagnostic errors. Developing a comprehensive process to identify diagnostic errors, analyze them to discover contributing factors and biases, and develop interventions based on the contributing factors is fundamental to learning from diagnostic error. Coupled with effective peer learning practices, supportive leadership, and a culture of quality, this process can unquestionably result in fewer diagnostic errors, improved patient outcomes, and increased satisfaction for all stakeholders. This article provides the foundational elements for implementing this type of process at a radiology practice, with examples to help radiologists and practice leaders achieve meaningful practice improvement. ©RSNA, 2018.

Papillary Thyroid Carcinoma Recurrence: Low Yield of Neck Ultrasound With an Undetectable Serum Thyroglobulin Level.

OBJECTIVES: To assess the yield of neck ultrasound (US) when serum thyroglobulin (Tg) is undetectable (<0.1 ng/mL) compared to elevated serum Tg in patients with differentiated papillary thyroid carcinoma (PTC) treated with thyroidectomy and radioactive iodine 131 (RAI) ablation. METHODS: A retrospective chart review was conducted from 2010 through 2015 at an academic institution evaluating US results in patients with serum Tg levels obtained within 6 months of a neck US examination after thyroidectomy and RAI. The reference standard for recurrence was pathologic results from US-guided fine-needle aspiration (FNA) or follow-up for at least 1 year. RESULTS: Among 76 patients with undetectable serum Tg levels, there were 19 examinations in 18 patients in which US raised the possibility of recurrence. None of these 18 patients had recurrence by FNA (n = 8) or clinical follow-up of at least 1 year (n = 10). Among 65 patients with elevated serum Tg levels, there were 24 examinations in 22 patients in which US raised the possibility of recurrence. Twelve patients underwent FNA, with 9 patients (34.6%) showing PTC; 7 patients had follow-up neck US examinations showing stability of findings; and 3 patients were lost to follow up. The yield of neck US was significantly lower when serum Tg was undetectable compared to when levels were elevated (P = .001). CONCLUSIONS: Neck US did not identify recurrent PTC when the serum Tg level was undetectable in patients who underwent total thyroidectomy and RAI therapy. Eliminating neck US when serum TG levels are undetectable could decrease unnecessary imaging examinations without negatively affecting the ability to detect recurrent disease.

Patient-centered Radiology.

Patient-centered care (ie, care organized around the patient) is a model in which health care providers partner with patients and families to identify and satisfy patients' needs and preferences. In this model, providers respect patients' values and preferences, address their emotional and social needs, and involve them and their families in decision making. Radiologists have traditionally been characterized as "doctor-to-doctor" consultants who are distanced from patients and work within a culture that does not value patient centeredness. As medicine becomes more patient driven and the trajectory of health care is toward increasing patient self-reliance, radiologists must change the perception that they are merely consultants and become more active participants in patient care by embracing greater patient interaction. The traditional business model for radiology practices, which devalues interaction between patients and radiologists, must be transformed into a patient-centered model in which radiologists are reintegrated into direct patient care and imaging processes are reorganized around patients' needs and preferences. Expanding radiology's core assets to include direct patient care may be the most effective deterrent to the threat of commoditization. As the assault on the growth of Medicare spending continues, with medical imaging as a highly visible target, radiologists must adapt to the changing landscape by focusing on their most important consumer: the patient. This may yield substantial benefits in the form of improved quality and patient safety, reduced costs, higher-value care, improved patient outcomes, and greater patient and provider satisfaction.

Developing an automated database for monitoring ultrasound- and computed tomography-guided procedure complications and diagnostic yield.

Monitoring complications and diagnostic yield for image-guided procedures is an important component of maintaining high quality patient care promoted by professional societies in radiology and accreditation organizations such as the American College of Radiology (ACR) and Joint Commission. These outcome metrics can be used as part of a comprehensive quality assurance/quality improvement program to reduce variation in clinical practice, provide opportunities to engage in practice quality improvement, and contribute to developing national benchmarks and standards. The purpose of this article is to describe the development and successful implementation of an automated web-based software application to monitor procedural outcomes for US- and CT-guided procedures in an academic radiology department. The open source tools PHP: Hypertext Preprocessor (PHP) and MySQL were used to extract relevant procedural information from the Radiology Information System (RIS), auto-populate the procedure log database, and develop a user interface that generates real-time reports of complication rates and diagnostic yield by site and by operator. Utilizing structured radiology report templates resulted in significantly improved accuracy of information auto-populated from radiology reports, as well as greater compliance with manual data entry. An automated web-based procedure log database is an effective tool to reliably track complication rates and diagnostic yield for US- and CT-guided procedures performed in a radiology department.

Hepatic transplantation: postoperative complications.

Advances in surgical techniques and immunosuppression have made orthotopic liver transplantation a first-line treatment for many patients with end-stage liver disease. The early detection and treatment of postoperative complications has contributed significantly to improved graft and patient survival with imaging playing a critical role in detection. Complications that can lead to graft failure or patient mortality include vascular abnormalities, biliary abnormalities, allograft rejection, and recurrent or post-transplant malignancy. Vascular abnormalities include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava, as well as hepatic artery pseudoaneurysm, arteriovenous fistula, and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not used to diagnose allograft rejection, it plays an important role in identifying complications that can mimic rejection. Ultrasound is routinely performed as the initial imaging modality for the detection and follow-up of both early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are used to characterize biliary complications and computed tomography is used to confirm abnormal findings on ultrasound or for the evaluation of postoperative collections. The purpose of this article is to describe and illustrate the imaging appearances and management of complications associated with liver transplantation.

The Role of Intuitive Cognition in Radiologic Decision Making.

The decision making involved in radiologic interpretation entails distinct cognitive pathways. On one side is analytic reasoning, which represents a deliberate, stepwise process integrating discrete data to formulate an interpretation, in which a range of diagnostic possibilities are directly compared. On the other side is intuition, which represents an automatic, rapid, and holistic form of decision making that generates an interpretation absent the sequential processing of data and direct comparison of possibilities. Nonexpert intuitive cognition often reflects domain-independent heuristics (ie, mental rules of thumb) that are often effective but prone to bias and systematic error. In contrast, expert intuition reflects the domain-specific skills developed among highly experienced practitioners who have gained deep knowledge in a given task domain from extensive practice and feedback. In this article, the authors define intuitive cognition, show evidence for its pervasive use among experts in a variety of fields, and explain its strengths and weaknesses relative to deliberate reasoning. Developing expert intuition requires the opportunity to learn from reliable feedback, and the authors describe various measures that can be used by radiology departments to foster such opportunities. Finally, the authors discuss implications for diagnostic performance and error reduction in clinical radiology.

Pancreatic Adenocarcinoma: Diagnostic Errors, Contributing Factors and Solutions.

The purpose of this article is to review diagnostic errors in preoperative and post-operative imaging for pancreatic ductal adenocarcinoma (PDAC), discuss contributing factors, and provide solutions that minimize errors. Accurate radiological staging and restaging of PDAC dictates surgical management and errors can have significant negative effects on patient care, such as missed vessel involvement or metastatic disease that would preclude surgery. Familiarity with these errors and their contributing factors improves diagnostic accuracy and ultimately leads to improved patient outcomes.

Using focused missed-case conferences to reduce discrepancies in musculoskeletal studies interpreted by residents on call.

OBJECTIVE: The purpose of this study is to determine whether focused missed-case conferences can significantly reduce the number of major discrepancies in musculoskeletal imaging studies interpreted by residents on call. MATERIALS AND METHODS: A review of major discrepancies in musculoskeletal conventional radiography imaging studies interpreted by radiology residents and fellows on call from July 2008 to July 2009 revealed 31 common and important musculoskeletal injuries missed or misinterpreted at our institution. These missed cases were presented during focused missed-case conferences from July through October 2009. Only residents attended missed-case conferences. RESULTS: Over the 12 months before the missed-case conferences, there were 55 resident major discrepancies and 25 fellow major discrepancies, representing 31 common and important missed musculoskeletal injuries. Over the 12 months after the missed-case conferences, there were 18 resident major discrepancies and 21 fellow major discrepancies involving these injuries. This corresponds to a 67% reduction in the number of resident major discrepancies involving the 31 musculoskeletal injuries covered during the missed-case conferences (chi-square p < 0.001). The overall major discrepancy rate for all musculoskeletal conventional radiography studies was 1.19% for residents and 1.55% for fellows (not significant) before the missed-case conferences and 0.87% for residents and 1.46% for fellows (p < 0.05) after the missed-case conferences. During this time, fellows missed more musculoskeletal injuries related to the topics discussed during missed-case conferences (16) compared with residents (8) although fellows read significantly fewer studies overall. This accounted for 0.49% of the 0.59% difference between residents and fellows. CONCLUSION: Focused missed-case conferences are an effective educational intervention to significantly reduce the number of major discrepancies in radiology resident interpretation of musculoskeletal imaging studies on call.

Orion: a web-based application designed to monitor resident and fellow performance on-call.

Radiology residency and fellowship training provides a unique opportunity to evaluate trainee performance and determine the impact of various educational interventions. We have developed a simple software application (Orion) using open-source tools to facilitate the identification and monitoring of resident and fellow discrepancies in on-call preliminary reports. Over a 6-month period, 19,200 on-call studies were interpreted by 20 radiology residents, and 13,953 on-call studies were interpreted by 25 board-certified radiology fellows representing eight subspecialties. Using standard review macros during faculty interpretation, each of these reports was classified as "agreement", "minor discrepancy", and "major discrepancy" based on the potential to impact patient management or outcome. Major discrepancy rates were used to establish benchmarks for resident and fellow performance by year of training, modality, and subspecialty, and to identify residents and fellows demonstrating a significantly higher major discrepancy rate compared with their classmates. Trends in discrepancies were used to identify subspecialty-specific areas of increased major discrepancy rates in an effort to tailor the didactic and case-based curriculum. A series of missed-case conferences were developed based on trends in discrepancies, and the impact of these conferences is currently being evaluated. Orion is a powerful information technology tool that can be used by residency program directors, fellowship programs directors, residents, and fellows to improve radiology education and training.

Use of a Dedicated Server to Perform Coronal and Sagittal Reformations in Trauma Examinations.

The purpose of this study was to evaluate the impact of implementing an automated process for generating coronal and sagittal reformatted images on radiologist workflow. When performing trauma-related CT examinations of the cervical, thoracic, and lumbar spine at our institution, technologists manually generate coronal and sagittal reconstructions at the scanner console and send these images to a picture archiving and communication system (PACS) for interpretation by radiologists and clinical viewing. Although certain PACS, thin-client three-dimensional systems, and CT scanners are capable of automatically generating reconstructed or reformatted images, the systems at our institution do not support this functionality. We have recently integrated a dedicated server that is capable of automatically generating multiplanar reformatted (MPR) images from source thin-section axial images and sending these images to PACS without requiring technologist input. This dedicated server was used to generate coronal and sagittal MPRs for trauma-related spine studies in parallel with technologist-generated coronal and sagittal reconstructions. When comparing the two methods, using the dedicated server to automatically generate reformations resulted in substantial time savings for the radiologist compared to technologist-generated reconstructions. Additionally, a survey of interpreting radiologists indicated that a significant majority preferred to view the automatically generated MPRs on PACS compared to the thin-client system, considered the image quality to be good or excellent, and believed that viewing MPRs increased diagnostic accuracy and confidence. It is expected that this automated process will significantly improve radiologist workflow with respect to image interpretation time and report turnaround time.

Circadian regulation of a-type potassium currents in the suprachiasmatic nucleus.

In mammals, the precise circadian timing of many biological processes depends on the generation of oscillations in neural activity of pacemaker cells in the suprachiasmatic nucleus (SCN) of the hypothalamus. Understanding the ionic mechanisms underlying these rhythms is an important goal of research in chronobiology. Previous work has shown that SCN neurons express A-type potassium currents (IAs), but little is known about the properties of this current in the SCN. We sought to characterize some of these properties, including the identities of IA channel subunits found in the SCN and the circadian regulation of IA itself. In this study, we were able to detect significant hybridization for Shal-related family members 1 and 2 (Kv4.1 and 4.2) within the SCN. In addition, we used Western blot to show that the Kv4.1 and 4.2 proteins are expressed in SCN tissue. We further show that the magnitude of the IA current exhibits a diurnal rhythm that peaks during the day in the dorsal region of the mouse SCN. This rhythm seems to be driven by a subset of SCN neurons with a larger peak current and a longer decay constant. Importantly, this rhythm in neurons in the dorsal SCN continues in constant darkness, providing an important demonstration of the circadian regulation of an intrinsic voltage-gated current in mammalian cells. We conclude that the anatomical expression, biophysical properties, and pharmacological profiles measured are all consistent with the SCN IA current being generated by Kv4 channels. Additionally, these data suggest a role for IA in the regulation of spontaneous action potential firing during the transitions between day/night and in the integration of synaptic inputs to SCN neurons throughout the daily cycle.

Fast delayed rectifier potassium current is required for circadian neural activity.

In mammals, the precise circadian timing of many biological processes depends on the generation of oscillations in neural activity of pacemaker cells in the suprachiasmatic nucleus (SCN). The ionic mechanisms that underlie these rhythms are largely unknown. Using the mouse brain slice preparation, we show that the magnitude of fast delayed rectifier (FDR) potassium currents has a diurnal rhythm that peaks during the day. Notably, this rhythm continues in constant darkness, providing the first demonstration of the circadian regulation of an intrinsic voltage-gated current in mammalian cells. Blocking this current prevented the daily rhythm in firing rate in SCN neurons. Kv3.1b and Kv3.2 potassium channels were widely distributed within the SCN, with higher expression during the day. We conclude that the FDR is necessary for the circadian modulation of electrical activity in SCN neurons and represents an important part of the ionic basis for the generation of rhythmic output.

The Incentive Dilemma: Intrinsic Motivation and Workplace Performance.

Incentive plans are a core component of many radiology positions and are often considered a major factor in the ability to recruit and retain high-performing radiologists. Financial incentives are widely thought to be effective at motivating individuals, but there is considerable evidence to the contrary. In this report, the authors examine basic assumptions about financial incentives and debate the potential negative impact of financial incentive systems on performance at radiology practices.

Cost-Effectiveness Analysis: An Overview of Key Concepts, Recommendations, Controversies, and Pitfalls.

The field of radiology has witnessed a burst of technological advances that improve diagnostic quality, reduce harm to patients, support clinical needs, and better serve larger more diverse patient populations. One of the critical challenges with these advances is proving that value outweighs the cost. The use of cutting-edge technology is often expensive, and the reality is that our society cannot afford all the screening and diagnostic tests that are being developed. At the societal level, we need tools to help us decide which health programs should be funded. Therefore, decision makers are increasingly looking toward scientific methods to compare health technologies in order to improve allocation of resources. One of such methods is cost-effectiveness analysis. In this article, we review key features of cost-effectiveness analysis and its specific issues as they relate to radiology.

Diagnostic Error Categorization at Abdominal Imaging Peer Learning Conference.

Recognizing and preventing diagnostic errors is an increasingly emphasized topic across medicine, and abdominal imaging is no exception. Peer-learning strives for quality improvement through understanding why errors occur and identifying opportunities to prevent errors from recurring. In an effort to learn from mistakes, our abdominal imaging section initiated a Peer Learning Conference, where errors are discussed and compartmentalized into one or more of the following categories: Observation, Interpretation, Communication, and Inadequate Data Gathering. In this manuscript, the structure of our Peer Learning Conference is introduced and the components of each discrepancy category are described in detail. Images are included to highlight learning points through exemplary cases from the conference.

Automated Segmentation of Tissues Using CT and MRI: A Systematic Review.

RATIONALE AND OBJECTIVES: The automated segmentation of organs and tissues throughout the body using computed tomography and magnetic resonance imaging has been rapidly increasing. Research into many medical conditions has benefited greatly from these approaches by allowing the development of more rapid and reproducible quantitative imaging markers. These markers have been used to help diagnose disease, determine prognosis, select patients for therapy, and follow responses to therapy. Because some of these tools are now transitioning from research environments to clinical practice, it is important for radiologists to become familiar with various methods used for automated segmentation. MATERIALS AND METHODS: The Radiology Research Alliance of the Association of University Radiologists convened an Automated Segmentation Task Force to conduct a systematic review of the peer-reviewed literature on this topic. RESULTS: The systematic review presented here includes 408 studies and discusses various approaches to automated segmentation using computed tomography and magnetic resonance imaging for neurologic, thoracic, abdominal, musculoskeletal, and breast imaging applications. CONCLUSION: These insights should help prepare radiologists to better evaluate automated segmentation tools and apply them not only to research, but eventually to clinical practice.