Cybersecurity in radiology: Cautionary Tales, Proactive Prevention, and What to do When You Get Hacked.

To improve awareness and understanding of cybersecurity threats to radiology practice and better equip healthcare practices to manage cybersecurity risks associated with medical imaging, this article reviews topics related to cybersecurity in healthcare, with emphasis on common vulnerabilities in radiology operations. This review is intended to assist radiologists and radiology administrators who are not information technology specialists to attain an updated overview of relevant cybersecurity concepts and concerns relevant to safe and effective practice of radiology and provides a succinct reference for individuals interested in learning about imaging-related vulnerabilities in healthcare settings. As cybersecurity incidents have become increasingly common in healthcare, we first review common cybersecurity threats in healthcare and provide updates on incidence of healthcare data breaches, with emphasis on the impact to radiology. Next, we discuss practical considerations on how to respond to a healthcare data breach, including notification and disclosure requirements, and elaborate on a variety of technical, organizational, and individual actions that can be adopted to minimize cybersecurity risks applicable to radiology professionals and administrators. While emphasis is placed on specific vulnerabilities within radiology workflow, many of the preventive or mitigating strategies are also relevant to cybersecurity within the larger digital healthcare arena. We anticipate that readers, upon completing this review article, will gain a better appreciation of cybersecurity issues relevant to radiology practice and be better equipped to mitigate cybersecurity risks associated with medical imaging.

Convolutional Neural Networks for Segmentation of Malignant Pleural Mesothelioma: Analysis of Probability Map Thresholds (CALGB 30901, Alliance).

Malignant pleural mesothelioma (MPM) is the most common form of malignant mesothelioma, with exposure to asbestos being the primary cause of the disease. To assess response to treatment, tumor measurements are acquired and evaluated based on a patient's longitudinal computed tomography (CT) scans. Tumor volume, however, is the more accurate metric for assessing tumor burden and response. Automated segmentation methods using deep learning can be employed to acquire volume, which otherwise is a tedious task performed manually. The deep learning-based tumor volume and contours can then be compared with a standard reference to assess the robustness of the automated segmentations. The purpose of this study was to evaluate the impact of probability map threshold on MPM tumor delineations generated using a convolutional neural network (CNN). Eighty-eight CT scans from 21 MPM patients were segmented by a VGG16/U-Net CNN. A radiologist modified the contours generated at a 0.5 probability threshold. Percent difference of tumor volume and overlap using the Dice Similarity Coefficient (DSC) were compared between the standard reference provided by the radiologist and CNN outputs for thresholds ranging from 0.001 to 0.9. CNN annotations consistently yielded smaller tumor volumes than radiologist contours. Reducing the probability threshold from 0.5 to 0.1 decreased the absolute percent volume difference, on average, from 43.96% to 24.18%. Median and mean DSC ranged from 0.58 to 0.60, with a peak at a threshold of 0.5; no distinct threshold was found for percent volume difference. The CNN exhibited deficiencies with specific disease presentations, such as severe pleural effusion or disease in the pleural fissure. No single output threshold in the CNN probability maps was optimal for both tumor volume and DSC. This study emphasized the importance of considering both figures of merit when evaluating deep learning-based tumor segmentations across probability thresholds. This work underscores the need to simultaneously assess tumor volume and spatial overlap when evaluating CNN performance. While automated segmentations may yield comparable tumor volumes to that of the reference standard, the spatial region delineated by the CNN at a specific threshold is equally important.

The University of Chicago Clinical Excellence Scholars Track: Aligning Dynamic Students With Innovative Programming in Early Medical Education at the Undergraduate Level.

The Clinical Excellence Scholars Track was developed in 2012 as a shared initiative between the Bucksbaum Institute for Clinical Excellence, the University of Chicago (UChicago) Careers in Healthcare office, and the UChicago Medicine Office of Community and External Affairs. The goal of the Clinical Excellence Scholars Track is to foster an understanding of the physician career and the doctor-patient relationship for a select group of undergraduate students. The Clinical Excellence Scholars Track achieves this goal through carefully tailored curricular requirements and direct mentoring experiences between Bucksbaum Institute Faculty Scholars and the student scholars. After participating in the Clinical Excellence Scholars Track program, student scholars report that their career understanding and preparation have benefitted as a result and that they meet with success in the medical school application process as well.

Using a Nationwide Virtual Radiology Student Interest Group to Expand Medical Students' General Awareness, Drive Greater Interest, and Achieve Uniform National Messaging in the Field of Radiology.

RATIONALE AND OBJECTIVES: Many medical schools offer minimal exposure to radiology, leading to a decreased understanding of the field and negative perceptions among medical students. The purpose of this study was to examine the effects of a radiology intensive series piloted by a novel virtual radiology interest group. Specifically, we were interested in how radiologists and medical educators can expand students' general awareness, drive greater interest in the field, and achieve more uniform national messaging across all trainees. MATERIALS AND METHODS: We launched a national/international interest group called Radiology Student Interest Group (RadSIG) and piloted the RadSIG Intensive, a series of five events aimed at increasing awareness and dispelling misconceptions among preclinical medical students. Validated pre-intensive and post-intensive surveys were used to ascertain the students' baseline and changed perspectives, respectively. A separate faculty survey was also distributed to understand how they perceived our events. Statistical analysis was carried out on the collected data to identify trends and assess the utility of our programming. RESULTS: 205 students completed the pre-intensive survey, and 61 students completed the post-intensive survey. Of the pre-intensive survey respondents, 51.7% (106/205) indicated that they had a limited understanding of what a career in radiology entails. Of those who completed the entire RadSIG Intensive, average 5-point Likert scale scores for understanding of a radiology career rose from 3.30 to 4.38 respectively pre- to post-completion. A Wilcoxon signed-rank test revealed that this difference was statistically significant (Z=-5.95, p<0.001), and that the RadSIG Intensive significantly improved perceptions of radiologists across every single question measured, except for perception of long hours worked (Z=-0.20, p=0.841). The results also showed increased student comfort in reaching out to radiology attendings (Z=-4.30, p<0.001) and residents (Z=-5.12, p<0.001). Faculty survey results indicated positive perceptions of the series. CONCLUSION: Our results show that the RadSIG Intensive was effective in increasing students' understanding of radiology as a field and a potential career. Online outreach can also lower the resistance and improve student comfort in reaching out for mentorship, which may provide a new pathway to reach underserved students with a unifying message. By furthering a platform based on voluntary and supplemental resources, we see a far greater potential of impacting the perception and known role of the imager in patient care among our next generation of physicians.

Considerations for Imaging of Malignant Pleural Mesothelioma: A Consensus Statement from the International Mesothelioma Interest Group.

Malignant pleural mesothelioma (MPM) is an aggressive primary malignancy of the pleura that presents unique radiologic challenges with regard to accurate and reproducible assessment of disease extent at staging and follow-up imaging. By optimizing and harmonizing technical approaches to imaging MPM, the best quality imaging can be achieved for individual patient care, clinical trials, and imaging research. This consensus statement represents agreement on harmonized, standard practices for routine multimodality imaging of MPM, including radiography, computed tomography, 18F-2-deoxy-D-glucose positron emission tomography, and magnetic resonance imaging, by an international panel of experts in the field of pleural imaging assembled by the International Mesothelioma Interest Group. In addition, modality-specific technical considerations and future directions are discussed. A bulleted summary of all technical recommendations is provided.

Perspective: Mandatory Radiology Education for Medical Students.

Radiology education of medical students is increasingly important given the intersection of radiology with virtually all medical specialties and integral role of imaging in modern patient care. Yet radiology education requirements in US medical schools are variable with only a minority of schools requiring a clerkship in radiology. When required, the radiology curriculum is often limited to anatomy courses in the preclinical years or partially incorporated into required core clerkships and often taught by nonradiologists. Given the growing mandate for value-based care and emphasis on patient outcomes, medical students require better imaging education, both interpretive and non-interpretative skills. They should be taught how to apply appropriateness criteria for exam ordering and the relative costs of different imaging modalities given the economic implications of imaging overutilization. Medical students should also be educated regarding imaging safety considerations. In addition, they must learn the radiologist's role as consultant to assure appropriate ordering of imaging studies, oversight for performance of diagnostic exams and image-guided procedures, interpretation of studies, and communication of results. Increasing radiologist teaching and engagement with medical students also has the potential to improve diversity and inclusivity in radiology by increasing interest in the specialty as physicians who identify as underrepresented minorities (URMs) are more likely to practice in underserved areas and with underserved populations thus addressing healthcare disparities and improving access to healthcare for those patient populations. Medical schools should support preclinical and clinical curricula that is designed and taught by radiologists.

Multilevel Approach to Support Diversity, Equity and Inclusion in Radiology.

Integrating diversity into healthcare systems has its challenges and advantages. Academic medicine strives to expand the diversity of the healthcare workforce. The Association of University Radiologists (AUR) put together a task force to review the concept of Diversity, Equity and Inclusion (DEI) as it pertains to Radiology and to propose strategies for better integrating DEI in Radiology. We present several measures aimed at the trainee, leadership, management and professional society levels to empower DEI in Radiology.

Current Perception of Diversity in Academic Radiology: A Mixed Methods Study of Radiology Program Directors.

OBJECTIVES: To assess the perceived state of diversity in Radiology Residency Programs in the United States and to evaluate the level of acceptance for diversity, equity, and inclusion (DEI) initiatives. METHODS: An electronic survey was conducted of the Radiology Residency Programs in the United States in December 2021 and January 2022. Respondents were recruited by email sent to the members of the Association of University Radiologists who were Radiology Residency Program Directors. Quantitative and Qualitative analyses were performed. RESULTS: Of the 198 emails sent out to the Radiology Program Directors, 53 completed surveys were returned (response rate of 27%). Although some progress has been made in increasing the number of women and Asians in Academic Radiology, there is persisting imbalance of the numbers of African American and Latinx radiologists which comprise far less than 25% of the physician workforce. Nearly half of the respondents reported having a Vice Chair of DEI. Three themes emerged from the qualitative analysis. Most respondents agreed that diversity should be considered when recruiting faculty and residents. Many noted a strong commitment to DEI but they felt there was room for improvement in formalizing efforts to aid in recruitment of underrepresented minorities. Diversity education was more likely mandatory for residents and optional for faculty. CONCLUSION: Academic Radiology programs are recognizing the value of internal DEI leadership roles. Radiologists are implementing DEI initiatives and making intentional changes in the recruitment of diverse radiologists. More concerted efforts are needed to increase the low numbers of African American and Latinx radiologists. Effective evaluation metrics for various DEI programs are needed to assess how successful these endeavors are in creating lasting changes.

Analysis of 10 Years of Diagnostic Radiology Match Data: Notable Changes and Their Potential Implications.

RATIONALE AND OBJECTIVES: Identification of shifts in match metrics, such as applicant volumes, match rates, and interview patterns, stands to inform and empower both applicants and programs participating in the NRMP residency match. Residency programs rarely publish their internal data. Accordingly, we employed publicly available resources to evaluate changes in such metrics for the diagnostic radiology match from 2008 to 2018. MATERIALS AND METHODS: Reports made available to the public by the NRMP, alongside student discussion on the AuntMinnie.com and StudentDoctor.net forums, were used to determine applicant volumes, interview volumes, program rank-order-list metrics, match rates, and interview invite patterns. Linear regression and correlation analyses were employed to identify statistically significant trends. RESULTS: No statistically significant trends were identified across the selected timeframe for applicant volumes or match rates. Statistically significant upward trends were identified for total interview volumes, average interviews attended per applicant, and the fraction of programs inviting students to interview before October 1st, the MSPE release date (p < 0.05). A very strong and significant positive correlation was identified between average interviews attended per applicant and the average number of ranks needed by programs to fill a position (p < 0.01, R = 0.804). CONCLUSION: Applicants pursuing a diagnostic radiology residency are attending more interviews, and programs are increasingly inviting students to interview based on incomplete applications. However, there has been no corresponding uptrend in match rates. Moreover, increased applicant interview attendance is highly associated with programs falling further down their rank lists. Given the expenses usually associated with the match process and forthcoming changes to USMLE scoring, these trends may be unsustainable.

It's a Two-Way Street: Giving and Receiving Feedback to the Unaware.

Giving and receiving constructive feedback is a valuable skill and an evolving process due to improved understanding and changes in culture. This article provides a practical review of key elements of effective feedback skills and strategies for providing constructive feedback, with a focus on how to address recipients who may have impaired insight into the issue at hand. Commonly known tips and tricks include direct, immediate, and specific feedback delivered in a safe setting and in a conversational manner. This article specifically considers how the feedback will be heard or accepted by the intended recipient, in order for the educator to best overcome hurdles in relaying constructive criticism.

Maximizing Value While Volumes are Increasing.

Radiologists are facing ever increasing volumes while trying to provide value-based care. There are several drivers of increasing volumes: increasing population size, aging population, increased utilization, gaps in evidence-based care, changes in the provider workforce, defensive medicine, and increasing case complexity. Higher volumes result in increased cognitive and systemic errors and contribute to radiologist fatigue and burnout. We discuss several strategies for mitigating high volumes including abbreviated MRI protocols, 24/7 radiologist coverage, reading room assistants, and other strategies to tackle radiologist burnout.

Are Women Disproportionately Represented in Education Compared to Other Roles in Academic Radiology?

RATIONALE AND OBJECTIVES: Women in academic medicine, and radiology specifically, are underrepresented in departmental leadership roles and achieve fewer professional metrics of success. We have observed, however, that women are more broadly represented in medical education leadership. The purpose of this study was to determine if women in academic radiology are overrepresented in educational scholarship and educational leadership compared to general research scholarship and leadership positions, and to determine if there is any difference in the distribution of women in these roles compared to internal medicine. MATERIALS AND METHODS: We performed a PubMed search of education articles in radiology and internal medicine over the last 5 years, and the gender of the authors was determined. Data on gender for authorship of general research topics, departmental leaders, and society leadership was obtained via literature and internet searches and the data was aggregated. Representation ratios (RR of 1.0 = parity) were obtained via risk ratio calculation to compare education versus general scholarship, and the distribution of leadership roles within and between these fields. RESULTS: Women make up 28.5% of academic radiologists and 40.1% of academic internists. A higher proportion of education articles were first authored by women than would be expected in both fields with an RR of 1.46 (p < 0.001) in radiology and 1.23 (p < 0.001) in internal medicine. This overrepresentation was significant compared to general research scholarship in both fields (p < 0.001). In both fields, women were overrepresented in the position of Medical Student Director (RR of 1.47 and 1.22, respectively). For Program Directors, women were overrepresented in radiology (RR of 1.12) and underrepresented in internal medicine (RR of 0.69-0.75). Women in radiology were overrepresented in education society leadership (RR = 1.63) compared to general society leadership (0.98, p = 0.001). CONCLUSION: We found that women in radiology are overrepresented in authorship of education articles, and in departmental and society education leadership roles. This trend was also seen in internal medicine, suggesting that women are more broadly represented in medical education.

Deep learning-based segmentation of malignant pleural mesothelioma tumor on computed tomography scans: application to scans demonstrating pleural effusion.

Tumor volume is a topic of interest for the prognostic assessment, treatment response evaluation, and staging of malignant pleural mesothelioma. Many mesothelioma patients present with, or develop, pleural fluid, which may complicate the segmentation of this disease. Deep convolutional neural networks (CNNs) of the two-dimensional U-Net architecture were trained for segmentation of tumor in the left and right hemithoraces, with the networks initialized through layers pretrained on ImageNet. Networks were trained on a dataset of 5230 axial sections from 154 CT scans of 126 mesothelioma patients. A test set of 94 CT sections from 34 patients, who all presented with both tumor and pleural effusion, in addition to a more general test set of 130 CT sections from 43 patients, were used to evaluate segmentation performance of the deep CNNs. The Dice similarity coefficient (DSC), average Hausdorff distance, and bias in predicted tumor area were calculated through comparisons with radiologist-provided tumor segmentations on the test sets. The present method achieved a median DSC of 0.690 on the tumor and effusion test set and achieved significantly higher performance on both test sets when compared with a previous deep learning-based segmentation method for mesothelioma.

Virtual and augmented reality: potential applications in radiology.

The modern-day radiologist must be adept at image interpretation, and the one who most successfully leverages new technologies may provide the highest value to patients, clinicians, and trainees. Applications of virtual reality (VR) and augmented reality (AR) have the potential to revolutionize how imaging information is applied in clinical practice and how radiologists practice. This review provides an overview of VR and AR, highlights current applications, future developments, and limitations hindering adoption.

Teaching Medical Students Optimal Consulting Skills: The Challenge of Generating Better Referring Physicians.

Rationale and objectives We sought to incorporate a new teaching module into the traditional medical student radiology clerkship, to improve the necessary skills for future referring physicians. Materials and methods A new required and graded module was introduced in 2014 into the radiology clerkship in year three of medical school: the Mystery Case. Each student was provided a unique and undifferentiated case from a dedicated teaching file containing de-identified images and requisition data. Students were expected to complete three serial tasks over one week: 1) prepare a voice recognition-derived, structured radiological report utilizing appropriate and relevant vocabulary; 2) discuss pertinent additional clinical information; and 3) discuss appropriate follow-up imaging, in addition to information on how to best prepare patients for these potential patient exams (e.g., with or without contrast, bowel preparation, and length of study). Students were provided written examples and dedicated class instruction with interactive discussions covering specific cases and associated related cases through random pairing with radiology resident and attending mentors. At the close of the week, students gave brief oral presentations of their cases and submitted the tasks for a written evaluation. Upon completion of the clerkship, the students completed a Likert-type six-item survey to evaluate the perceived improvement in select skills. Results The survey was completed by 82% (54/66) of the enrolled students, with 85% finding the Mystery Case an effective use of time. Medical students perceived an improved awareness of the patient care process (77%), awareness of the medical imaging resources available (89%), ability to understand a radiology report (74%), and ability to advise patients (69%). Conclusion Introduction of the Mystery Case as a graded exercise in the medical school radiology clerkship was perceived by students as effective use of time, with an improvement in the skills essential for future referring physicians.

Radiology Education in the 21st Century: Threats and Opportunities.

Over the past 25 years, radiology has seen tremendous growth in interpretive demands, including increasing imaging volumes and shorter turnaround times, as well as increased noninterpretive demands often targeting value-adding opportunities. These mounting pressures have led to increased burnout among radiologists nationwide and, in the academic setting, have begun to threaten the core educational mission. Despite these threats, radiology has also proven itself over the years to be a leader when it comes to innovation, and as such, no other field is better suited to confront these challenges with innovative solutions. This article explores the impact these workload trends have had on radiology education and educators, as well as opportunities to confront these challenges.