NAM National Plan for Health Workforce Well-being: Applications for Radiology.

The National Academy of Medicine Plan for Health Workforce Well-Being identifies seven priority areas, including creating positive work environments, addressing burnout and stress, promoting transparency and equity in compensation, providing education and training to promote resilience, enhancing community and social support systems, addressing the stigma associated with seeking help for mental health and substance use disorders and fostering leadership commitment and accountability for workforce well-being. This paper will explore the National Plan for Health Workforce Well-Being, providing an overview of the seven priority areas and offering strategies for implementation in radiology.

The ADVICER Template for Faculty Reviewer Letters for Promotion and Appointment.

RATIONALE AND OBJECTIVES: Promotion is an important milestone in the career of academic radiologists. Appointments, Promotion and Tenure (APT) committees require multiple letters of support from both internal and external referees. Traditional narrative letters are highly subjective, have high inter-reader variability, are time-intensive, and vulnerable to gender and other biases. The Alliance of Directors and Vice Chairs of Education in Radiology (ADVICER) recognized the need for a standardized template to assist academic faculty, letter writers, and APT committees. MATERIALS AND METHODS: An ADVICER ad hoc committee of six educators with experience serving as external referees was convened to create a standardized template. Committee members performed a search of the relevant literature and internet sites, spoke with stakeholders such as APT chairs, and ultimately developed a template for faculty reviewer letters using the common clinician-educator pathway as a focal point. RESULTS: An open source, modifiable, standardized, template was produced. The template has been made available to ADVICER members and is available on the Association of University Radiologists (AUR) website at: https://www.aur.org/resources/Template-for-Faculty-Reviewer-Letters-for-Promotion-and-Appointment CONCLUSION: This external referee template has the potential to reduce subjectivity, eliminate bias, and provide a flexible, modifiable, comprehensive faculty review letter template which will be useful for academic faculty, letter writers, and promotions committees.

Effect of Out-of-Pocket Costs on Subsequent Mammography Screening.

OBJECTIVE: Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening. METHODS: The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later. RESULTS: Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient = -0.014, 95% CI: -0.025 to -0.003). DISCUSSION: Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.

Association Between Dense Breast Legislation and Cancer Stage at Diagnosis.

INTRODUCTION: Many states have mandated breast density notification and insurance coverage for additional screening; yet, the association between such legislation and stage of diagnosis for breast cancer is unclear. This study investigates this association and examines the differential impacts among different age and race/ethnicity subgroups. METHODS: The Surveillance, Epidemiology, and End Results database was queried to identify patients with breast cancer aged 40-74 years diagnosed between 2005 and 2016. Using a difference-in-differences multinomial logistic model, the odds of being diagnosed at different stages of cancer relative to the localized stage depending on legislation and individual characteristics were examined. Analyses were conducted in 2020-2021. RESULTS: The study included 689,641 cases. Overall, the impact of notification legislation was not significant, whereas insurance coverage legislation was associated with 6% lower odds (OR=0.94, 95% CI=0.91, 0.96) of being diagnosed at the regional stage. The association between insurance coverage legislation and stage of diagnosis was even stronger among women aged 40-49 years, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.96) of being diagnosed at the regional stage and 12% lower odds (OR=0.88, 95% CI=0.81, 0.96) of being diagnosed at the distant stage. Hispanic women benefited from notification laws, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.97) of being diagnosed at distant stage. Neither notification nor supplemental screening insurance coverage legislation showed a substantial impact on Black women. CONCLUSIONS: The findings imply that improving insurance coverage is more important than being notified overall. Raising awareness is important among Hispanic women; improving communication about dense breasts and access to screening might be more important than legislation among Black women.

Vice Chair for Education: Twelve Roles to Provide a Framework for Success.

RATIONALE AND OBJECTIVES: An increase in the administrative work in our healthcare system has led to an increase in the number of administrative positions in radiology departments. Many of these are Vice Chair roles, including Vice Chair for Education (VCEd). The responsibility of this position has expanded, often far beyond the original definition. This article defines the role and expectations of the Vice Chair for Education and provides suggestions for success. MATERIALS AND METHODS: This article will review 12 vital roles that a Vice Chair for Education must play to be an effective advocate for radiology education within a department. RESULTS: Key attributes of an educational leader are delineated, divided into 12 areas or roles. CONCLUSION: This article summarizes key leadership skills needed by Vice Chairs for Education in order for them to be effective in their role.

Collaborative Learning in Radiology: From Peer Review to Peer Learning and Peer Coaching.

BACKGROUND: A Radiology Research Alliance Task Force was assembled in 2018 to review the literature on peer review and report on best practices for peer learning and peer coaching. FINDINGS: This report provides a historical perspective on peer review and the transition to peer collaborative learning and peer coaching. Most forms of current peer review have fulfilled regulatory requirements but have failed to significantly impact quality improvement or learning opportunities. Peer learning involves joint intellectual efforts by two or more individuals to study best practices and review error collaboratively. Peer coaching is a process in which individuals in a trusted environment work to expand, refine, and build new skills in order to facilitate self-directed learning and professional growth. We discuss the value in creating opportunities for peer learning and peer coaching. CONCLUSION: Peer collaborative learning combined with peer coaching provides opportunities for teams to learn and grow together, benefit from each other's expertise and experience, improve faculty morale, and provide more opportunities for collaborations between faculty.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment.

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Reducing Barriers to Breast Imaging in Patients with Mobility Limitations.

Over 1 billion people worldwide live with a disability. Patients living with disability are often challenged by many barriers to healthcare access, especially preventive and screening services. The Americans with Disabilities Act of 1990 mandated that access to public accommodations related to medical care in the United States be available to all; however, many healthcare facilities fall short of meeting this requirement. Research studies suggest that women with chronic disabilities are less likely to undergo breast cancer screening due to financial, environmental, and physical limitations, as well as psychological barriers. There is scarcity of research on the needs of individuals with mobility impairments and the features of the barriers they face when accessing healthcare services, especially breast imaging services. The objective of this article is to illustrate the existing barriers to breast imaging services that individuals with mobility impairments face and to provide a list of guidelines to be used in clinical practice for breast care practices and medical staff working with patients who have mobility impairments.

Addressing Burnout in Radiologists.

Burnout is a global health problem affecting physicians across all medical specialties. Radiologists, in particular, experience high rates of burn out, and this trend has only continued to worsen. The "Promoting Health and Wellness for Radiologists Task Force of the Association of University Radiologists-Radiology Research Alliance" presents a review of the prevalence, causes, and impact of burnout among radiology faculty and trainees, and a discussion on strategies for overcoming burnout and promoting overall health and well-being among radiologists.

Excision recommended in high-risk patients: Revisiting the diagnosis of papilloma on core biopsy in the context of patient risk.

We investigate the clinical history, past medical history, and risk status in women with benign intraductal papillomas(IDP). We observed an upgrade rate of 3.9% to ductal carcinoma in situ (DCIS) and upgrade rate of 10.7% to a high-risk lesion. Prior or concurrent atypia or cancer and high-risk status had a significant increase risk of upgrade. Surgical excision of papillomas is recommended especially in high-risk patients and women with concurrent or history of atypia or malignancy.

Pre- and post-magnetic resonance imaging features of suspicious internal mammary lymph nodes in breast cancer patients receiving neo-adjuvant therapy: Are any imaging features predictive of malignancy?

Internal mammary lymph nodes constitute a major lymphatic chain draining the breast and a route of spread for breast cancer metastases. Both physiologic and metastatic internal mammary lymph nodes enhance on breast magnetic resonance imaging, and the clinical significance of their prevalence, size, and morphology when visualized in a patient with breast cancer remains unknown. We studied the characteristics of internal mammary lymph nodes visualized on breast MRI studies before and after neo-adjuvant therapy in twenty-three patients with newly diagnosed breast cancer. A measured decrease in internal mammary lymph node size on post-neo-adjuvant therapy MRI indicated metastatic involvement. Determining suspicious features of internal mammary nodes on initial diagnostic MRI can aid radiologists in reporting probable IMLN metastases and may alter the course of care for patients with breast cancer. This study concludes that metastatic internal mammary lymph nodes should be considered when more than two ipsilateral internal mammary lymph nodes measuring 6 mm or greater are seen on diagnostic MRI in a patient with newly diagnosed breast cancer.

Should we excise? Are there any clinical or histologic features that predict upgrade in papillomas, incidental or non-incidental?

The clinical decision to excise intraductal papilloma (IDP) without atypia diagnosed on biopsy remains controversial. We sought to establish clinical and histologic predictors (if any) which may predict upgrade in IDP. 296 biopsies (in 278 women) with histologic diagnosis of IDP without atypia were retrospectively identified and placed into Incidental (no corresponding imaging correlate), or Non-incidental (positive imaging correlate) groups. 253/296 (85.5%) cases were non-incidental, and 43/296 (14.5%) were incidental. 73.1% (185/253) non-incidental and 48.8% (21/43) incidental cases underwent excision. 12.4% (23/185) non-incidental cases underwent an upgrade to cancer or high-risk lesion; namely 8-Ductal carcinoma in situ (DCIS), 8-atypical ductal hyperplasia (ADH), 6-lobular neoplasia, and 1-flat epithelial atypia. There was no histopathologic feature on the biopsy in the non-incidental group which predicted upgrade; however a past history of atypia was significantly associated with upgrade. 2 of the 21 incidental cases upgraded (1 to ADH and 1 to lobular neoplasia); the former had a past history of ADH. Both incidental upgrades were >1 mm in size, and were not completely excised on the biopsy. None of the incidental cases which appeared completely excised on biopsy upgraded, irrespective of the size on biopsy. These findings suggest that all non-incidental IDPs should be considered candidates for surgical excision, given the 12.4% upgrade rate and no definitive histologic predictors of upgrade. Patients with incidental IDPs (if <1 mm, completely excised on biopsy and with no history of high risk breast lesion) can be spared excision.

Radiology Research Funding: Current State and Future Opportunities.

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.

Another Time, Another Space: The Evolution of the Virtual Journal Club.

Virtual journal clubs (VJCs) provide a standardized, easily accessible forum for evidence-based discussion. The new virtual reality setting in which journal clubs and other online education events now take place offers great advantages and new opportunities for radiologists in academic medicine and private practice. VJCs continue to evolve, largely due to many emerging technologies and platforms. VJCs will continue to play an increasingly important role in medical education, interdisciplinary interaction, and multi-institutional collaboration. In this article, we discuss how to conduct and lead a critical review of medical literature in the setting of a virtual or traditional journal club. We discuss the current applications of VJCs in medical and graduate medical education and continued lifelong learning. We also explain the advantages and disadvantages of VJCs over traditional venues. Finally, the reader will be given the tools to successfully implement and run a VJC.

Mastalgia: Imaging Work-up Appropriateness.

RATIONALE AND OBJECTIVES: Radiologists frequently image women with the sole complaint of mastalgia (breast pain). We hypothesized that whereas the vast majority of women ultimately have no imaging explanation for their breast pain, a small percentage of patients may have a correlative imaging finding and confirm the current American College of Radiology Appropriateness Criteria recommendations. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective review, we evaluated 236 women between the ages of 18 and 83 years who presented to our Breast Care Center in 2013 with the sole complaint of breast pain or tenderness. Patients' clinical presentation, diagnostic imaging work-up, and clinical and radiographic follow-up were documented. Outcomes of the diagnostic work-up were compared with the American College of Radiology Appropriateness Criteria recommendations. RESULTS: Of the 236 patients, 10 women had cyclical breast pain, 116 had noncyclical, nonfocal breast pain, and 110 had noncyclical, focal breast pain. No imaging correlates were discovered to explain the etiology of cyclical pain, supporting the American College of Radiology Appropriateness Criteria rating values. A definitive imaging correlate for breast pain was identified in seven women (3%) with noncyclical, focal pain, one of which was a cancer diagnosis (0.4%), which correlates with the American College of Radiology Appropriateness Criteria ratings. No imaging correlates were found in women with noncyclical, nonfocal pain, supporting the American College of Radiology Appropriateness Criteria ratings. CONCLUSION: There was no radiological imaging finding to explain the etiology of mastalgia in most women. Diagnostic imaging may be an appropriate diagnostic evaluation in patients with noncyclical, focal breast pain, supporting the American College of Radiology Appropriateness Criteria recommendations.

A Simulation Screening Mammography Module Created for Instruction and Assessment: Radiology Residents vs National Benchmarks.

RATIONALE AND OBJECTIVES: To improve mammographic screening training and breast cancer detection, radiology residents participated in a simulation screening mammography module in which they interpreted an enriched set of screening mammograms with known outcomes. This pilot research study evaluates the effectiveness of the simulation module while tracking the progress, efficiency, and accuracy of radiology resident interpretations and also compares their performance against national benchmarks. MATERIALS AND METHODS: A simulation module was created with 266 digital screening mammograms enriched with high-risk breast lesions (seven cases) and breast malignancies (65 cases). Over a period of 27 months, 39 radiology residents participated in the simulation screening mammography module. Resident sensitivity and specificity were compared to Breast Cancer Surveillance Consortium (BCSC data through 2009) national benchmark and American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) acceptable screening mammography audit ranges. RESULTS: The sensitivity, the percentage of cancers with an abnormal initial interpretation (BI-RADS 0), among residents was 84.5%, similar to the BCSC benchmark sensitivity of 84.9% (sensitivity for tissue diagnosis of cancer within 1 year following the initial examination) and within the acceptable ACR BI-RADS medical audit range of ≥75%. The specificity, the percentage of noncancers that had a negative image interpretation (BI-RADS 1 or 2), among residents was 83.2% compared to 90.3% reported in the BCSC benchmark data, but lower than the suggested ACR BI-RADS range of 88%-95%. CONCLUSIONS: Using simulation modules for interpretation of screening mammograms is a promising method for training radiology residents to detect breast cancer and to help them achieve competence toward national benchmarks.

JOURNAL CLUB: Scatter Radiation Dose From Digital Screening Mammography Measured in a Representative Patient Population.

OBJECTIVE: The purpose of this study was to quantify the amount of scatter radiation received at the skin surface overlying the thyroid gland, salivary gland, lens of the eye, sternum, and uterus during a routine screening digital mammographic examination measured in a representative patient population. SUBJECTS AND METHODS: The subjects were 207 women without symptoms with varied body mass indexes who underwent annual screening mammography while wearing six optically stimulated luminescence dosimeters placed at the bridge of the nose, right submandibular gland, right and left thyroid lobes, mid sternum, and 2 cm caudal to the umbilicus to assess scatter radiation dose to the skin. RESULTS: The average scatter radiation doses at the skin surface during digital screening mammography in the representative population of women were as follows: overlying the right lobe of the thyroid, 0.24 mGy; left lobe of the thyroid, 0.25 mGy; salivary gland, 0.2 mGy; bridge of the nose, 0.025 mGy; sternum, 0.87 mGy; and umbilicus, 0.011 mGy. The scatter radiation doses at the umbilicus and the bridge of the nose were too low to measure with statistical confidence. Scatter radiation dose increased with increasing body mass index and increasing breast compression thickness. CONCLUSION: Scatter radiation dose at the skin overlying organs of interest is a small fraction of the entrance skin dose to the breast. The low levels of scatter radiation measured do not support delaying clinically indicated mammography during early pregnancy.

Conventional Medical Education and the History of Simulation in Radiology.

Simulation is a promising method for improving clinician performance, enhancing team training, increasing patient safety, and preventing errors. Training scenarios to enrich medical student and resident education, and apply toward competency assessment, recertification, and credentialing are important applications of simulation in radiology. This review will describe simulation training for procedural skills, interpretive and noninterpretive skills, team-based training and crisis management, professionalism and communication skills, as well as hybrid and in situ applications of simulation training. A brief overview of current simulation equipment and software and the barriers and strategies for implementation are described. Finally, methods of measuring competency and assessment are described, so that the interested reader can successfully implement simulation training into their practice.