State of Academic Radiology: Current Challenges, Future Adaptations.

There are approximately 200 academic radiology departments in the United States. While academic medical centers vary widely depending on their size, complexity, medical school affiliation, research portfolio, and geographic location, they are united by their 3 core missions: patient care, education and training, and scholarship. Despite inherent differences, the current challenges faced by all academic radiology departments have common threads; potential solutions and future adaptations will need to be tailored and individualized-one size will not fit all. In this article, we provide an overview based on our experiences at 4 academic centers across the United States, from relatively small to very large size, and discuss creative and innovative ways to adapt, including community expansion, hybrid models of faculty in-person vs teleradiology (traditional vs non-traditional schedule), work-life integration, recruitment and retention, mentorship, among others.

COVID-19 and Radiology Resident Imaging Volumes-Differential Impact by Resident Training Year and Imaging Modality.

RATIONALE AND OBJECTIVES: The COVID-19 pandemic has greatly impacted radiology departments across the country. The pandemic has also disrupted resident education, both due to departmental social distancing efforts and reduced imaging volumes. The purpose of this study was to assess the differential impact the pandemic had on radiology resident imaging volumes by training year and imaging modality. MATERIALS AND METHODS: All signed radiology resident reports were curated during defined prepandemic and intrapandemic time periods. Imaging case volumes were analyzed on a mean per resident basis to quantify absolute and percent change by training level. Change in total volume by imaging modality was also assessed. The number of resident workdays assigned outside the normal reading room was also calculated. RESULTS: Overall percent decline in resident imaging interpretation volume from the prepandemic to intrapandemic time period was 62.8%. R1s and R2s had the greatest decline at 87.3% and 64.3%, respectively. Mammography, MRI and nuclear medicine had the greatest decline in resident interpretation volume at 92.0%, 73.2%, and 73.0%, respectively. During the intrapandemic time period, a total of 478 resident days (mean of 14.5 days per resident) were reassigned outside of the radiology reading room. CONCLUSION: The COVID-19 pandemic caused a marked decrease in radiology resident imaging interpretation volume and has had a tremendous impact on resident education. The decrease in case interpretation, as well as in-person teaching has profound implications for resident education. Knowledge of this differential decrease by training level will help residency programs plan for the future.

Impact of the COVID-19 pandemic on radiology physician work RVUs at a large subspecialized radiology practice.

PURPOSE: As the COVID-19 pandemic continues, efforts by radiology departments to protect patients and healthcare workers and mitigate disease spread have reduced imaging volumes. This study aims to quantify the pandemic's impact on physician productivity across radiology practice areas as measured by physician work Relative Value Units (wRVUs). MATERIALS AND METHODS: All signed diagnostic and procedural radiology reports were curated from January 1st to July 1st of 2019 and 2020. Physician work RVUs were assigned to each study type based on the Medicare Physician Fee Schedule. Utilizing divisional assignments, radiologist schedules were mapped to each report to generate a sum of wRVUs credited to that division for each week. Differential impact on divisions were calculated relative to a matched timeframe in 2019 and a same length pre-pandemic time period in 2020. RESULTS: All practice areas saw a substantial decrease in wRVUs from the 2020 pre- to intra-pandemic time period with a mean decrease of 51.5% (range 15.4%-76.9%). The largest declines were in Breast imaging, Musculoskeletal, and Neuroradiology, which had decreases of 76.9%, 75.3%, and 67.5%, respectively. The modalities with the greatest percentage decrease were mammography, MRI, and non-PET nuclear medicine. CONCLUSION: All radiology practice areas and modalities experienced a substantial decrease in wRVUs. The greatest decline was in Breast imaging, Neuroradiology, and Musculoskeletal radiology. Understanding the differential impact of the pandemic on practice areas will help radiology departments prepare for the potential depth and duration of the pandemic by better understanding staffing needs and the financial effects.

Operational Radiology Recovery in Academic Radiology Departments After the COVID-19 Pandemic: Moving Toward Normalcy.

This article presents a current snapshot in time, describing how radiology departments around the country are planning recovery from the baseline of the coronavirus disease 2019 pandemic, with a focus on different domains of recovery such as managing appointment availability, patient safety and workflow changes, and operational data and analytics. An e-mail survey was sent through the Society of Chairs of Academic Radiology Departments list server to 114 academic radiology departments. On the basis of data reported by the 38 survey respondents, best practices and shared experience are described for three key areas: (1) planning for recovery, (2) creating a new normal, and (3) measuring and forecasting. Radiology practices should be aware of the common approaches and preparations academic radiology departments have taken to reopening imaging in the post-coronavirus disease 2019 world. This should all be done when maintaining a safe and patient-centric environment and preparing to minimize the impact of future outbreaks or pandemics.

Early-Stage Radiology Volume Effects and Considerations with the Coronavirus Disease 2019 (COVID-19) Pandemic: Adaptations, Risks, and Lessons Learned.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic resulted in significant loss of radiologic volume as a result of shelter-at-home mandates and delay of non-time-sensitive imaging studies to preserve capacity for the pandemic. We analyze the volume-related impact of the COVID-19 pandemic on six academic medical systems (AMSs), three in high COVID-19 surge (high-surge) and three in low COVID-19 surge (low-surge) regions, and a large national private practice coalition. We sought to assess adaptations, risks of actions, and lessons learned. METHODS: Percent change of 2020 volume per week was compared with the corresponding 2019 volume calculated for each of the 14 imaging modalities and overall total, outpatient, emergency, and inpatient studies in high-surge AMSs and low-surge AMSs and the practice coalition. RESULTS: Steep examination volume drops occurred during week 11, with slow recovery starting week 17. The lowest total AMS volume drop was 40% compared with the same period the previous year, and the largest was 70%. The greatest decreases were seen with screening mammography and dual-energy x-ray absorptiometry scans, and the smallest decreases were seen with PET/CT, x-ray, and interventional radiology. Inpatient volume was least impacted compared with outpatient or emergency imaging. CONCLUSION: Large percentage drops in volume were seen from weeks 11 through 17, were seen with screening studies, and were larger for the high-surge AMSs than for the low-surge AMSs. The lowest drops in volume were seen with modalities in which delays in imaging had greater perceived adverse consequences.

Comparison of procedure costs of various percutaneous tumor ablation modalities.

Microwave ablation, radiofrequency ablation, cryoablation, and irreversible electroporation are percutaneous ablation modalities commonly employed to treat tumors. The procedure cost of treating the same lesion with each of the four modalities is compared. A cost model was created for each ablation modality estimating the cost of treating a tumor based on the number of probes required, which is estimated by the tumor size.Total cost of treating a 3 cm kidney lesion with each modality was individually calculated. There was a strongly positive and statistically significant relationship between estimated cost based on the cost modules and actual cost for all procedures. The number of required probes is the dominant factor in determining the cost of an ablation procedure. The most expensive ablation modalities in decreasing order are irreversible electroporation, cryoablation, and microwave and radiofrequency ablations.

Work and retirement preferences of practicing radiologists as a predictor of workforce needs.

RATIONALE AND OBJECTIVES: The radiology job market has been described as highly variable, and recent practice hiring surveys predict that the number of available jobs will remain flat. Radiologists may be working more hours and retiring later than desired, activities that influence overall job availability. A national survey was performed to determine the desired work rate and retirement preferences of practicing radiologists, and the responses are used to estimate current and potential future work output and future workforce needs. MATERIALS AND METHODS: Practicing radiologists were surveyed regarding current and preferred work level and desired and expected retirement age. A model incorporating these preferences and stratified by age was developed using survey responses and American Medical Association full-time equivalent (FTE) estimates. Available FTE radiologists are estimated under four scenarios from 2016 to 2031 in 5-year intervals. RESULTS: The model predicts a total of 26,362 FTE radiologists available in 2011, which corresponds to previous estimates. Participants reported working more hours and expecting to retire later than desired, with younger radiologists and women reporting the greatest desired decrease in FTE hours worked. Under each scenario, there is an initial FTE availability in 2016 ranging from 21,156 to 24,537, which increases to between 27,753 and 31,435 FTE by 2031 depending on work rate and retirement patterns. CONCLUSIONS: Practicing radiologists report that they currently work more hours than desired and expect to retire later than they would prefer. If radiologists changed current personal work rate and expected retirement age to meet these preferences, there would be an immediate shortage of FTE radiologists continuing until at least 2020 assuming no other workforce needs changes.

Improving imaging utilization through practice quality improvement (maintenance of certification part IV): a review of requirements and approach to implementation.

OBJECTIVE: The purposes of this article are to review the American Board of Radiology requirements for practice quality improvement and to describe our approach to improving imaging utilization while offering a guide to implementing similar projects at other institutions, emphasizing the plan-do-study-act approach. CONCLUSION: There is increased emphasis on improving quality in health care. Our institution has undertaken a multiphase practice quality improvement project addressing the appropriate utilization of screening cervical spinal CT in an emergency department.

We have much in common: the similar inter-generational work preferences and career satisfaction among practicing radiologists.

PURPOSE: There are many reported generational differences regarding workplace motivators, but these have not been previously studied in radiologists. The aim of this study was to assess for generational differences in workplace satisfaction and desired workplace characteristics among practicing radiologists. METHODS: An electronic survey distributed to ACR, Society of Chairs of Academic Radiology Departments, and Association of Program Directors in Radiology members generated 1,577 responses from baby boom (BG) and generation X (GX) radiologists in active practice. Nineteen workplace characteristics and their associations with workplace satisfaction were tested in a univariate analysis using χ(2) tests and in a multiple logistic regression model to test for associations with satisfaction. RESULTS: Workplace satisfaction among BG and GX radiologists was 78% and 80%, respectively. Both generations reported higher satisfaction if they were optimistic about the future of radiology (87% of BG vs 85% of GX radiologists), believed the difference in the desired versus expected age of retirement was narrow (1.5 ± 3.3 years for BG radiologists vs 3.0 ± 4.1 years for GX radiologists), felt that social interactions in the workplace were important (81% of BG vs 83% of GX radiologists), and believed that professionalism in their peers was important (79% of BG vs 82% of GX radiologists). BG radiologists were more satisfied if they valued staff diversity, while GX radiologists were more satisfied if they felt that job security and the amount of compensation were important. There was no significant association of satisfaction with generation, gender, practice setting, or additional administrative work. CONCLUSIONS: Workplace satisfaction among practicing radiologists remains high but has decreased compared with prior surveys. The two dominant generations of practicing radiologists have similar workplace satisfaction rates and desired workplace characteristics.

ACR/ABR clinical statement on credentialing and privileging of radiologists for therapeutic nuclear medicine.

Processes for credentialing physicians and criteria used for delineating their practice-specific clinical privileges vary widely across the United States. The ACR and the ABR have jointly developed this resource document to define the requisite credentials for specialty board-certified diagnostic radiologists and subspecialty board-certified nuclear radiologists to be privileged to practice therapeutic nuclear medicine. Through its initial specialty and subspecialty certification processes and its maintenance of certification programs for practicing certificate holders, the ABR assures the competence of its professional diplomates for clinical practice. On the basis of their education, training, and clinical work experience, board-certified radiologists have the qualifications to supervise and perform therapies using unsealed radioisotopes. Optimum patient care is best served by a physician with training and expertise in supervising and performing radioisotope therapies in conjunction with multimodality imaging technologies for initial diagnosis and follow-up.

Screening cervical spine CT in a level I trauma center: overutilization?

OBJECTIVE: The objective of our study was to analyze the use of screening cervical spine CT performed after trauma and establish the opportunity of potentially avoidable studies when evidence-based clinical criteria are applied before imaging. MATERIALS AND METHODS: All cervical spine CT examinations performed in the emergency department of a level 1 trauma center between January and December 2008 on adult patients with trauma were analyzed; 1589 studies were evaluated. Radiology reports and clinical data were reviewed for the presence of fracture or ligamentous injury and for the mode of injury. We also looked for documentation of clinical criteria used to perform the CT study. In particular, we looked for mention of posterior midline cervical tenderness, focal neurologic deficit, level of alertness, evidence of intoxication, and clinically apparent distracting injury. These five criteria were established by the National Emergency X-Radiography Utilization Study (NEXUS) to identify patients with a low probability of cervical spine injury who consequently needed no cervical spine imaging. RESULTS: Of the 1589 studies reviewed, 41 (2.6%) were positive for an acute cervical spine injury and 1524 (95.9%) were negative. The remaining 24 studies (1.5%) were indeterminate on the initial CT examination but subsequent imaging and clinical follow-up failed to show acute injury. Of the 1524 examinations with no acute injury, 364 (23.9%) had no documentation of any of the five NEXUS low-risk criteria. CONCLUSION: The strict application of the NEXUS low-risk criteria could potentially reduce the number of screening cervical spine CT examinations in the setting of trauma in more than 20% of cases, thereby avoiding a significant amount of unnecessary radiation and significant cost.

Prevalence effect in a laboratory environment.

PURPOSE: To measure observer performance at various levels of prevalence. MATERIALS AND METHODS: A multiobserver multiabnormality receiver operating characteristic (ROC) study to assess the effect of prevalence on observer performance was conducted. Fourteen observers, including eight faculty members, two fellows, and four residents, interpreted 1,632 posteroanterior chest images with five prevalence levels by using a nested study design. Performance comparisons were accomplished by using a multireader multicase approach to assess the effect of prevalence from 28% (69 of 249) to 2% (31 of 1,577) on diagnostic accuracy. The mean times required to review and report a case were analyzed and compared for different levels of prevalence and readers' experience. RESULTS: Area under the ROC curve demonstrated that, with the study experimental conditions, no significant effect could be measured as a function of prevalence (P >.05) for any abnormality, group of cases, or readers. There were no significant differences (P >.05) in the mean times required to review and report cases at different prevalence levels and with different groups of readers. CONCLUSION: The consistency in the results and the size of this study suggest that with laboratory conditions, if a prevalence effect exists, it is quite small in magnitude; hence, it will not likely alter conclusions derived from such studies.

Sentinel lymph node biopsy in head and neck squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Sentinel lymph node biopsy is a minimally invasive method to stage the regional lymphatics that has revolutionized the management of patients with intermediate-thickness cutaneous melanoma. Head and neck surgeons have been encouraged by the accuracy of sentinel lymph node biopsy in cutaneous melanoma and have applied the technique to patients with head and neck squamous cell carcinoma (HNSCC). The objectives of the study were 1) to study the feasibility and accuracy of sentinel lymph node biopsy as a method to stage the regional lymphatics in HNSCC and 2) to determine whether there are qualitative differences between the cutaneous and mucosal lymphatics that would affect the technique used in HNSCC. STUDY DESIGN: Two methods of investigation were employed: a prospective laboratory study using a feline model for sentinel lymph node biopsy and a retrospective review of patients who received lymphoscintigraphy before neck dissection and intraoperative identification of the sentinel lymph node. METHODS: Lymphoscintigraphy and a gamma probe were used in four felines to study the kinetics of technetium-labeled sulfa colloid (Tc-SC) in the mucosal lymphatics. In the second part of the feline study, eight subjects were studied intraoperatively. Tc-SC and isosulfan blue dye were used to study the injection technique for the mucosal lymphatics and to determine the time course of the dye and Tc-SC to the sentinel lymph node. In Part II of the present study, a retrospective review of 33 patients with HNSCC was conducted. Twenty patients (stage N0) whose treatment included elective neck dissection were studied with preoperative lymphoscintigraphy and underwent intraoperative identification of the sentinel lymph node to determine the accuracy and feasibility of sentinel lymph node biopsy. Eight patients with palpable neck disease and five patients with recurrent or second primary disease whose previous treatment included neck dissection were also studied with lymphoscintigraphy before neck dissection. RESULTS: In the feline study, both Tc-SC and isosulfan blue dye traversed the lymphatics rapidly, appearing in the sentinel lymph node in less than 5 minutes. Modification of the injection technique used for cutaneous melanoma was required to depict the sentinel lymph node of the base of tongue. In the human study, the sentinel lymph node was accurately identified in 19 of 20 (95%) N0 patients. On average, 2.9 sentinel lymph nodes (range, 1-5) were identified in 2.2 (range, 1-4) levels of the neck. Sentinel lymph nodes were bilateral in 4 of 19 patients. When the sentinel lymph node was identified, it accurately predicted the pathological nodal status of the regional lymphatics. Three of 20 patients had cervical metastases, and the sentinel lymph node was identified in 2 of 3 patients with pathologic nodes (pN+). Focal areas of radiotracer uptake were identified in seven of eight patients with palpable disease. These areas corresponded to the level with palpable disease in four patients. The lymphatics delineated by lymphoscintigraphy in the five patients with previous neck dissection were outside the levels that had been dissected. Lymphoscintigraphy depicted collateral patterns of lymphatic drainage. CONCLUSIONS: Sentinel lymph node biopsy is technically feasible and is a promising, minimally invasive method for staging the regional lymphatics in patients with stage N0 HNSCC. Lymphoscintigraphy alone may determine the levels that require treatment in patients with disrupted or previously operated cervical lymphatics.

Observer performance studies: detection of single versus multiple abnormalities of the chest.

OBJECTIVE: We used receiver operating characteristic (ROC) analysis to compare two methods of evaluating observer performance in detecting an abnormality on chest radiographs. In the first method, the abnormality in question, rib fracture, was one of five investigated, and it was the only one of interest in the second. MATERIALS AND METHODS: Eight experienced observers viewed 117 posteroanterior chest radiographs in two interpretation modes. Fifty-four of these images depicted rib fractures that had been rated as subtle for detection. The likelihood of the presence of a rib fracture was rated as one of five abnormalities in question in one mode and the sole abnormality of interest in the other mode. RESULTS: Six of the observers performed better during the single-abnormality mode, one performed equally well in both modes, and one performed better during the multiple-abnormality mode. The average area under the ROC curves (A(z)) was 0.73 +/- 0.07 for the multiple-abnormality mode and 0.80 +/- 0.04 for the single-abnormality mode. The results were significantly different (p < 0.05). CONCLUSION: Study methodology can significantly affect the results in ROC studies, particularly for abnormalities that may not be perceived as primary or important. The order in which abnormalities appear on a checklist report form may be important.