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FEBRUARY 2010 VOL. 65 ISSUE 2 ADVOCACY • ECONOMICS • EDUCATION • CLINICAL RESEARCH • QUALITY & SAFETY inside Case Studies for Lean Six Sigma p. 12 ACR Image Metrix™ Grows Despite Recession p. 20 Economics: Draconian Cuts for 2010? p. 24 ARE YOU EXPOSED? LESSONS LEARNED FROM CEDARS-SINAI WWW.ACR.ORG ARRS–ACR Chest Imaging Symposium 2010 May 15, 2010, in conjunction with the ACR Annual Meeting and Chapter Leadership Conference, Washington, D.C. 7 CME Credits; 4 SAM credits (pending approval) Course Directors: Melissa Rosado de Christenson, M.D. and Gerald Abbott, M.D. This day-long course is designed to meet the needs of all practicing radiologists who interpret thoracic images during the course of their work. The course will include presentations on: t New strategies in the diagnosis and management of solitary pulmonary nodules and lung cancer t Imaging features of frequently encountered diseases t Imaging approaches to interstitial lung disease and airway disease t Thoracic interventional techniques t Classic concepts in radiographic interpretation Registration for the chest symposium is being done in conjunction with registration for the ACR AMCLC. You can choose to attend the symposium only, and pay just the symposium registration fee. Registration now open. Log on to www.arrs.org for more information. www.arrs.org www.acr.org Bulletin0210 Contents Bulletin FEBRUARY 2010 • VOLUME 65 • ISSUE 2 features ANALYZING THE CEDARS-SINAI CASE By Cary Boshamer Errors do happen, but are you and your patients protected? Amid allegations of radiation overexposure and class-action lawsuits, now’s the time to review your equipment, policies, and procedures. 16 12 12 IMPROVING PRODUCTIVITY AND FISCAL HEALTH By Cary Boshamer What does it take to build a strong bottom line and increase productivity? Find out in these case studies of two radiology departments that implemented Lean Six Sigma. 20 THE SMARTER, FASTER PARTNER By Matthew Robb Pharmaceutical, biotech, and medical device manufacturers are choosing ACR Image Metrix™, the College’s contract research organization, to speed their drugs and medical devices to market in a scientifically sound way. 20 Plug into the ACR. Be sure to visit us on: >>also inside 6 8 10 23 26 28 29 30 TAKING CARE OF BUSINESS EARLY DIAGNOSIS IS VITAL THE POWER OF PARTICIPATION NAVIGATING THE MEDIA HONORING THE BEST CONTINUING EXCELLENCE MORE THAN A NUMBERS GAME departments 2 3 24 25 31 32 www.acr.org LOWER IS SAFER FROM THE CHAIR: IMAGING LEADS THE WAY IN DRUG DEVELOPMENT DISPATCHES ECONOMICS REPORT: CMS DELAYS BUT REFUSES TO RESCIND MASSIVE CUTS RADLAW: LAWS YOU NEED TO UNDERSTAND TRANSITIONS FINAL READ >> From the Chair By James H. Thrall, M.D., FACR, BOC Chair Imaging Leads the Way in Drug Development T he number of new drugs in the development pipeline has never been higher than it is today. However, most drug candidates will fail at some point in the process, making drug development both risky and expensive. Major new breakthrough drugs are variably estimated to cost from $100 million to as much as $800 million — including opportunity costs — and clinical trials can cost another $100 million or more. It is becoming increasingly clear that imaging can play beneficial roles in reducing the costs of drug development and in shortening development and testing time. Among the challenges of fully exploiting imaging methods are how best to teach the pharmaceutical and device industries what imaging can and cannot do and how best to organize the application of imaging. To that end, two years ago, the ACR established a contract research organization, ACR Image Metrix™. The College uses Image Metrix to make its substantial collective expertise available to industries and to take advantage of the image-handling and analysis infrastructure developed to support ACRIN®, the National Cancer Institute’s medical-imaging clinical-trials cooperative group. (Image Metrix is described in more detail in an insightful article on page 20 of this issue of the ACR Bulletin.) During the early stages of drug development, imaging can be used in 2 | Bulletin | February 2010 pharmacokinetic and biodistribution studies to monitor the location of a compound in the body and determine the rates of transfer from different administration sites. Typically, a drug is radiolabeled with a positron emitter or gamma emitter, allowing external detection and tracking — truly the embodiment of tracer methodology. Such studies are useful in determining whether a drug will ever reach its intended target in a sufficient quantity to have the desired therapeutic effect. Later, in clinical trials, imaging can be used to assess drug pharmacodynamics or action. For example, the desired action or effect of an oncolytic drug is to kill tumor cells. Imaging can be used to efficiently determine tumor shrinkage as an indicator that the drug is working. Other examples include osteoporosis drugs, antiarthritis drugs, and drugs for cardiac and neurological applications with appropriate disease markers. An advantage of imaging is that each patient often can serve as his or her own control, greatly reducing the number of subjects who must be studied. Also, the U.S. FDA accepts evidence of an oncolytic effect as sufficient proof of efficacy for the approval of cancer drugs, thereby avoiding lengthy clinical trials that use death as the endpoint. In essence, clinical trials with imaging endpoints can be smaller, shorter, and less expensive than classic randomized clinical trials. It is likely that, increasingly, imaging will be used to guide drug development because the pharmaceutical industry has now awakened to the opportunity. Some drug companies even have their own cyclotrons and PET scanners for testing drugs in animal models before committing the significant resources needed for clinical trials. Working with the pharmaceutical industry is a new avenue for the ACR and for practicing radiologists, and one that we should aggressively pursue. Imaging has transformed the clinical practice of medicine and is poised to guide research as well, further improving the quality of health-care services for patients. // Bulletin EXECUTIVE EDITOR Lynn King, M.P.S. MANAGING EDITOR, EDITORIAL Cary Boshamer MANAGING EDITOR, PRODUCTION Betsy Colgan SENIOR WRITERS WRITER Raina LeslieKeefer Miller Raina Keefer DESIGN & PRODUCTION DESIGN www.touch3.com & PRODUCTION www.touch3.com CONTACT US To contact CONTACT a member US of the Bulletin staff, e-mail ToACR contact a member of the [email protected]. Bulletin staff, e-mail [email protected]. ACR Bulletin (ISSN 0098-6070) is published 10 times a year by the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4326. The subscription price for nonmembers is $90. Single copies are available on request. Printed in USA. Copyright ©2010. American College of Radiology. All rights reserved. Opinions expressed in the ACR Bulletin are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher. No information contained in this issue should be construed as medical or legal advice or as an endorsement of a particular product or service. Postmaster: Send address changes to ACR Bulletin, Attn: Membership Services, American College of Radiology, 1891 Preston White Drive, Reston, VA 201914326. Change of address may be made by sending the old address (as it appears on the ACR Bulletin) and the new address with ZIP code. You may also e-mail address changes to [email protected]. Remember to include your new telephone number(s), fax number(s), and e-mail address(es). The ACR logo is a registered trademark and service mark of the American College of Radiology. For information on how to join the College, visit www.acr.org, or contact staff in membership services at [email protected] or 800-347-7748. For comments, suggestions, or to order reprints of the ACR Bulletin, contact Managing Editor Betsy Colgan at [email protected]. dispatches NEWS BRIEFS FROM THE ACR, ARRS, AND AROUND THE STATES. ACR REVISES ACCREDITATION-PROGRAM REQUIREMENTS The ACR has revised its accreditation requirements for medical physicists and MR scientists, as a result of receiving many thoughtful comments from individuals currently providing medical physics services, and after consultation with ACR legal counsel and the chairs of the Quality and Safety Commission, the Committee of Accreditation Chairs, and the chairs of the Accreditation Subcommittees on Physics. These critical new criteria went into effect on Jan. 1, 2010. Previous requirements for medical physicist/MR scientist initial qualifications, continuing experience, and continuing education vary significantly across accreditation programs. Although recommended, neither board certification nor other education or experience (when an individual is not board certified) are mandated for medical physicists. Revising the initial qualifications strengthens the accreditation programs, brings them into line with the existing ACR Practice Guidelines and Technical Standards for each modality, and ensures that essential personnel stay up-to-date with the modalities for which they provide service. And, the modifications to continuing education criteria will actually provide more flexibility to medical physicists/MR scientists as they choose curricula to fulfill their own needs, as well as accreditation requirements. These new requirements have not addressed all concerns; however, the ACR believes that these changes address the major ones. If you have additional questions, please contact pbutler@ acr-arrs.org. ACR DESIGNATED NATIONAL MEDICAL IMAGING ACCREDITING BODY The Centers for Medicare and Medicaid Services (CMS) has selected the ACR as a designated accrediting organization for medical imaging facilities, able to satisfy all accreditation requirements for providers of advanced medical imaging mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The ACR stands ready to help providers comply with CMS’ requirement that all providers of CT, MRI, PET, and nuclear medicine exams who bill for the technical component under the fee schedule be accredited by Jan. 1, 2012, in order to be reimbursed by Medicare for these services. ACR accreditation is an efficient process of both self-assessment and independent external expert audit, based on the ACR Practice Guidelines and Technical Standards, and signifies that the physicians supervising and interpreting medical imaging meet certain education and training standards. To read the ACR press release on this announcement, please visit http://bit.ly/bj0BJZ. To apply online, visit www.acr. org/accreditation/apply.aspx; for the accreditation section of the ACR Web site, visit www.acr.org/ accreditation.aspx. Advocacy Advocacy• •Economics Economics• •Education Education• •Clinical ClinicalResearch Research• •Quality Quality&&Safety Safety|| 3 dispatches ACR OPPOSES CONTROVERSIAL MAMMOGRAPHY GUIDELINES If cost-cutting mammography recommendations from the U.S. Preventive Services Task Force (USPSTF) are adopted as policy, two decades of decline in breast-cancer mortality could be reversed, and countless American women may die needlessly from breast cancer each year. Created by a federal government-funded committee with no medical-imaging representation, the recommendations would advise against regular mammography screening for women who are 40–49 years old, provide mammograms only every other year for women between the ages of 50 and 74, and stop all breast-cancer screening in women older than 74. “These recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against during the past 20 years,” says Carol H. Lee, M.D., chair of the ACR Breast Imaging Commission. “Mammography is not a perfect test, but it has unquestionably been shown to save lives, including women who are 40–49 years old,” she adds. “These new recommendations seem to reflect a conscious decision to ration care.” Since the onset of regular mammography screening in 1990, the mortality rate from breast cancer, which had been unchanged for the preceding 50 years, has decreased by 30 percent. The USPSTF based its recommendations on conflicting computer models and the unsupported and discredited idea that the parameters of mammography screening change abruptly at age 50. “I am deeply concerned about these actions in severely limiting screening,” says James H. Thrall, M.D., FACR, chair of the ACR Board of Chancellors. “I can’t help but think that we are moving toward a new health-care rationing policy 4| Bulletin | February 2010 that will turn back the clock on medicine for decades and reverse advances in cancer detection that have saved countless lives.” Sebelius’ View HHS Secretary Kathleen Sebelius issued the following statement on the controversial USPSTF recommendations for breast-cancer screening: There is no question that the [USPSTF] recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The [task force] is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy, and they don’t determine what services are covered by the federal government. There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The task force has presented some new evidence for consideration, but our policies remain unchanged. My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions, and make the decision that is right for you. ACR Responds to Sebelius “The ACR is pleased that Secretary Sebelius has reaffirmed that mammography is a vital, lifesaving tool in the battle against breast cancer,” College officials noted in an online statement. “Additionally, as the task force is referenced in health-care reform legislation as a significant factor in determining which preventative services may be offered under government ‘insurance exchanges’ outlined in the legislation, we ask that the Secretary officially ask the task force to rescind its mammography recommendations to avoid confusion as health-care reform moves forward.” Jewells Pens Op/ed on Cuts Valerie L. Jewells, D.O., president of the N.C. Radiological Society and an associate professor of neuroradiology at UNC-Chapel Hill, recently penned an op/ed for the (Raleigh, N.C.) News and Observer on potential cuts to the Medicare program and their impact on the practice of radiology and patient care: The introduction of advanced medical imaging … into the health-care arena has allowed physicians to better detect disease, diagnose patients, and determine treatment. With national health-care reform taking center stage, it is crucial that lawmakers advance policies to improve our system without compromising care. To curtail escalating healthcare costs, the administration has proposed Medicare reimbursement cuts to imaging services in the form of an increased utilization rate for imaging equipment. The administration’s proposal would increase the … amount of time that private medical imaging facilities must use their … imaging equipment to 95 percent … instead of the current 50 percent requirement for Medicare reimbursements. Recent data demonstrate that imaging centers in rural areas utilize equipment 48 percent of the time their offices are open. … Imaging has already been subject to dramatic reimbursement reductions in recent years. These cuts … reduced reimbursement for imaging by 19 percent, or approximately $13 billion, while the volume of imaging services grew only 1.9 percent. … Congress should thoroughly examine the implications of increased utilization requirements and RBM interventions. … These policies would jeopardize patient access to critical imaging services. There are practical, comprehensive means for cutting costs that also preserve health-care capabilities and access in communities nationwide. //Calendar/ April 9–11 34th National Confer- May 15 ARRS-ACR Chest Imaging May 2–7 2010 ARRS Annual 2010 ACR Annual Meeting and Chapter Leadership Conference Washington, D.C. ence on Breast Cancer Palm Desert, Calif. Meeting San Diego Symposium 2010 Washington, D.C. 15–19 In Memoriam: Harold J. Lasky, M.d. Harold J. Lasky, M.D., a recognized innovator in the field of mammography and a driving force behind the development of the ACR’s renowned mammography accreditation program, passed away Oct. 15 at the age of 87 at his Evanston, Ill., home. In private practice for more than 55 years, Lasky was a consultant on mammography who held leadership positions with various local, state, and national organizations. Among his notable achievements was the fact that he was searching for ways to provide quality screening with minimal radiation exposure before mammograms became the accepted gold standard for diagnostic testing. Lasky led the way in developing new methods of quality assurance in women’s imaging. He grew up in the Houston area, earned his medical degree from the University of Texas, and completed his internship at Michael Reese Hospital in Chicago. After completing his internship, Lasky remained at Michael Reese Hospital, where he became assistant director of the department of radiology. In addition to his private practice in Chicago, Lasky also taught radiology to several generations of new imagers at the Chicago Medical School and the University of Illinois at Chicago. The Chicago Radiological Society has created the Harold Lasky Annual Oration in recognition of his achievements and contributions to the field. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 5 // CT SAFETY Lower Is Safer CAN WE REDUCE CT RADIATION RISKS? By Nicole Belanger I n recent years, there has been a growing emphasis on the conscientious, careful balance between obtaining the highest quality medical images possible and assuring that patients do not receive an excessive dose of radiation. And in recent months, no modality has received a greater amount of attention in this regard than CT. Given the controversy swirling around whether a CT scan is always necessary for a patient diagnosis, the pressure to use low-dose scans whenever possible is building. “There’s an increasing awareness that the absolutely highest quality image isn’t always needed to make a diagnosis,” says Paul A. Larson, M.D., FACR, chair of the ACR Commission on Quality and Safety and a private practice radiologist in Neenah, Wisc. a task force of experts to develop educational resources for radiologists, medical physicists, and technologists who provide medical imaging care for adults within the United States, and to communicate the availability of these educational resources using a wide variety of electronic and print media and through networking with affiliated health-care organizations, educational institutions, and government agencies. Building on the success of a similar campaign for pediatric imaging (Image GentlyTM), the task force has tentatively labeled its initiative as “Image Wisely.” E. Steven Amis, M.D., FACR, chair of the Department of Radiology at Albert Einstein Medical School, and James A. Brink, M.D., FACR, chair of the Department of Radiology at Yale “It’s so important that the individuals who perform these tests know how best to reduce radiation and know how to keep it as low as possible.” — Pamela K. Woodard, M.D. In fact, recent journal articles have suggested that these unnecessary radiation overexposures could lead to an increase in cancer cases in the years ahead. For instance, an article in the November 2007 issue of the New England Journal of Medicine by David J. Brenner, Ph.D., and Eric J. Hall, Ph.D., cited the possibility that 1.5–2 percent of all cancers occurring in the next few decades in the United States may be linked to radiation from CT scans. Regardless of whether future cancers can definitively be tied to current CT use, radiologists are debating about which practices to use now to ensure patients’ safety. The ACR and the Radiological Society of North America recently convened 6 | Bulletin | February 2010 University School of Medicine in New Haven, Conn., co-chair this task force. “Although this doesn’t involve mandating a reduction in CT scans, it is necessary to alert people to the risks involved,” Brink says. “We’re trying to control the utilization — using the right test in the right way.” Goal Is to ‘Image Wisely’ In this campaign, which includes a social marketing component, both patients and physicians are encouraged to consider whether CT scans are really needed and at what doses. Obviously, as Larson points out, the lowest dose is 0. “An important concept is: Do you need to do this exam at all?” Larson says. “We look at the suitability of the exam by applying our appropriateness criteria,” he adds. “Getting to 0 can be the biggest reduction, of course. While this may not always be the case in CT, it can be a factor in other areas.” Larson emphasizes that when scans are necessary, physicians should consider using the modality that provides the lowest dose of radiation possible. “It’s important that we follow the ALARA (as low as reasonably achievable) principle,” he says. As technology has led to improvements in CT equipment, more manufacturers are building machines that introduce methods of reducing radiation dose. For example, tube current modulation can allow the tube current to drop to as low as 20 percent during less critical portions of the cardiac cycle of a cardiac CT scan. Other techniques, such as prospective EKG-gating, permit only certain portions of a cardiac cycle to be imaged, even further decreasing radiation dose delivered in cardiac imaging. “This greatly reduces the radiation dose given,” says Pamela K. Woodard, M.D., of the Washington University School of Medicine in St. Louis and immediate past president of the North American Society for Cardiovascular Imaging. With mathematical formulas, newer CT scanners can “cut radiation dose significantly, by about 25–30 percent, without affecting the quality of the scan,” Larson says. Individualized scans also allow radiologists to adjust the dose on the basis of the patient’s size and age, with children receiving the lowest dose necessary, and the density of the body part being scanned. Physicians should also avoid ordering repeat scans as much as possible and use extreme caution when performing cardiac scans in certain patients, such as young women. “They need to be aware of the risk of radiation to breast tissue,” Woodard says. “We’re trying to control the utilization [of CT] — using the right test in the right way.” — James A. Brink, M.D., FACR Many of these recommendations were discussed this month at a two-day ARRS course on cardiac CT angiography (CTA), one of the specific areas receiving increased attention in terms of appropriate radiation dosage. The course was presented by Brink and Sanjeev Bhalla, M.D., of the Mallinckrodt Institute of Radiology in St. Louis. Although there are currently no plans to repeat the course in the near future, the ARRS offers 15 AJR articles (www.ajronline. org) and one Web lecture on CTA at http://bit.ly/cuGnVI. According to Woodard, more research on the safety of CT will keep attention focused on this subject. “There have been many articles about this, especially on coronary CT angiography and radiation reduction,” she says. Radiation-Free Screening Before the use of CT becomes necessary, radiologists can encourage patients to seek out cardiovascular screening opportunities, which are often plentiful during February, American Heart Month. Since 1964, every U.S. president has declared February American Heart Month and encouraged Americans to decrease their risk of heart disease by losing weight, eating healthful foods, and exercising. The month has garnered significant attention because of the activities of federal agencies such as the National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention (CDC). The institute’s “Red Dress” campaign urges women to be screened for heart disease, which includes quick, simple, and radiation-free procedures, such as blood pressure, cholesterol, and diabetes screening. In fact, Woodard says that she emphasizes the point in many of the courses she teaches for the ACR. Moreover, she points out that radiation-dose modification is featured heavily in the ACR’s examination for the Certificate of Advanced Proficiency (www.acr.org/educenter). “It’s so important that the individuals who perform these tests know how best to reduce radiation and know how to keep it as low as possible,” she adds. // Nicole Belanger (nmbelanger@comcast. net) is a freelance writer. Similarly, the CDC’s “WISEWOMAN” program encourages low-income, older women to improve their lifestyle behaviors to prevent heart disease. WISEWOMAN offers free screenings as well as nutritional assessments and referrals. Related activities include the “Act in Time” campaign, which is sponsored by the American Heart Association; this campaign aims to increase knowledge of the symptoms of a heart attack and emphasize the need to immediately call 911, as recommended in the CDC’s heart-disease fact sheets (http://bit.ly/cS0RYQ). With events such as National Wear Red Day, Feb. 5 this year, awareness of cardiovascular disease has become more mainstream, with campaigns, public interest stories, and marketing activities on the rise nationwide. Courtesy The Heart Truth, National Heart, Lung, and Blood Institute, www.hearttruth.gov Advocacy • Economics • Education • Clinical Research • Quality & Safety | 7 MEETINGS Taking Care of Business THE FIRST JOINT MEETING OF THE ACR AND THE RBMA COVERS DIFFICULT SUBJECTS. By Raina Keefer W ith complex contract language, toxic personalities, and recruiting in tough times, some radiology groups face daunting challenges. Exacerbating the situation is health-care reform. All of the issues were discussed at the ACR-Radiology Business Management Association (RBMA) meeting Nov. 14–15, 2009. Keynote speaker Richard C. White, of Alpine Group in Grand Junction, Colo., an expert on government relations, said that although health-care plans change “with the 24-hour news cycle,” these plans and other hard-hitting topics, such as hospital contracts, are part of the business aspects of today’s radiology profession. Ron Howrigon, owner of Fulcrum Strategies in Raleigh, N.C., discussed the language in managed-care contracts. When you review your contracts, “look at the fee schedule, and ask if it’s just a sample,” says Howrigon. “One group looked at the MR rates, which appeared good, as did CT, but their brand-new PET scanner wasn’t on the fee sample.” Adding Value Moving from obstacles in negotiating to challenges in optimizing patient care, two presenters spoke about personalizing the radiology practice experience: Rosemary Broderick, M.S., of Advanced Imaging Specialists in Dunmore, Pa., and Frank J. Lexa, M.D., M.B.A., vice chairman and professor of radiology at Drexel University College of Medicine, project faculty, United Arab Emirates, and East Asia regional manager at the Global Consulting Practicum, adjunct professor of Marketing at The Wharton School, and professor of Business Development in the Life Sciences, Instituto de Empresa, Madrid, Spain. 8 | Bulletin | February 2010 Images courtesy Raina Keefer // James V. Rawson, M.D.; John A. Patti, M.D., FACR; Howard B. Fleishon, M.D., M.M.M., FACR; and Brad Short take a break between sessions at the ACR-RBMA meeting. Despite the many demands on radiologists, Lexa says, “If you want to be doing this in the next 20 years, we need to add more value to health care.” The pair surveyed their patients, who they see becoming buyers or customers of radiology services, to learn what they expect from radiologists. “Especially in economic downturns, toxic personalities can spin out of control.” — Mitch Kusy, Ph.D. “Find out what terms mean to your population,” Lexa says. “I shared the same doctor with my mother, and her definition of friendliness is different than mine. She expects a hug from them; I just want a piece of paper that says I don’t need physical therapy.” They also found that the act of surveying improved their practices’ ratings because the patients realized that the practices wanted to find how they could improve their experience. Lexa and Broderick also focused on establishing connections, which you’ll need to do to recruit talent in tough times says James V. Rawson, M.D., chair of the department of radiology at the Medical College of Georgia in Augusta. In his presentation with Joseph P. White, C.P.A., M.B.A., principal of health care for LarsonAllen in Minneapolis, Rawson revealed tactics and models for finding high-quality employees. In this model, practices should “recruit to their strengths,” says Rawson. “Be aware of generational differences and spend some time not only on salary, but benefits, work environment, and lifestyle, as well.” Strategic Planning If you’re having problems getting organized, consider a practice retreat. Will Latham, owner of Latham Consulting Group, a strategic planning firm in Chattanooga, Tenn., has worked with “If you want to be doing this in the next 20 years, we need to add more value to health care.” — Frank J. Lexa, M.D., M.B.A. Rosemary Broderick, M.S., discusses the shift from patient to customer. Joanne Center and Katherine S. Hall, M.D., recharge with coffee after a morning of educational presentations. groups of all sizes and specialties. He advises radiologists to first find out how each member of the leadership deals with conflict. “Eighty percent test as avoiders,” says Latham. He adds, “At retreats, you’re working on things that are important to your group, some internal, some external, and asking questions such as, ‘What is our market need?’ and ‘What should our relationship be with others?’” However, when reviewing your relationships, first look internally for weak spots like toxic personalities. Elizabeth Holloway, Ph.D., and Mitch Kusy, Ph.D., of Antioch University, authors of Toxic Workplace! Managing Toxic Personalities and Their Systems of Power 1, provided some ideas for dealing with these productivity saboteurs. “Especially in economic downturns, toxic personalities can spin out of control,” contends Kusy. ”Our research of 400 leaders found three systems of intervention: addressing the organization, the team, and the individual,” notes Holloway. Some toxic behaviors include shaming, passive hostility, and team sabotage. One way of dealing with these types of behaviors is to put more effort into reference checks. “These likely are individuals who’ve had problems in previous organizations,” adds Kusy. Radiology and the Economy Other sessions offered a fiscal focus, including an informative, helpful presentation on the ACRATM’s latest lobbying efforts and successes. Radiology’s bipartisan lobbying arm, RADPAC®, When you review your contracts, “look at the fee schedule, and ask if it’s just a sample.” — Ron Howrigon has become, in a relatively short period of time, one of the most respected, influential health-care lobbying organizations on Capitol Hill — a critical benefit during this time of debate about health-care reform and reimbursement upheaval. “A lot of people ask why we are spending so much time and energy on these lobbying efforts,” RADPAC Director Ted Burnes says. “The simple answer is that everyone else is doing it, and if you don’t get involved, you’re going to be left behind. You’re leaving the future of your profession in the hands of others who are less familiar with the issues and challenges you face.” John A. Patti, M.D., FACR, of Boston, vice chair of the ACR’s Board of Chancellors and a leading economic voice in the profession, offered an overview of radiology’s current state in the overall debate of health-care reform and reimbursement adjustments. “We don’t expect to see any change in the physician-work relative-value units,” Patti told the gathering. “We feel good about maintaining those values. However,” he continued, “we do expect dramatic changes in practice-expense payments that could seriously affect various practices and radiologists around the country.” After his economic update, Patti presented “Can Your Practice Afford to Support a National Leader? Can It Afford Not To?” In this presentation, he debunked several excuses radiology practices or departments give to explain why they don’t encourage and support their members’ participation in state and national organizations and activities. (For more details on this presentation, see the related story on page 23 of this issue.) A success, the first joint meeting of the ACR and the RBMA offered radiologists and administrators potential strategies for confronting current issues that may often be overlooked but are important to radiology’s survival. With the uncertain economic and health-care future, everyone can use some expert advice. // ENDNOTE 1. Kusy, Mitchell, and Holloway, Elizabeth. Toxic Workplace! Managing Toxic Personalities and Their Systems of Power. Jossey-Bass, 2009. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 9 // IMAGING ALZHEIMER’S Early Diagnosis Is Vital ADVANCES IN PET AND MRI IMPROVE DIAGNOSIS AND TREATMENT EVALUATION. By Celia Vimont A s an aging U.S. population presents increasing prevalence and incidence of Alzheimer’s disease, imaging specialists are seeking better ways to diagnose the disease early in its course. Radiologists across the country are making important advances by using imaging techniques, such as PET and MRI, to distinguish Alzheimer’s disease from other types of dementia. Generally, Alzheimer’s disease is diagnosed only when symptoms of brain failure are clinically detectable. “By the time the disease is diagnosed, the patient usually has suffered significant deficits,” says Clifford R. Jack Jr., M.D., professor of radiology at the Mayo Clinic in Rochester, Minn. “There is a strong impetus to come up with biomarkers that will enable clinicians to more confidently make the diagnosis and make it much earlier in the course of the disease,” he adds. “These biomarkers could also provide a better measure of disease progression and could be useful for evaluating the effects of therapy on disease progression that is more precise than [the methods currently used].” Researchers are designing imaging techniques to detect neuritic amyloid plaques and neurofibrillary tangles — the hallmark pathologic lesions of Alzheimer’s disease that are thought to develop before disease symptoms are clinically apparent. PET-Based Techniques According to Jack, the most important development in imaging research in the past decade is the use of radiolabeled PET tracers that bind to the aggregated Aβ peptides in amyloid plaques in the brain. The most studied such agent is Pittsburgh compound B (PIB), developed by Chet A. 10 | Bulletin | February 2010 Mathis, Ph.D., and Bill E. Klunk, M.D., Ph.D., at the University of Pittsburgh. Investigators are using this agent and a PET-based technique to directly visualize plaques in the brain instead of indirectly estimating levels of amyloid plaques from levels of Aβ peptides in cerebrospinal fluid. “It has revolutionized the imaging of Alzheimer’s disease,” Jack says. However, PIB, made with carbon 11, has a half-life of only 20 minutes. “This makes it difficult to work with and not feasible for use in a clinical setting,” explains Andrew B. Newberg, M.D., associate professor of radiology at the University of Pennsylvania and a co-investigator in one of two ACRIN® studies evaluating novel amyloid imaging agents that may be more clinically useful than PIB. Researchers at the University of Pennsylvania and the University of Pittsburgh are comparing PIB with two experimental amyloid imaging agents made with a fluorine 18 isotope, which has a 110-minute half-life. “If they prove to be as effective as PIB, they will be more practical to use,” Newberg says. A PET-based technique being studied through the National Institute on Aging’s Alzheimer’s Disease Neuroimaging Initiative is fluorodeoxyglucose (FDG) PET, in which a fluorine 18–labeled glucose molecule is used. In Alzheimer’s disease, characteristic brain regions in the temporal and parietal lobes show decreased glucose metabolism. FDG PET is a sensitive marker for differentiating early Alzheimer’s disease from frontaltemporal dementia. MRI-Based Techniques Jack and his colleagues at the Mayo Clinic are studying a new approach for the MRI-based differential diagnosis of Alzheimer’s disease and two other Courtesy Clifford R. Jack Jr. neurodegenerative disorders (using structural MRI). The framework, called the structural abnormality index (STAND), searches for unique patterns of atrophy specific to each neurodegenerative disorder on MRI. According to Jack, if each disorder can be associated with a unique pattern of atrophy, then it may be possible to differentially diagnose new cases. Prashanthi Vemuri, Ph.D., a senior research fellow at the Mayo Clinic Aging and Dementia Imaging Research Lab, developed an algorithm that extracts atrophy information from a patient’s 3-D MRI scan. A STAND score is assigned on the basis of the degree of atrophy in the patient’s brain relative to atrophy patterns in a library of MRI scans from 160 patients with Alzheimer’s disease and 160 people who were cognitively healthy. A positive STAND score indicates that the brain shows signs of Alzheimer’s disease; a negative score suggests that the brain is healthy. This research indicates that STAND scores are 90 percent accurate in distinguishing the scans of people with Alzheimer’s disease from those of people without the disease.1 Another MRI-based technique under study as a tool to detect brain dysfunction in very early Alzheimer’s disease is functional MRI (fMRI). “We are looking at people without dementia who are at risk for Alzheimer’s disease because of high levels of amyloid in the brain,” says Reisa A. Sperling, M.D., MMSc, associate professor of neurology at Brigham and Women’s Hospital in Boston. “Functional MRI should be particularly useful in early clinical trials to determine if reducing amyloid burden will make the brain work better,” she adds. Moreover, fMRI can also measure functional connectivity in the brain, as represented by neural activity in the brain during a 6- to 8-minute rest period. fMRI can detect connectivity problems in the parietal and hippocampal regions, which show abnormalities in very early Alzheimer’s disease. And while early identification of the disease is a widespread goal, the ultimate FDG PET, MRI, and PIB (amyloid) scans were obtained for a subject with Alzheimer’s disease. objective is a cure. The radiologists, physicists, and dozens of other professionals from a variety of specialties handling the more than 600 trials for Alzheimer’s that are either currently ongoing or planned in the future, according to the U.S. National Institutes of Health Clinical Trials Web site (www.clinicaltrials.gov), are all working toward the same end. Imaging science is but one contributor in the fight against this destructive disease. // ENDNOTE 1. Vemuri P., Whitwell J.L., Kantarci K., et al. “Antemortem MRI Based Structural Abnormality iNDex (STAND)-Scores Correlate With Postmortem Braak Neurofibrillary Tangle Stage,” Neuroimage, August 2008;42:559–67. Celia Vimont ([email protected]) is a freelance writer. ACR’s PET/CT Course The ACR is offering an intensive three-day PET/CT interpretation course for radiologists April 12–14, 2010, at the ACR Education Center in Reston, Va. “The course will offer hands-on experience in reading PET/CT scans, giving participants more confidence and providing them with a systematic approach to interpretation,” says course director Marc A. Seltzer, M.D., associate professor of radiology and director of the PET/CT Program at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. Attendees will interpret more than 150 PET/CT scans representing all oncologic indications. The course is designed for radiologists who have already completed some formal course work on PET or PET/CT but who have limited experience reading scans in daily clinical practice. For more information, visit http://bit.ly/2DDD8. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 11 IMPROVING FISCAL 12 | Bulletin | February 2010 productivity & health the successful lean six sigma program translates into better performance and a stronger bottom line . T he Lean Six Sigma project in the radiology department at the Mayo Clinic in Arizona cost $21,000 to formulate and implement, primarily from dedicating personnel by cary boshamer already on staff to the project, including a nurse and a radiologic technologist. However, Catherine C. Roberts, M.D., associate professor of radiology and associate dean for the Mayo School of Health Sciences, is quick to point out that the resultant savings have been “exponential.” According to financial projections, the new system will allow the facility to perform 7,000 more scans per year. With a reimbursement of $986 per exam, the facility feasibly could generate an additional $6.9 million in reimbursement, which translates to a realistic increase in revenue (based on backlogs) of about $770,000. Moreover, Roberts says that the facility was able to forego the expense of buying a new CT scanner, with an estimated price tag of $1 million, because the team was able to use its existing CT equipment in a much more efficient manner. Savings were also realized through changes in staffing needs. Roberts adds that the department was able to free up one full-time nurse, who was reassigned within the department; this change also enabled the team to forego hiring a new radiologic technologist when one employee left the staff. In addition, the program freed up about 20 percent of a full-time clinical engineer’s salary and related costs when that staffer was assigned elsewhere within the institution. Previously, 20 percent of the engineer’s time was dedicated to the department. Ultimately, Roberts says, the department collected a sizable return of about 4,000 percent on its initial study investment, excluding the deferred purchase of a new CT scanner. Not a Difficult Process Although implementing a new course of action can often present significant challenges to a large, technically reliant department, executing a Lean Six Sigma plan “is not hard to do,” Roberts explains, “with the exception of making sure the staff is comfortable with the project’s intent and their job security. They must also be assured that their opinions and feedback will be heard and considered during the evaluation process. Editor’s Note: This is Part 2 of a two-part series on the development of a new practice-management methodology that is generating interest throughout the radiology community. For a thorough overview of the background and concept of the Lean Six Sigma program, please see Part 1 in the January ACR Bulletin. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 13 Patient Volume Versus Budgeted Volume FACING THE FACTS Patient Volume Versus Budgeted Volume. “The obvious finding is that we have cared for patient volumes well over expected budget in a tough economy,” says Christopher J. Roth, M.D. “We are seeing more people during the day than we have previously.” What you do not see on the chart, he says, is that on July 1, the department decreased the number of inpatient clinical scanners from four to three while the number of patients remained steady. Purple = pre-project; Yellow = pilot, improvement period; Green = formal improvements implementation Dotted red line = number of available scanners decreases from four to three. Red line = budgeted patient volume; Blue line = actual patient volume Patient-Satisfaction Scores Purple = Pre-project; Yellow = pilot, improvement period; Green = formal improvements, implementation Patient-satisfaction Scores. Roth says patient-satisfaction scores are now well over the historical mean and received a boost from the Lean Six Sigma improvements. “In the pilot period, we started sending technologists to screen patients who would be getting MRIs that day before they reached the department,” Roth explains. “It gives our nurses and techs a good sense of who the patients are and how sick they are. It also weeds out those patients who have contraindications, need translators, or present unique problems before they arrive and delay our care. We now do one more patient for every six that we did before the project started, a modest improvement,” he says. Another important factor: Before the qualityimprovement program, the MRI department’s pediatric-sedation slot backlog was around 31 days. Today, there is no backlog. Courtesy Christopher J. Roth “Any time you start an efficiency project, people are going to feel threatened,” she cautions. “Not only are they afraid, but they can also become offended because they feel like you are telling them that if you can make something better, then you are really saying that they’ve been doing something wrong. Of course, that is not the case.” Failing to handle the situation in the appropriate manner can mean that the project is doomed before it even starts. “Your allied health staff can make everything come to a complete stop 14 | Bulletin | February 2010 because they are afraid,” Roberts adds. “It is extremely important that you communicate with your support staff throughout the process and make sure they are playing a key role in the process.” Success at Duke At Duke University in Durham, N.C., radiologist Christopher J. Roth, M.D., says the radiology department staff was able to increase MRI throughput while looking at the process objectively and asking critical questions. “For example, what are we doing when they [patients] arrive, how are they getting scanned, and what problems do they face?” Roth explains. “We found we didn’t have an adequate waiting area; much of our equipment was not optimally placed in our prep area, such as gloves and IV supplies not being located close to where we needed them; and our scheduling system wasn’t efficient,” Roth adds. “That doesn’t even take into account scheduling challenges, such as patients showing up late or not at all.” By applying Lean Six Sigma principles to the situation, Roth says the staff was able to successfully address these issues. “Bottlenecks as small as needing an additional computer workstation for the MRI technologist coordinator could be seen clearly and alleviated,” he says. “We also streamlined the schedule based on who was coming in and improved communication lines among nurses, RTs, and physicians — areas that had affected not only the level of care we provided and how many patients we could see, but also many of the recurring daily employee frustrations, such as being unable to clear a patient for an MRI scan.” By revising work roles for nurses and technologists, patients were prescreened for contraindications to MRI before transport to the department, allowing prompt placement within the scanner and better workflow predictability upon arrival. “In addition, we looked hard at the studies we were performing,” Roth notes. “Many of the scanner-hardware technological improvements we thought were increasing our throughput were not. We removed many low diagnostic yield sequences and revised study protocols to minimize downtime between sequences in parallel with ACR accreditation, which requires us to have certain sequences in our exams to earn accreditation.” The results were impressive, including quickly setting new volume records for Duke University Medical Center’s MRI department. Other results include permitting the use of one MR scanner frequently used for clinical purposes exclusively for research studies, significantly improved patient-satisfaction scores, and decreasing the backlog of pediatric sedation cases awaiting scanning from 31 days to zero days. Looking Ahead Although the radiology department staff at Mayo realized significant workflow and financial benefits from embracing the Lean Six Sigma process, Roberts says they continue to strive to improve the situation as demands for imaging studies increase. “We will use Lean Six Sigma for everything we do in the future,” she predicts. “It is [a] highly structured process that you can’t vary from, but it is a valuable investment both in time and money.” With current political and economic pressures, that level of care may not be good enough, and striving for a higher level of success may be necessary. Strong internal quality-improvement programs, including Lean Six Sigma, can do this. — Christopher J. Roth, M.D. Roth also says that his facility and staff will continue to apply Lean Six Sigma principles in light of their success to date. “We are ramping up our quality improvement and Six Sigma work,” he notes. “Doing it requires training for the staff to ensure that everyone is on the same page to make the program work properly. According to Roth, “An applicable quote in the book, Good to Great1, well-known in business and quality-control circles, says, ‘The vast majority of companies never become great, precisely because the vast majority become quite good, and that is their main problem.’ I would argue that one could substitute ‘radiology departments’ in that quote because, historically, practices have deemed themselves successful if they provide reasonably prompt interpretations, patients are relatively satisfied with their encounter, and the practices are sufficiently financially viable. “Yet, with current political and economic pressures, that level of care may not be good enough, and striving for a higher level of success may be necessary,” Roth continues. “Strong internal quality-improvement programs, including Lean Six Sigma, can do this.” How is the concept being received by other radiology practices and facilities? “Lean Six Sigma is catching on in the field, but slowly,” Roth says. “Doctors aren’t trained to be engineers and efficiency experts. The efficiency experts who typically would be able to help us can’t do so without our supervision, given patient privacy issues, or our medical insight as radiologists. Radiology is extremely sophisticated, and they don’t understand many of the complexities of health-care delivery — for example, when and why you need intravenous contrast.” “There are radiology departments that have seen big improvements to their bottom line, to referring physician satisfaction, and to patient experience using principles like Lean Six Sigma,” notes Roth. “It is a process that means revamping many aspects of a practice, and change of this size often takes time. Like politics, health care often is local, and every facility is going to be different and present a unique series of challenges.” Although Lean Six Sigma originated in the world of manufacturing, it has a critical place in today’s complicated health-care environment. // ENDNOTE 1. Collins, Jim. Good to Great: Why Some Companies Make the Leap ... and Others Don’t. HarperBusiness, 2001. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 15 BY NOW, EVERY RADIOLOGIST IN AMERICA is aware of the recent allegations that a faulty CT brain scanner at noted Cedars-Sinai (C-S) Medical Center in Los Angeles exposed as many as 260 patients to radiation levels eight times the necessary amounts during imaging procedures. According to reports, the problem began in February 2008 when the facility reconfigured the scanner and was discovered in August 2009, when a patient who had undergone a scan at C-S began experiencing hair loss. The following month, the hospital notified ARE YOU AT RISK FOR A 206 patients of the potential problem before discovering that even RADIATION BLUNDER? ARE more patients had undergone scans with the malfunctioning maYOU PREPARED TO RESPOND? chine. Moreover, an investigation BY CARY BOSHAMER by hospital staff discovered that about one-fifth of the patients had received exposure directly to the lenses of their eyes, which could put them at a higher risk for developing cataracts later in life. The hospital sent out a letter to each affected patient, with the signatures of the facility’s chief operating officer and chief medical officer, apologizing for the situation. In the letter, C-S also offered to pay for any medical care that would be required as a result of the inappropriate radiation levels and the opportunity to meet with a medical specialist to answer any questions they might have about the matter. Of those patients involved in the case, 47 had already passed away by the time the hospital contacted the victims, which hospital officials maintain was the result of the severity of their illnesses, not the radiation exposure. According to a Nov. 9, 2009, update on the case in the Los Angeles Times, about 80 patients temporarily lost patches of hair as a result of the overexposure. With the affected patients being, on average, 70 years old, experts have opined that most of them will likely die from other causes before they could develop any symptoms related to the overexposure. Now, the celebrated facility is facing a litany of lawsuits, scrutiny, and further blows to its reputation. In fact, several class action and individual lawsuits have already been filed against the hospital, which will be the focus of intensive investigations by the state’s Department of Public Health and the U.S. Food and Drug Administration. Analyzing the 16 | Bulletin | February 2010 Can It Happen in Your Facility? Reports indicate that the scanner at the center of the firestorm was reset in February 2008, overriding the manufacturer’s instructions and guidelines, to increase radiation doses and enable improved analysis of the blood flow to brain tissue. Hospital officials have said that steps have been taken to prevent future such incidents and that staff will undergo additional training and review. But is this type of incident more common than we would like to believe? Is it simply receiving the inordinate amount of attention because of the hospital’s reputation as a medical facility catering to a celebrity patient base? “I have seen nothing in the lay or scientific literature that leads me to doubt that the Cedars incident is isolated and rare,” suggests noted radiologist and medicolegal expert Leonard Berlin, M.D., FACR, a professor of radiology at Rush University Medical Center in Chicago, chair of the Department of Radiology at NorthShore University HealthSystem in Skokie, Ill., and author of Malpractice Issues in Radiology. “I suppose it is possible that similar incidents have been reported at other facilities over past years, but, if so, they have not been publicized, and I certainly think they would have been.” “No institution, now or ever, can be completely immune to errors, some of which may carry significant risk of harm; outstanding institutions with strong Leonard Berlin M.D., quality and safety programs, FACR such as Cedars-Sinai, are not exempt,” contends Michael A. Bruno, M.D. Bruno, associate professor of radiology and medicine at the Penn State Hershey Medical Center in Hershey, Penn., where he also serves as director of quality management services and Michael A. Bruno, patient safety in the DepartM.D. ment of Radiology, adds, “We know that errors will still occur with a small, but measurable frequency, even under ideal working conditions and despite the extreme diligence of well-trained and well-meaning professionals.” Of course, several experts note, if your facility performs a large number of imaging procedures involving high levels of radiation, such as CT scans and nuclear medicine, your leadership and staff should conduct a close review of your equipment, as well as your policies and procedures, to minimize the likelihood that the C-S case could happen to you. Cedars-Sinai Case Reviewing the Technology “How do we know if the dosing of a scan is accurate?” asks Anand P. Lalaji, M.D., chair of The Radiology Group in Atlanta, a network of subspecialty radiologists who support a national digital platform of hospitals, imaging centers, and surgery centers with imaging services. “We rely on Anand P. Lalaji, M.D. the technicians and the technology companies to make sure the machines are performing to optimum standards, but, as a radiation specialist, I can’t tell if the dosage is in line with a manufacturer’s specifications,” he adds. “We need more inspections and certification to ensure the technology is accurate,” he insists. “If it can happen at Cedars-Sinai, it can happen anywhere.” The key is for designated staff members to be involved with the equipment and its settings from the moment it is installed, Lalaji recommends. Typically, when a new piece of equipment such as a CT scanner is installed in a facility, it is done by a representative of the manufacturer who is working with a radiologic technologist from the company as well. The company representative will normally program the machine with the necessary codes and guidelines for radiation dosage and imaging performance if the software isn’t already loaded into the system. Lalaji recommends that a departmentdesignated radiologist, perhaps the head of CT or a medical physicist, also be involved in the installation process, even if only as an observer, to ensure that the necessary protocols are entered correctly to meet the department’s needs. After it is installed, only the radiologist should have the authority to change or reconfigure the machine’s protocol. “Once a machine is in place, only a signature from the radiologist, the head of the department, or someone in hospital administration can change the designated protocols,” Lalaji maintains. “The consumer of imaging services is at the mercy of the equipment and the imaging technology operator,” Lalaji continues. “There is very little patients can 18 | Bulletin | February 2010 do to protect themselves in these instances. In fact, we need more oversight about the quality of the technology and the training of the imaging technicians.” Fortunately, there are avenues for radiologic technologists to learn about various aspects of technology and potential risks of radiation, one of which includes the ARRS’ Continuing Education for Radiologic Technologists (CERT) program. With CERT, RTs can earn continuing education credits by reviewing content — from the American Journal of Roentgenology — relevant to their jobs. Plus, each CERT lesson is designed by an RT. For more information and available lessons, visit http://cert.arrs.org. the staff, and there typically is little in place to ensure the safety of the patient. And while having a detailed quality-assurance program in place is a good idea for any department or facility, Lalaji points out that most of these programs “don’t take radiation dosage into account. “The actual delivery of radiation to patients is not addressed in these programs at a lot of facilities,” Lalaji says. “This is simply a problem across the board.” Berlin explains that in the event such as the one that occurred at Cedars-Sinai, a department has to respond promptly to ensure that such an incident doesn’t happen again. “Obviously there [have] to “I have seen nothing in the lay or scientific literature that leads me to doubt that the Cedars incident is isolated and rare.” — Leonard Berlin, M.D., FACR A Quality Monitoring Program Can Help With the recent increased emphasis on quality-management programs within medical facilities, specifically radiology departments, more and more sections are developing and implementing quality oversight programs to identify potential problem areas and take the appropriate steps to address them before they become reality. “An established quality program, which relies on evidence and quantitative analysis and which regularly analyzes potential threats and responds proactively, especially when ‘near-miss’ events are recognized and dealt with, has been shown to be extremely effective in improving the quality and safety of care,” Bruno says. “Sadly, however, studies have proven that not all errors are preventable.” Lalaji points out that one of the key problems is that unless you are looking for the exact exposure information, there is no way to know whether or not the amount of radiation being delivered is excessive. While any radiology department has specific safeguards, such as radiationdetection badges, they are there for the protection and safety of the doctors and be daily and weekly checks evaluating the functioning of the equipment to ensure that everything is operating as it should,” he emphasizes. “This usually falls within the realm of the medical physicist. All daily checks should be documented and kept in a log or record book.” Additionally, Berlin adds, “technologists and radiation oncologists should be shown how to be on the lookout for any untoward reaction that may occur in the future.” In the meantime, Berlin points out that there is no evidence of an extensive system failure or other kind of problem at C-S, “so we have to assume the occurrence is isolated.” (Editor’s Note: Since this story was originally written, other reports of excessive CT dosages have come to light. For more information, please see http:// tinyurl.com/ye2b975 ). Public Response While questions have arisen about why it took C-S so long to publicly acknowledge the overexposure incidents, many radiologists suggest that the facility handled it appropriately. “Cedars seems to have responded in a fairly good manner,” Berlin says, “acknowledging the errors, notifying the patients involved, apologizing, and offering to cover the costs of additional testing that the patients may require. “The question has been raised as to why Cedars didn’t discover the error earlier, and thus why it took so long for them to react publicly. We don’t know the answer to that yet — was it all an innocent situation where they simply didn’t know what had happened, or did they know and try to cover it up?” Berlin asks. “Let’s hope for Cedars’ sake that it was the former. However, if an ensuing investigation reveals the latter, then it will be a bad PR and financial situation for Cedars, as many lawsuits would be generated and, perhaps, even criminal charges could result. “The PR for Cedars has not been particularly good,” Berlin continues, “but I don’t think they’ve been harmed — yet. I suspect that there will be no significant long-term injuries sustained by the patients and, if any of them should be litigious, settlements will be made without any publicity. “If that is the case, things will be fine and the incident will be forgotten within several months. On the other hand,” he notes, “should there be a big lawsuit alleging significant injury (and I’d be surprised if that happens), then it would get on the front pages again.” So, is there such a thing as an “ideal response” to an incident such as this one? It depends on who you ask. Lalaji says if a mistake is recognized, then it should be handled as discreetly as possible while the facility notifies those involved. “You should identify the patients affected and take the necessary steps to settle the matter quietly and effectively as soon as possible. Of course,” he adds, “the more patients involved, the more likely word will get out to the press and public about what has happened, and then you’re dealing with an entirely different PR ballgame.” “Only open disclosure and unblinking scrutiny of all errors, done in a nonpunitive way, can allow any needed corrective or ameliorative action to be put into place rapidly,” Bruno maintains. At Hershey, he explains, the department convenes a ‘rootcauses analysis [RCA]’ team to address the matter. “RCA is an established methodology to essentially dissect every aspect of an error “If it can happen at Cedars-Sinai, it can happen anywhere.” — Anand P. Lalaji, M.D. once it is brought to light, including all of the factors that led to it, as well as those elements of the underlying system that might have served as safeguards but failed. “At Hershey Medical Center, we wholeheartedly embrace the concept of the ‘blameless culture,’ originally championed by the aviation industry. This concept presupposes the competence and best intentions of all involved professionals and emphasizes that all errors must quickly be brought to light. And that is done without fear or recrimination.” Bruno continues, “Errors and ‘nearmisses’ must be analyzed at multiple levels. This would include their ‘systems’ component, which can be corrected only by fully understanding the involved systems flaw, such as an equipment malfunction or workflow maldesign, as well as at the individual or interpersonal level, such as a failure of communications, memory lapse, or flawed performance by an individual.” In the end, Bruno maintains that mistakes of any magnitude can happen anywhere, even at the best and most highly regarded medical centers in the country. However, he insists, “it is important not to become fatalistic about the inevitability of mistakes but to face them honestly and openly, and with the optimism and belief that the fundamental quality-improvement process — error analysis, corrective action, and remeasurement/verification — will lead to future performance improvement.” // Reducing Radiation While mistakes can and do happen in radiology, there are steps you can take to improve your practice and examine your current protocols, beginning with ACR accreditation. The College offers facility accreditation in a variety of modalities, from CT to breast ultrasound. The process includes a rigorous review process to be sure your facility meets nationally accepted standards. It also ensures that your personnel are well-qualified, through education and certification, to perform and interpret patients’ medical images and administer radiation therapy treatments. Perhaps more importantly, especially in an effort to avoid a case like the one at the Cedars-Sinai Medical Center, accreditation tells your patients that your equipment is appropriate for the test or treatment they are to receive, and that your facility meets or exceeds qualityassurance and safety guidelines. To learn more about the value ACR accreditation can add to your facility, visit www.acr.org/accred. Safety is also notably important for the younger patient population, who are extra sensitive to radiation dose. Image GentlyTM, a campaign to increase the awareness of opportunities to lower radiation dose in children’s imaging, offers many ways to address this issue. The Image Gently Web site (www.imagegently.org) includes protocol recommendations, worksheets, and resources for radiologists, technologists, medical physicists, and even parents. Pledging to Image Gently is easy — visit the Web site and click “take the image gently pledge” on the left navigation bar. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 19 RO B HEW A TT BY M SMARTER, FASTER PARTNER B THE 20 | Bulletin | Feburary 2010 ACR IMAGE METRIX™ GARNERS RECOGNITION AS THE IMAGING CONTRACT RESEARCH ORGANIZATION OF CHOICE. development, design of electronic data forms, and comprehensive archiving, interpretation, and quantification of images. Outsourcing to a CRO results in potential cost savings, smaller and more manageable clinical trials, earlier decisions about trial continuation, faster regulatory approval, and shorter time to market. Now in its third full year of operation, ACR Image Metrix continues to enjoy robust growth during the worst economic recession in 70 years. Sales in 2009 outpaced those in the previous year by 150 percent, and according to Michael Morales, general manager for ACR Image Metrix, the long-term prospects are encouraging. In fact, industry watcher IMS Health projects growth in the global pharmaceutical market from $820 billion in 2009 to more than $1 trillion by 2013. Solid Foundation The secret of Image Metrix’s rapid success is no secret at all, proclaims Morales. “We are getting a lot of the projects that some of the more ‘bluecollar’ competitors just can’t do,” he says. “Manufacturers — including GE, ACR Image MetrixTM helps its clients unlock the secrets to success. On the right, Bruce J. Hillman, M.D., FACR, explains the valuable services provided by the CRO during a scientific meeting. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 21 Courtesy SCORR Marketing W hen manufacturers in the pharmaceutical, biotech, and medical-device sectors seek expert imaging for their clinical trials, increasingly, their preferred partner is ACR Image Metrix™. Headquartered in the ACR’s acclaimed Clinical Research Center in Philadelphia — also home to ACRIN®, RTOG®, and QRRO® — this for-profit subsidiary leverages the College’s storied accomplishments in clinical project management to speed advances in radiologic care and extend the frontiers of medical knowledge. Based on the success of ACRIN (the renowned NCI-funded clinical-trials cooperative group), ACR Image Metrix is associated with smarter, faster development of drugs and medical devices. This contract research organization (CRO) fields a blue-ribbon team of radiologists and imaging scientists and boasts one of the world’s most advanced core imaging laboratories. As federal regulations tighten on the pharmaceutical, biotech, and medical device sectors, Image Metrix provides a host of critical services, such as protocol glucose PET, fast 3-D imaging, and fluorothymidine PET. ™ WHO’S LEADING ACR IMAGE METRIX ? Philips, Siemens, iCad, Aurora, Aegerion, and some 25 other companies — see us as the ACR and, therefore, as the imaging experts,” Morales adds. Of the other approximately dozen or so imaging CROs nationwide, he observes, none is backed by an organization with the College’s stature. “ Michael Morales, general manager — Heading the CRO with 15 years of experience in leadership positions in sales and marketing at Warner Lambert and Searle, Morales founded and was CEO of a successful phase IV, community-based trials contract research organization. Brenda Young, senior director of clinical operations — Young’s 26 years of clinical experience in radiology and radiation oncology as well as data management, data collection, and leadership in the functional development of the ACR’s Clinical Trials Management System have prepared her well for her work at Image Metrix. dent way.” In short, ACR Image Metrix acts as an impartial referee to ensure that the research under its watchful eye is scientifically sound and responsible and meets the FDA’s stringent standards. Although ACR Image Metrix is 12 employees strong, it can rapidly scale up by tapping data managers, statisticians, “ These accomplished individuals are just a few members of the “blue-ribbon team” that manages the activities of Image Metrix. Mehdi Adineh, Ph.D., scientific director of the core laboratory — A medical physicist with 15 years of experience in the applications of multimodality image acquisition/ processing in clinical trials, Adineh is also familiar with biomarker research and instruments’ performance and standardization. Bruce Hillman, M.D., FACR, chief scientific officer — This founder/chair of ACRIN®, professor of radiology at the University of Virginia, and editor-in-chief of the Journal of the American College of Radiology has received 22 grants and authored or coauthored 170 publications. Manufacturers … see us as the ACR and, therefore, as the imaging experts. — Michael Morales Perhaps the question most frequently posed to Morales is also the most fundamental: What does an imaging CRO actually do? “If academia’s objective is publication,” he says, “our objective at ACR Image Metrix is to help get something approved by a regulatory agency. “We don’t do diagnosis; we do analysis,” says Morales. “We provide quality control for images and do reads in an indepen- 22 | Bulletin | Feburary 2010 project managers, and medical specialists from the Clinical Research Center and from facilities worldwide. Radiologists unfamiliar with Image Metrix’s capabilities, Morales says, would be astonished by its “cutting-edge facilities.” These include two learning laboratories where researchers receive training in advanced imaging techniques, such as dynamic contrast-enhanced MRI, fluorodeoxy- Current Trials At present, about 32 ACR Image Metrix trials are in progress. About 80 percent focus on oncology, “but coming up fast is imaging research involving the central nervous system, such as Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis,” Morales says. “Additionally, we are conducting trials in other therapeutic categories, such as musculoskeletal and cardiovascular imaging.” According to Chief Scientific Officer Bruce Hillman, M.D., FACR, ACR Image Metrix recently completed a trial on computer-aided-detection software for New Hampshire–based manufacturer iCad and conducted another trial on the safety of a new drug developed by Aegerion Pharmaceuticals to reduce lipid levels. Both products are awaiting U.S. FDA approval. Most of these studies require extensive scientific development and clinical administration. Hillman, a member of the ACR Board of Chancellors, cites as an example a recently completed readers’ study that required more than 4,000 interpretations. “We had radiologists here Thursday through Monday for months, doing individual reads on site, using our reading rooms and workstations,” says Hillman. To ensure accuracy and consistency and as required by the U.S. FDA, Image Metrix monitored the readers’ efforts. Bright Future Hillman foresees a promising future for ACR Image Metrix. “Already, we are seeing repeat business from a number of clients satisfied with the work we have done,” he says. He envisions ACR Image Metrix “as a highly profitable company that assists industry in speeding more effective drugs and devices to market and helps eliminate technologies that are less effective so that, ultimately, patients benefit more from the care they receive.” Adds Hillman, “That would be a very satisfying result.” // Matthew Robb (matthew.robb@ comcast.net) is a freelance writer. // SERVING RADIOLOGY The Power of Participation UPHOLDING VOLUNTEERISM BENEFITS YOUR PRACTICE AND YOUR PROFESSION. By Cary Boshamer V olunteerism is the very heart, soul, and lifeblood of any effective representative organization; each individual offers a unique perspective on key issues and challenges its members face. Nowhere is this energy and outlook more critical than in the field of health care, especially for radiologists, as federal regulators and lawmakers continue to curtail what they perceive as out-ofcontrol growth and overutilization. Today, the ACR relies upon the volunteer support of members who serve in a variety of leadership roles to represent the collective interests of the nation’s medical imaging specialists. Yet, there remain practices and facilities whose leaders do not encourage or aid partners’ and employees’ contributions to these associations at the state, much less the national, level. This lack of support has a negative effect on the profession and equally damaging consequences for the facility in terms of professional respect and standing among not only the partners and employees but with the public as well, notes John A. Patti, M.D., FACR, vice chair of the ACR Board of Chancellors. Patti’s presentation, “Can Your Practice Afford to Support a National Leader? Can It Afford Not To?” held the attention of those attending the November 2009 ACRRBMA forum. The forum, New Strategies for Business and Clinical Leaders in Radiology, was held in Reston, Va. Keeping Radiology Alive “The specialty of radiology, and those who practice it, have become the focus of intense public scrutiny,” Patti reminds the audience. “We have evolved from a group who wore red goggles and lived in the dark, performing a small number of X-ray procedures, to a complex enterprise without which the modern practice of medicine would be impossible.” Supporting just one day per week on volunteer efforts costs a practice less than one percent of annual gross revenues. — John A. Patti, M.D., FACR Without active participation, Patti warns that organizations such as the ACR would “fade into irrelevance.” Thankfully, he adds, the ACR is fortunate to have a “fairly high level of participation” among its members, but he expresses concern about the number of practices and facilities that continue to withhold support of staff who are interested in serving national or state organizations in some capacity. Patti pointedly defuses many of the arguments presented by practice leaders who do not embrace volunteerism, dismissing such arguments as, “They’re enjoying themselves at meetings in fabulous locations while the rest of us pick up the slack,” or “Their absences cut into our productivity and financial bottom line.” Excuses such as these are little more than short-sighted pretexts, he argues, TO THE POINT • Despite the struggles of radiology in the health-care environment, some practice leaders do not support the volunteerism of their partners or employees. • This lack of encouragement can be detrimental to a practice’s standing among peer groups and could negatively influence a practice’s bottom line. • Volunteerism is one of the ways that we can remain current in today’s changing health-care environment. and, in fact, with many of today’s larger practices, supporting just one day per week on volunteer efforts costs a practice less than one percent of annual gross revenues. Staying Connected He emphasizes that support for volunteerism is “good for the profession.” Moreover, it is good for practices and facilities because their employees’ involvement provides an important conduit to an influential representative voice within the industry. This connection enables them to stay informed. “It also allows the practice a sense of prestige among its peers and within the local business community,” Patti counsels. “It elevates your group’s status among your other employees by demonstrating your dedication to the profession and, in turn, to their efforts on behalf of the practice.” On the other hand, lack of support for these volunteer efforts could cast the practice in a negative light, Patti cautions, which can result in a significant loss of revenue if your patient base holds a less-than-favorable view of your practice. “We cannot resort to old-fashioned tunnel vision and insist that our only job is to read films,” Patti says. “There is a lot more about being a radiologist that is important to our patients. We have to … educate our members about the importance of value-added services if our profession is to remain relevant in today’s spirited health-care environment.” Patti concluded by asking the audience to consider a quote from Franklin D. Roosevelt: “It’s a terrible thing to look over your shoulder when you are trying to lead … and find no one there.” // Advocacy • Economics • Education • Clinical Research • Quality & Safety | 23 >> ECONOMIC CMS Delays But Refuses CHAIRMAN’S REPORT to Rescind Massive Cuts By Bibb Allen Jr., M.D., FACR O n Oct. 30, 2009, the CMS released the Final Rule for the 2010 Medicare Physician Fee Schedule. Rather than immediately implementing the egregious cuts in imaging payments proposed in last summer’s Notice of Proposed Rule Making, the CMS elected to phase in regulations for practiceexpense payments, delaying full implementation until 2013. In the Final Rule, the CMS reiterated its intention to change the equipment-usage assumption for CT and MRI from 50 percent of a 50-hour week to 90 percent of a 50-hour week. Additionally, the CMS did not modify its intention to use the data from the Physician Practice Information Survey (PPIS) as the sole source for calculating practice-expense payments. At the end of the four-year phase-in period, the estimated impact of the payments for diagnostic radiology is negative 14 percent. The reductions are most severe for technical-component payments; however, professional-component payments are also affected. CMS’s refusal to rescind its proposal for a 90 percent equipment-usage assumption for CT and MRI is disappointing, considering the data that we provided during the comment period. We are pleased that comments from the ACR and other societies prompted the CMS to recognize the lack of data supporting reduced payment rates on the basis of equipment usage for interventional radiology, radiation oncology, and PET. However, citing comments from the Medicare Payment Advisory Commission supporting the proposal, the CMS 24 | Bulletin | February 2010 continues to assert that the data from the commission’s limited survey of a few urban facilities are valid. The CMS essentially ignores the data from a Radiology Business Management Association (RBMA) sample of many more facilities, which showed equipmentusage rates of no more than 65 percent in urban facilities and less than 50 percent in rural facilities. The CMS states that it is open to additional sources of data for equipment usage, and we hope this is the case. The ACR, the RBMA, and other societies are ready to conduct surveys and supply the CMS with the results so that payment calculations can be based on true data rather than supposition. Despite comments from the ACR and other specialty societies questioning the validity of the PPIS, in the Final Rule, the CMS reiterated both its position that the PPIS data are representative and its intention to use those data as the sole source for calculating practice-expense payments. The College continues to believe that the PPIS data, which reduce the radiology practice expense per hour from $204 to $135, are incorrect. Limited Access at Last Through vigorous lobbying at the AMA and the CMS, we have finally been granted limited access to the source data from the PPIS, and an in-depth analysis is under way. We anticipate that the analysis will highlight our contention that office-based radiology practices were significantly underrepresented in the PPIS and that the complexity of the survey process skewed the results from office-based practices because of the time required for office-based providers to complete the survey. The ACR is relieved that the CMS’s egregious proposals have not been fully implemented in 2010. The combined impact of all of the CMS’s regulations for 2010 is about negative 5 percent. At the current level of implementation, 50 percent of technical-component payments for MRI and CT remain capped by the DRA, meaning that the new regulations have no impact on those services in 2010. The College intends to use the transition period to pursue all possible avenues to provide the CMS and Congress with the analysis and data that will support reversing these draconian cuts in advanced medical-imaging payments. // Laws You Need to Understand A LITTLE KNOWLEDGE OF REGULATORY ISSUES CAN HELP YOU AVOID LEGAL TROUBLE. This article is an excerpt from Medical-Legal Issues in Radiology, a booklet developed by the ACR MedicalLegal Committee and published by the American College of Radiology. It is available on CD-ROM by calling the ACR Membership Department at 800-227-7762. T he federal antikickback statute1 makes payment for referrals illegal. It states that “… whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe, or rebate [directly or indirectly, overtly or covertly, in cash or in kind]) … in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under [Medicare] or [Medicaid] shall be guilty of a felony and … shall be fined not more than $25,000 or imprisoned for not more than five years, or both.” Remember, it is not necessary that an improper referral actually occurred, only that the payment might induce a referral. Also, the possible existence of proper reasons for the referral is no excuse if one of the reasons for the referral was the improper inducement.2 Again, radiologists could be held liable for an employee’s improper actions, of which they were unaware. The government has created numerous “safe harbors”3 that, if the requirements are met, insulate individuals from prosecution for conduct that would otherwise be illegal. ENDNOTES 1. The Medicare and Medicaid Patient Protection Act of 1987 (42 U.S.C. § 1320a-7b). 2. United States v. Greber, 760 F.2d 68, 71 (3rd Cir.), cert. denied, 474 U.S. 988 (1985). 3. Found at 42 C.F.R. § 1001.952. Stark Law The “Stark law”1 prohibits the referral of patients or the submission of Medicare or Medicaid claims for “designated health services,” including radiology and radiation therapy services, if the referring physician or an immediate family member has an ownership or investment interest in, or a compensation arrangement with, the entity to which the referral is made. If a financial relationship exists, then either an exception applies and referrals are still permitted, or the referral is illegal. The Stark law specifically exempts the provision or supervision of services by radiologists or radiation oncologists in their own offices or departments, provided these exams have been requested by another physician. However, the law could be impacted if, for example, a radiologist were being paid to provide services in another physician’s office or clinic. Liability here can be avoided through what is called a “personal services” exception, the requirements of which are specific, including that the agreement be in writing, cover at least a one-year term, and that compensation be at fair market value. Penalties for violation of this law could include exclusion from the Medicare program, and payment of up to $15,000 for each service improperly billed and up to $100,000 for a scheme to circumvent this law. ENDNOTE 1. Social Security Act sec. 1877; 42 USC § 1395nn. Antitrust Antitrust laws were originally passed to combat the growing economic power of railroads and, for many years, they were used to dissuade organized labor. This is a legally complex subject, any significant discussion of which is beyond the scope of this summary. At a minimum, however, the radiologist should be aware of the following: 1. The antitrust laws apply to physicians.1 Lack of awareness of the implications of an antitrust violation has resulted in the bankruptcy and dissolution of at least one medical group.2 These laws RADLAW << By Bill Shields, J.D., LL.M., CAE, and Tom Hoffman, J.D., CAE can be implicated in physician disputes over medical staff privileges,3 disputes about exclusive contracts,4 fee disputes with managed-care organizations and insurance companies,5 and efforts by physicians to organize.6 2. Certain antitrust violations are considered so onerous that the courts have devised a special name for offenses falling into this category. These are called “per se offenses.” No legal justification for these activities is permitted once their existence has been shown (i.e., one is not permitted to offer justification or explanation as a defense). These are attempts at price fixing (arranging fees with other doctors who are not your business partners), dividing markets (dividing areas of practice with other doctors who are not your business partners), and boycotts (organizing other doctors to boycott an HMO or insurance company for more money or other benefits). 3. Penalties for violation of these laws can be severe, including heavy fines and prison terms. // ENDNOTES 1. Goldfarb v. Virginia State Bar 421 U.S. 773 (1975). 2. Op. cit., Note 29; Patrick v. Burget 486 U.S. 94 (1988). 3. Ibid., Patrick v. Burget. 4. Op. cit., Note 30. 5. The seminal case is Arizona v. Maricopa County Medical Soc., 457 U.S. 332 (1982), in which the U.S. Supreme Court held as per se (see definition in the body of the text, above) illegal an attempt by physicians with separate practices to set a mutually agreed-upon fee schedule for dealing with insurance companies. A more recent example is U.S. v. A. Lanoy Alston, D.M.D., P.C., 974 F2d 1206(9th Cir. 1992), a case in which a group of Arizona dentists were criminally prosecuted by the U.S. Justice Department after they got together and wrote letters, all drafted by one of them, to prepaid dental plans demanding more money. They were not imprisoned, although this was a possible outcome. Another recent example is U.S. v Federation of Physicians and Dentists, Inc., No. 98-475, (U.S. Dist. Ct. Del). The Federation of Physicians and Dentists (FPD), an organization that primarily continued on page 27 Advocacy • Economics • Education • Clinical Research • Quality & Safety | 25 // COMMUNICATION Navigating the Media HOW DO YOU KNOW WHAT TO SAY OR WHAT NOT TO SAY? By Raina Keefer R oss Perot and Howard Dean have something in common besides running for U.S. president: Their reputations were tarnished after ill-conceived quotes and outbursts, which likely undermined anything positive that they had done during their campaigns. In this age of YouTube and smart phones, nothing stays private for long, which is why learning how to interact with the media is essential, whether you’re the head of a large radiology department or a typical radiologist. Past ACR Chair James P. Borgstede, M.D., FACR, of the University of Colorado Denver has interview experience with both national and local news outlets, including CNN and CBS, mostly on behalf of the ACR. “I like giving interviews,” says Borgstede. Maintaining Perspective However, remember that interviewers have their own agendas, and they may not match your own. “Some quotes are taken out of context, and I’ve had it happen to me — where they quote one part of what I said and not another,” Borgstede says. “I wouldn’t say they were dishonest, but it was part of the process.” Valerie L. Jewells, D.O., of the University of North Carolina School of Medicine in Chapel Hill, has found that if you ask, some reporters will often let you check your quotes before an article is printed. Jewells tells them up front that “that’s the way it will be, and if they ask why, I just tell them that there are a lot of facts with regard to this issue, and I want to make sure it’s properly written.” But before fingers are put to a keyboard, you need to prepare. “You should be a master of the material,” says Bruce J. Hillman, M.D., FACR, of the University of Virginia in Charlottesville, Va., editorin-chief of JACR, and chief scientific 26 | Bulletin | February 2010 “Doing interviews gives our specialty an opportunity to put a face on radiology.” — James P. Borgstede, M.D., FACR a variety of publications, including those with often-questionable content. “At an RSNA meeting in the 1980s, a woman had been trying to track me down to discuss a new technology, and she was with the National Enquirer,” says Hillman. “At first, I didn’t think it was such a good idea, being in with the two-headed babies and Martians, but she was one of the better interviewers I’ve encountered; she really knew the subject matter.” officer of ACR Image MetrixTM. “But even when you go out of your way to explain in the simplest possible language, it can get messy,” he adds. “There are relatively few truly superior science writers in the country, and even the best will occasionally get factual information wrong.” Recalling his media experience, Hillman has been interviewed by reporters for Whose Team Are You On? How do you know what to keep under wraps when you’re talking to a reporter? “If you have the thought in your head, ‘I don’t know if I should say this,’ then don’t,” advises Hillman. If you speculate incorrectly, then you may ruin an opportunity to reach out to patients and the medical community. Nothing is wrong with not having all of the answers. “You can’t be expected to know everything,” notes Borgstede. Instead, tell them that you don’t know, and that you’ll get the information for them later, but be sure to follow through. It may be advantageous to tell the interviewer that you want the interview to be as successful as he or she does. Says Borgstede, “Since you can’t expect that you’ll get the opportunity to review the interview, I usually tell the interviewer, ‘I really want this to come out well for you, and if you want me to review this, I can do that for you.’ A lot of reporters will buy into that, thinking, ‘I want my editor to be happy, so if this person can do that, I’ll look good.’ Remind them that you can help them and that they can help you,” he adds. This tactic may also help you discover the true reason for the interview. “If a reporter wants to talk about breast imaging, you want to know exactly what you’ll be discussing,” says Borgstede. For example, does he or she want to discuss tomosynthesis or the latest hot topic, such as mammogram screening? Either way, be prepared. Opening up to your local media can be a boon for yourself, your practice, your institution, and radiology as a whole because the general community does not truly understand the value of a radiologist. For physicians who spend a majority of their time in a darkened room, “doing interviews gives our specialty an opportunity to put a face on radiology,” says Borgstede. Take his advice: Emerge from the reading room and “take the specialty for a spin.” // Yikes, Stripes? All ACR leaders receive media training from ACR Public Relations Director Shawn Farley, who has worked in television and as a reporter. When dealing with the media, follow his tips: • Dress conservatively. “No vertical stripes; they can take on an ‘electric’ effect on camera,” says Farley. “Women — or men — should not wear large earrings because they can become distracting.” • Don’t be fooled. One trick reporters use is to wait two or three seconds after you’ve finished answering a question. “Interviewers know that subjects are uncomfortable with silence, and it’s at that point where some might say something they didn’t intend,” he explains. • Don’t speculate. “It’s always better to say, ‘I don’t know the answer,’ than to guess,” Farley notes. • Don’t go off the record. “There is no such thing as an off-therecord statement,” he adds. • Assume all microphones are “live.” “Never say anything into or around a microphone that you would not feel comfortable being published in The New York Times,” cautions Farley. Farley provides more tips for interacting with the media in his online guide, Basic Media Tips, at http://bit.ly/8POyXh. Laws You Need to Understand continued from page 25 represents employed physicians, began in l996 to recruit mostly orthopedic surgeons in Delaware and other states on the basis that it could legally represent them in fee negotiations. The insurance company thus could not negotiate with physicians individually, which, of course, it preferred. The federal government sued on the basis that this represents a price-fixing conspiracy and boycott, both per-se offenses. In November 2002, the parties entered into a settlement under which FPD agreed not to engage in collective bargaining for independent physicians nor exchange competitive information among them, but could analyze and compare offered contract terms in a manner that does not communicate competitively sensitive information among them nor recommend specific contracts. This so-called “messenger model” means of physician-payer bargaining is legal, provided the above rules are obeyed. 6. An example of physicians’ unsuccessful attempt to unionize is AmeriHealth Inc./AmeriHealth HMO and United Food and Commercial Workers Union, Local 56, AFL-CIO, Petitioner. Case 4-RC-19260 [329 NLRB No. 76]. The union sought certification from the National Labor Relations Board (NLRB) as the collective bargaining representative for 652 physicians in New Jersey who claimed that AmeriHealth HMO exerted such control over them that they were de facto employees of the HMO and therefore eligible to organize as a union. The NLRB denied the petition, on the grounds that the doctors had sufficient control over their own activities to be deemed independent contractors, not employees. Only about one-sixth of U.S. physicians are employees under the legal definition of “employee,” which has mostly to do with degree of control by the “employer.” Bill Shields, J.D., LL.M., CAE (bshields@ acr-arrs.org), is ACR general counsel. Tom Hoffman, J.D., CAE (thoffman@ acr-arrs.org), is ACR associate general counsel. The ACR Legal Office exists to represent the College and to provide legal advice to the leadership and the executive director, as well as to handle the day-to-day legal activities. The attorneys are not licensed in all 50 states, the District of Columbia, Puerto Rico, Guam, and Canada, and therefore, cannot give direct legal advice to members or represent chapters, practices, or individual members. The office can provide general information of interest to members as well as general guidance on a variety of legal topics. All information is provided with the express understanding that no attorney-client relationship exists and that members, practices, and chapters should always consult their personal or corporate counsel on matters of concern. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 27 // EXTRAORDINARY SERVICE Honoring the Best ACR SEEKS NOMINATIONS FOR 2011 GOLD MEDALISTS, HONORARY FELLOWS. By Mary Jane Donahue T he ACR Gold Medal is awarded annually by the Board of Chancellors (BOC) to individuals who have contributed distinguished and extraordinary service to the ACR or to the discipline of radiology. Service to radiology encompasses teaching, basic research, clinical investigation, and statesmanship, such as outstanding contributions in working with other medical organizations, government agencies, and quasi-medical organizations. Since 1927, the award has been presented to more than 166 diagnostic radiologists, radiation oncologists, and physicists who have attained notable stature in the specialty of radiology. The BOC also elects honorary fellows in recognition of preeminent contributions to the science or practice of radiology by individuals who are ineligible for admission as members of the College. Since 1947, this award has been presented to approximately 188 outstanding individuals worldwide. The ACR Committee on Awards and Honors seeks nominations for the 2011 awards. Nominations and supporting materials for candidates must be submitted by July 1, 2010. The awards will be presented in May 2011 at the College’s annual meeting in Washington, D.C. Who Can Nominate Candidates? Any ACR member or fellow may submit a nomination for gold medalist; any fellow may submit a nomination for honorary fellow. A College member or a fellow can serve only once each year as either a primary nominator or a sponsor of a gold-medalist nominee. For example, a College member or a fellow cannot be the primary nominator for one nominee and a sponsor for another nominee or act in either capacity for more than one candidate each year. A fellow can serve only twice each year as a primary nominator or a sponsor of 28 | Bulletin | February 2010 Each year, the ACR Gold Medalists and Honorary Fellows are honored during a ceremony at the Annual Meeting and Chapter Leadership Conference. honorary-fellow nominees. For example, a fellow can serve as the primary nominator for one candidate and as a sponsor for another candidate or in either capacity for no more than two candidates each year. Members of the Committee on Awards and Honors, current College officers and members of the BOC, the executive director, and ACR staff are excluded from nominating or sponsoring candidates. Reactivation Rules Reactivation of an individual’s nomination for gold medalist is permissible for one year only. If the candidate is not chosen to receive the gold medal during the first year, then the primary nominator can reactivate the nomination for consideration the next year without submitting additional supporting documents. If the nominee is not selected to receive the medal after reactivation, he or she will be ineligible for one year before a new nomination can be brought forward for consideration. A candidate can be nominated for an honorary fellowship one year, and the nomination can be reactivated the second year if the candidate is not chosen to receive the award during the first year. A nominee who is not selected to receive the award after reactivation will be ineligible for one year before a new nomination can be brought forward for consideration. How to Submit Nominations Nominations must be submitted in writing. Accompanying materials must include detailed background information on the nominee’s qualifications for the award and a comprehensive curriculum vitae. Additionally, at least two letters of recommendation from a nominee’s sponsors are required. Send nominations for the 2011 awards, including all supporting materials, to: W. Max Cloud, M.D., FACR Chair, ACR Committee on Awards and Honors 1891 Preston White Drive Reston, VA 20191 Attention: Harvey L. Neiman, M.D., FACR Alternatively, the information can be e-mailed to Mary Jane Donahue at [email protected]. // Mary Jane Donahue (mjdonahue@ acr-arrs.org) is assistant director, Board of Chancellors and Executive Projects for the ACR. // MANAGED SOCIETIES Continuing Excellence THE SCBT-MR ADVANCES RADIOLOGISTS’ PROFICIENCY IN CT AND MR. By Michele Wittling E ditor’s Note: In addition to serving as the leader and watchdog for more than 33,000 ACR members and their practices and facilities, the ACR provides management services for several smaller, specialized imaging organizations that focus on specific areas of treatment or technology. To help raise members’ awareness of the College’s involvement with these groups and their critical role in the evolving and complicated health-care continuum, the ACR Bulletin will present a series of articles about these organizations in future issues. Academic and research pioneers founded the Society of Computed Body Tomography & Magnetic Resonance (SCBT-MR) in 1977 to educate practicing radiologists in the use of body CT and MR. For more than 30 years, it has been one of the most respected professional organizations in the field of radiology. Additionally, the society serves governmental and medical-practice regulatory and policy agencies in a consulting capacity. Initially, society membership was by election only, and nominees were limited to physicians who had attained preeminence in academic practice and research in the fields of body CT or MR. In 2004, membership was then opened to physicians actively involved in radiology, those who were ABR board-certified, or those who were board-eligible. However, the society evolved to offer a mark of distinction for some members, who were awarded the privilege of fellowship. The designation of fellow is a highly regarded honor bestowed on individuals who have made significant academic contributions to the fields of body CT or MR. SCBT-MR fellows serve as faculty members at key educational conferences and remain active in valuable research related to the modalities. Many fellows present their research or offer program suggestions for SCBT-MR’s popular annual course. Gathering the Minds With more than 120 topics, SCBT-MR’s annual course, which will be held March 7–11 at the San Diego Hilton Bayfront, will focus on cutting-edge topics related to both modalities, approaches that practicing radiologists can use for addressing incidentally discovered lesions, the critical topic of radiation safety, use of contrast media with CT and MR, and quality in radiology. The meeting also offers practicing radiologists a matchless opportunity to learn contemporary and essential aspects of body CT and MR from the field’s leading experts. An important feature of the annual course is the members-only scientific session. Data presented at this gathering represent the most current science in body CT and MR. All society members are encouraged to attend the session and evaluate the presentations. The SCBT-MR offers a more focused, personal learning experience at its annual summer practicum. Additionally, research presented at the course is eligible for consideration for several awards. Named in honor of Sir Godfrey Hounsfield, the 1979 Nobel Prize winner for the development of CT, the Hounsfield Award is given to the author or authors of the most highly rated presentation about CT. The best presentation about MR is recognized with the Lauterber Award, named for Paul Lauterber, who first described the basic MR technique in 1972 and who shared the 2003 Nobel Prize in physiology or medicine with Sir Peter Mansfield. In addition, prizes are bestowed for the best presentations given by a junior faculty member and by a trainee. The society’s annual course also showcases an expert faculty member, who presents the latest information on body CT and MR. This year, the course will consist of carefully selected and highly concentrated 10- and 20-minute lectures. However, if you prefer a more focused, personal learning experience, consider the SCBT-MR’s annual summer practicum. This course, held each August in a familyfriendly location, includes lectures each morning and leisure time in the afternoon. This year’s course will be held at the Jackson Lake Lodge in the Grand Teton National Park in Moran, Wyo., Aug. 8–11. For more information on this and other educational meetings, please visit http://bit.ly/7nrfhj. New Look for Web Site One of the society’s most recent accomplishments was the redesign of its Web site (www.scbtmr.org). The reformatted site now includes a members-only section with access to a member directory, as well as protocols for various exams compiled from many leading U.S. institutions. The SCBT-MR continues to update the site with topical, relevant content for practicing radiologists. // Michele Wittling (mwittling@acr-arrs. org) is executive director of the Society of Computed Body Tomography & Magnetic Resonance. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 29 // CODING More Than a Numbers Game BASIC FAMILIARITY WITH CODING AND REGULATIONS IS ESSENTIAL FOR PROPER REIMBURSEMENT. By Carolyn Hughes By “T he radiologist is ultimately responsible for the charges that go out under his or her name,” says Daniel Picus, M.D., FACR, vice chair of the Department of Radiology at Mallinckrodt Institute of Radiology and professor of radiology and surgery at Washington University School of Medicine in St. Louis. Further, “A radiologist needs to know how to structure his report and what specifically to mention, so that coders can accurately report the work and obtain appropriate reimbursement,” emphasizes Richard Duszak Jr., M.D., FACR, of MidSouth Imaging and Therapeutics, Memphis, Tenn., vice chair of the ACR Commission on Economics, and member of the AMA CPT® Editorial Panel. “While coding is typically something done by an administrative person assigning the correct CPT code to the exam performed and the correct ICD-9 to the diagnosis or reason for examination, radiologists need to know the importance of being crystal clear in their exam description (including number of views, contrast usage, etc.) and stating a meaningful reason for the examination,” says Bibb Allen Jr., M.D., FACR, a partner in the Birmingham Radiological Group at Trinity Medical Center, Birmingham, Ala., and chair of the ACR Commission on Economics. “Bean Counting” — Not Interested “Some physicians may describe coding as tedious, uninteresting, complicated,” Picus explains. Duszak agrees, saying, “They may not know where to start. We have a scientific background and may think, ‘Never mind the economics and correct reporting — I’d be an accountant or a lawyer if that’s what I wanted to do, right?’” “Wrong!” insists Duszak. Diane Hayek, B.A., RCC, ACR director of the Government Relations & Economic Policy Department, advises, 30 | Bulletin | February 2010 “The radiologist is ultimately responsible for the charges that go out under his or her name.” — Daniel Picus, M.D., FACR “Physicians are under scrutiny for fraud and abuse. The Health Insurance Portability and Accountability Act of 1996 and the Balanced Budget Act of 1997 provided additional support to fight fraud [and] abuse.” She adds, “These acts gave the OIG [Office of the Inspector General] greater powers to investigate, prosecute, and impose civil monetary penalties for such things as upcoding (coding for a higherpaid service than what was performed), unbundling (billing for multiple codes when one code accurately defines the service), providing medically unnecessary services, not adhering to the CMS’ Ordering of Diagnostic Tests rule, and offering improper inducements to Medicare and Medicaid patients.” Hayek also recommends that radiologists recognize the importance of having a compliance plan in place to prevent inadvertent billing and coding violations. “Each radiology office should, and most do, employ radiology certified coders [RCCs] certified by the Radiology Coding Certification Board,” says Pam Kassing, M.P.A., RCC, ACR senior director of the Government Relations & Economic Policy Department. “It’s also helpful for physicians to know coding rules and regulations in order to negotiate with a billing service. Often, those services do not use RCCs, nor have they interpreted payment policy correctly.” Sources for Coding Information Radiologists and their staffs can learn and stay current on coding nuances and changes through various Web sites, publications, and educational courses provided by the ACR and the Radiology Business Management Association. At its Annual Meeting and Chapter Leadership Conference, for example, the ACR regularly presents a symposium on reimbursement updates. The College also offers several published resources for coding information and updates, including the highly respected ACR Radiology Coding Source™, published bimonthly and available at www.acr.org/ rcs. Additionally, JACR, published monthly, is a valued source of information on this critical issue. The journal features such articles as “Radiology Coding, Reimbursement, and Economics: A Practical Playbook for Housestaff ”1, published in the September 2009 issue. // Carolyn Hughes (carjon301@hotmail. com) is a freelance writer. ENDNOTE 1. Petrey W.B., et al. “Radiology Coding, Reimbursement, and Economics: A Practical Playbook for Housestaff,” Journal of the American College of Radiology, September 2009;6:643-48. TO THE POINT • Although administrative personnel often do coding, it’s important for radiologists to know how to structure their reports to comply with coding rules and regulations for proper reimbursement. • The College has several coding resources available, including the ACR Radiology Coding Source™, which is available free at www.acr.org/rcs. >>>> TRANSITIONS CALIFORNIA - RIVERSIDE - Interventional Radiologist - Riverside Radiology is seeking an interventional radiologist competent in all areas of interventional radiology. The position is available immediately. One year to partnership, $350k the first year with additional pay for after hours & weekend procedures. Contact: Donald Massee by e-mail at [email protected] if interested. FLORIDA - HOLLYWOOD - Cardiac Imaging Radiologist - Seeking a fellowship-trained cardiac imager to head & further advance the cardiac imaging section of our practice. Contact: Jill Avendano at 954-437-4800, ext. 2148, by fax to 954-437-6628, by e-mail at jill.avendano@ rahmail.net, or mail to Radiology Associates of Hollywood, 9050 Pines Blvd., Ste. 200, Pembroke Pines, FL 33024. FLORIDA - HOLLYWOOD - Chief of Pediatric Radiology – Three-year partnership or per diem. All pediatric subspecialties presently represented at children’s hospital with new hospital planned. Competitive starting salary without buy-in, excellent benefits. Contact: Jill Avendano at 954-437-4800, ext. 2148, by fax to 954-437-6628, by e-mail at jill.avendano@ rahmail.net, mail to Radiology Associates of Hollywood, 9050 Pines Blvd., Ste. 200, Pembroke Pines, FL 33024. FLORIDA - HOLLYWOOD - Nuclear Medicine Radiologist - Large radiology group undergoing significant growth, currently servicing 6 hospitals in a highly profitable health care system seeks BC, fellowship-trained radiologist. Contact: Jill Avendano at 954-437-4800, ext. 2148, by fax to 954-437-6628, by e-mail at [email protected], or mail to Radiology Associates of Hollywood, 9050 Pines Blvd., Ste. 200, Pembroke Pines, FL 33024. FLORIDA - ORLANDO - Pediatric Radiologist Contact: Wei-Shen Chin at 407-832-0176 or by e-mail at [email protected]. FLORIDA - TAMPA BAY - Radiologists - $600,000 plus partnership compensation package. Candidates will work with all BC, fellowshiptrained radiologists. Dynamic practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage providing final reads. Contact: Please send your CV & contact information to Keith Nussbaum at 813-675-0405 or by e-mail at [email protected]. MINNESOTA - ST. CLOUD - Radiologist Quality 20-member private practice group serving 9 hospitals, & 2 outpatient imaging centers, including an independently owned vein center, is seeking radiologists with general radiology skills & fellowship training or special interest in interventional, pediatric radiology, mammography, MRI, or MSK. Contact: Mary Hondl, Administrator at 320-257-7794 or by e-mail at [email protected]. MONTANA - KALISPELL - Interventional Radiologist – Practice in northwest Montana, a 4-season paradise. Progressive 11-person radiology group with 1 dedicated special procedure RPA, seeking motivated IR for 1 year to full partnership track. No turf issues. Superb relationship with administration. Very competitive income/vacation. Contact: Ty Weber at 406-751-7545 or by e-mail at [email protected]. NEW YORK - NEW YORK - Division Chief of Breast Imaging - The Department of Radiology at Columbia University Medical Center invites applications for a clinical faculty position & leadership role as Division Chief of Breast Imaging. Columbia University is an Equal Opportunity/Affirmative Action Employer. Contact: Please visit our online application site at http://academicjobs.columbia.edu/ applicants/Central?quickFind=52576 for further info & to submit your application. OREGON - HILLSBORO - Diagnostic Radiologist - Established group of 5 radiologists in the Portland metro area seeks to add a well-rounded general radiologist to replace an outgoing partner. Fellowship training in neuroradiology is desirable, but all subspecialties considered. Candidate should be comfortable with routine biopsy & drainage procedures. Contact: Aijiro Suzuki at 503-201-6819 or by e-mail at [email protected]. PENNSYLVANIA - CARLISLE - Full-time Radiologist. Contact: Christopher Ladd by e-mail at [email protected]. PENNSYLVANIA - POTTSVILLE - Interventional Radiologist - Schuylkill Health System is looking for a BC, fellowship-trained interventional radiologist to provide comprehensive IR services. Wonderful opportunity for a driven individual to practice in an eastern Pennsylvania suburban community. Contact: Lynda Hutton by fax to 570-621-5328 or by e-mail at lhutton@ schuylkillhealth.com. SOUTH CAROLINA - CHARLESTON - Body Imager – Partnership-track opportunity for fellowship-trained, BC body imager. Join a progressive 20-member subspecialized group. Quality of life being a group priority, we engage a nighthawk service, IR coverage, & generous time off. Comprehensive salary, benefit package, & relocation assistance. Contact: Vicki Hunt by e-mail at Vicki@ charlestonradiologists.com. SOUTH CAROLINA - CHARLESTON Interventional Radiologist – Partnership-track opportunity for fellowship-trained, BC MSK radiologist. Join a progressive 20-member subspecialized group. Quality of life being a group priority, we engage a nighthawk service, IR coverage, & generous time off. Comprehensive salary, benefit package, & relocation assistance. Contact: Vicki Hunt by e-mail at Vicki@ charlestonradiologists.com. SOUTH CAROLINA - CHARLESTON Mammographer – Fellowship-trained, BC mammographer for established practice in rapidly expanding region close to beaches & year-round golf. Hospital coverage & our new imaging center with women’s imaging open 3T MRI, breast MRI & biopsy w/CAD, digital mammography w/CAD, & ultrasound. Partnershiptrack, comprehensive salary/benefit package. Contact: Vicki Hunt by e-mail at Vicki@ charlestonradiologists.com. TEXAS - STEPHENVILLE - Interpreting Radiologist - Partnership opportunity in north central Texas. High-quality equipment & fully integrated PACS with a balanced life style. Metroplex proximity allows easy access to the city without everyday road rage experience. Contact: Please send CV to [email protected]. CLASSIFIED ADS These job listings are paid advertisements. The ACR offers a bundled advertising package entitling advertisers who purchase an online and ACR Bulletin classified ad to a 15 percent discount on a classified ad in the Journal of the American College of Radiology. To learn more about this bundled offer, e-mail [email protected]. RATES: ACR members: $50 per ACR Bulletin ad. Nonmembers: $125 per ACR Bulletin ad. These fees are in addition to online posting fees. Ad length is a maximum of 50 words. Advertising instructions, rate information, and complete policies are available at http://jobs.acr.org. Publication of a job listing does not constitute a recommendation by the ACR. The ACR and the ACR Career Center assume no responsibility for accuracy of information or liability for any personnel decisions and selections made by the employer. These job listings previously appeared on the ACR Career Center Web site. Only jobs posted on the Web site are eligible to appear in the ACR Bulletin, on a space-available basis. TEXAS - TEXARKANA - Partnership Radiology Position - Radiology Consultants, LLP, is based at CHRISTUS St. Michael Health Care Center in Texarkana. We are seeking a BC/BE radiologist to join our 7-man partnership. Contact: Joe Robbins, M.D., at 903-614-2950 or by e-mail at robbinsj@ cableone.net or Phyllis Wilson at 903-223-1014 or e-mail at [email protected]. TEXAS - WICHITA FALLS - General Radiologist - Stable 8-member group seeks to replace retiring partner. Ideal work environment with PACS & state-of-the-art equipment. Partners get 12 weeks’ vacation plus post call days off. Teleradiology coverage 11 p.m. – 7 a.m. Excellent benefit package/competitive salary. No buy in. Contact: By fax to 940-766-0730 or by e-mail at [email protected]. VIRGINIA - ALEXANDRIA - Mammography/ Women’s Imaging - AAR, a well established private practice, is seeking a fellowship-trained mammography/women’s imaging radiologist. Opportunity to practice in a high-quality environment with the latest imaging technology. Partnership-track position & highly competitive compensation package. No call & no hospital weekends. Contact: By phone at 703-824-3216 or by e-mail at mclinton@ alexandriaradiology.com. WISCONSIN - WAUSAU - MR or IR Radiologist Body imager or IR with strong CT/MR/CTA skills to join expanding premier private practice, hospital-based, 10-person group. Fellowship experience preferred. No trapline driving. Nighthawk coverage 11 p.m. – 7 a.m. Contact: Steve Stine, M.D., at 715-847-2283, by e-mail at [email protected], or mail to POB 1324, Wausau, WI, 54402-1324. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 31 final read Q: >> Paul A. Larson, M.D., FACR Diagnostic Radiologist Radiology Associates of the Fox Valley, Neenah, Wis. W All these residents were standing under lamps in the parking lot trying to cram, and I had to laugh. hen I look back to 1986, I wonder if I was missing something because you hear so much today about board frenzy. I came from a small private program with only six residents, but it had an outstanding history of people passing the boards, so that gave me a lot of confidence. I continued to do normal work and normal call leading up to the boards. The most stressful thing was flying to Louisville, Ky., to take the exam. I was almost stranded in Pittsburgh but made it to Cincinnati and drove the rest of the way. Compared to that, the boards weren’t that bad. I was fairly comfortable with the cases. There were things that I hadn’t seen before, but I felt good, and indeed I did pass. While in Louisville, I went across the street to the baseball stadium to watch a game. When I got back to the hotel that night, someone had pulled the fire alarm, and all these residents were standing under lamps in the parking lot trying to cram, and I had to laugh. I just didn’t think it was that hard of an experience. // 32 | Bulletin | February 2010 — Paul A. Larson, M.D., FACR Courtesy Paul A. Larson TELL US ABOUT THE TIME YOU TOOK YOUR BOARD EXAMS. ACR 2010 CME Calendar of Events www.acr.org/educenter Breast MR With Guided Biopsy Education Center Cardiac CT Certificate of Advanced Proficiency Exam March 17; June 22 The ACR Education Center, Reston, VA May 13–14; Sept. 27–28; Nov. 15–16 The ACR Education Center, Reston, VA This 100-case course provides practicing radiologists with intensive, handson experience reading breast MRI under expert supervision. CME: 19.25 AMA PRA Category 1 Credits and 4 SAM Credits TM With the new Cardiac CT Certificate of Advanced Proficiency Exam, you can demonstrate to patients, payers, and hospital credentialing boards your knowledge and high standard for patient care. Apply today at www.acr.org/CoAP. Body MR Coronary CT Angiography May 21–23; Aug. 9–11; Oct. 15–17 The ACR Education Center, Reston, VA Optimize your clinical practice skills with course leader Shawn D. Teague, MD in this intensive training course interpreting coronary CTA exams. March 29–31; June 11–13; Oct. 1–3 The ACR Education Center, Reston, VA CME: 31.5 AMA PRA Category 1 Credits and 4 SAM Credits TM This intensive, practical course on abdominal MR image interpretation focuses on the most common current indications for abdominal MRI. Cardiac and Peripheral Vascular MR CME: 34.5 AMA PRA Category 1 Credits and 4 SAM Credits May 28–30; Aug. 20–22; Dec. 3–5 The ACR Education Center, Reston, VA CT Colonography: Supervised Case Review This course is designed to optimize clinical practice skills by providing intense training in interpreting cardiac MR examinations. TM April 8–9; July 26–27 The ACR Education Center, Reston, VA CME: 29.5 AMA PRA Category 1 Credits TM Learn the technique, performance, and interpretation of CTC through the supervised review of a minimum of 50 cases. CME: 20 AMA PRA Category 1 Credits and 4 SAM Credits TM Education Off-Site Meetings ACR-Dartmouth PET/CT Course 4th Annual Body MRI Update April 12–14; June 25–27; Sept. 20–22 The ACR Education Center, Reston, VA March 26–28 Sheraton National, Arlington, VA In this course led by Marc A. Seltzer, MD, you’ll interpret in a frontline fashion more than 150 PET/CT scans covering all clinical applications. Attend the 4th Body MRI Update to obtain state-of the-art updates and trends and review advanced methods and applications for disease detection and characterization. CME: 34.75 AMA PRA Category 1 Credits and 4 SAM Credits TM NCBC — 34th National Conference on Breast Cancer SM Musculoskeletal MR April 9–11 Desert Springs JW Marriott Resort and Spa, Palm Desert, CA April 23–25; Aug. 27–29; Oct. 22–24 The ACR Education Center, Reston, VA This 100-case course provides intensive experience in the technique and interpretation of MR imaging of the knee, shoulder, ankle, foot, and hip. CME: 33 AMA PRA Category 1 Credits TM Benefit from engaging lectures, case-based education, and the latest technology at this dynamic meeting for breast imagers. ACR/NASCI Cardiac CT & MR Business Course June 12, 2010 Hyatt Regency, Reston, VA To learn about the ACR’s broad portfolio of educational products and services, visit www.acr.org. Learn the business of starting, directing, and operating a successful CT and MR imaging service from leading experts and determine the special requirements of a radiologist. To sign up for automatic notifications, or to register for these ACR meetings and more, visit www.acr.org and select “Meetings and Events”. MKT CODE: CAL0210BUL 7535 02.10 Non-Profit U.S. Postage PAID Pewaukee, WI Permit #592 ACR BULLETIN 1891 Preston White Drive Reston, VA 20191-4326 Join Us for the 2010 ARRS Annual Meeting San Diego, CA, May 2–7 Meeting Highlights Include: 2010 Categorical Course: “Practical Approaches to Common Clinical Conditions” This course describes appropriate use of imaging in the wide spectrum of diseases and disorders affecting the heart, lungs, brain, spine, gastrointestinal tract and musculoskeletal system for efficient evidence-based management of adult and pediatric patients in the ambulatory and emergency settings. 2010 Case-Based Imaging Review Course This course includes a review of 330 cases in all subspecialty areas. Register now at www.arrs.org. The regular registration deadline is March 26. After March 26, plan to register on-site in San Diego. www.arrs.org Bulletin0210