Download February 2010 ACR Bulletin - American College of Radiology

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
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ACR Bulletin (ISSN 0098-6070) is published
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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
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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
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