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JANUARY 2011 VOL. 66 ISSUE 1 ADVOCACY • ECONOMICS • EDUCATION • CLINICAL RESEARCH • QUALITY & SAFETY URGENT MATTERS RADIOLOGY IN THE ER in this issue 8 WWW.ACR.ORG R esearch Results From ACRIN® 11 Should You Communicate Directly With Patients? 26 Financial Report itation. d e r c c a R C mitment “I trust A m o c e m a s the We share d safety.” n a y t i l a to qu diologist ertified ra , board-c — Vaden MD Padgett, The ACR advantage • Image quality review by radiologists • Accredit your facility in 90 days or less after image submission • Multi-site pricing • Easy online application; flexible time frames Your colleagues at ACR are the imaging experts – and the only CMS-approved partner you’ll need to meet the 2012 accreditation deadline. That’s peace of mind for you and your practice. Apply for ACR accreditation today at acr.org or 1.800.770.0145. • Dedicated team of experienced technologists on call Choose Standard. Choose ChooseACR. ACR. Choose the Gold Standard. 7639 1.11 ACR Board of Chancellors John A. Patti, M.D., FACR (Chairman) Bulletin Paul H. Ellenbogen, M.D., FACR (Vice Chair) James H. Thrall, M.D., FACR (President) Contents Bulletin JANUARY 2011 • VOL. 66 • ISSUE 1 Lawrence P. Davis, M.D., FACR (Vice President) Alan D. Kaye, M.D., FACR (Speaker) Howard B. Fleishon, M.D., FACR (Vice Speaker) Executive Editor Anne C. Roberts, M.D., FACR Lynn King, M.P.S. (Secretary-Treasurer) features Managing Editor, Editorial Bibb Allen Jr., M.D., FACR Cary Boshamer Albert L. Blumberg, M.D., FACR (ASTRO) Managing Editor, Production James A. Brink, M.D.,Colgan FACR Betsy Manuel L. Brown, M.D., FACR Senior Writer Cheri L. Canon, M.D. Keefer Raina Gerald D.D Dodd FACR esignIII, &M.D., Production THE RIGHT TO SPEAK? Radiologists are divided when it comes to communicating directly with patients. Find out the implications — whether you give imaging results directly to patients or not. By Leah Lakins www.touch3.com Burton P. Drayer, M.D., FACR (RSNA) Cassandra S. Foens, M.D., Contact UFACR s a member JamesTo D.contact Fraser, M.D., FACR of the ACR Bulletin staff, e-mail (CAR Observer) TRAUMA 14 TACKLING Emergency department Donald P. Frush, M.D., FACR radiologists are under pressure to provide quick, accurate reads while practicing triage and prioritizing the patient. How do they keep up? By Alyssa Martino [email protected]. James H. Hevezi, Ph.D., FACR Bruce J. Hillman, M.D., FACR (JACR) Richard T. Hoppe, M.D., FACR (ARS) David C. Kushner, M.D., FACR Paul A. Larson, M.D., FACR Carol H. Lee, M.D., FACR Deborah Levine, M.D., FACR Jonathan S. Lewin, M.D., FACR (ARRS) Lawrence A. Liebscher, M.D., FACR Carolyn C. Meltzer, M.D., FACR AND CLEAR 17 LOUD Speech-recognition software has come a long way. But will this tool revolutionize radiology reporting? By James Brice 11 >>also inside 8 CLINICAL RESEARCH: INNOVATION IN IMAGING 20 23 26 RESEARCH AND TOOLS TESTING: THE ART OF THE QUESTION SCHOLARLY PUBLISHING: TAPPING INTO RICH RESOURCES FINANCIAL REPORT: ON SOLID GROUND Cynthia S. Sherry, M.D., FACR Geoffrey G. Smith, M.D., FACR departments 2 Executive Editor Lynn King, M.P.S. Senior Managing Editor Betsy Colgan Copywriter Plug into the ACR. Be sure to visit us on: Alyssa Martino 3 10 Leah Lakins, M.P.S. www.touch3.com Contact Us To contact a member of the ACR Bulletin staff, e-mail [email protected]. RECAPTURING THE CENTER DISPATCHES NEWS FROM THE COUNCIL: PRESERVING TRADITION, Contributing Writer Design & Production FROM THE CHAIR: Check out our new digital issue at: www.nxtbook.com/nxtbooks/acr/ acrbulletin_201101/ 24 25 EXPANDING OPPORTUNITY RADLAW: PROTECTING YOUR PEER-REVIEW RIGHTS ECONOMIC CHAIRMAN’S REPORT: THE CONGRESSIONAL FORECAST www.acr.org 27 28 FOR RADIOLOGY TRANSITIONS FINAL READ >> FROM THE CHAIR By John A. Patti, M.D., FACR Chair, Board of Chancellors Recapturing the Center O ver the past 115 years, radiologists have been blessed by the technological advances of our specialty. In each new era of health-care delivery, some new technology has captured the hearts and minds of physicians and patients. Our reliance on that technical propagation has, in part, contributed to a sense that radiology and radiologists are in such a central position because that is the natural order of health-care evolution. In today’s world, no one would argue that excellent health care could be delivered without imaging. However, storm clouds that were on the horizon are now directly overhead. Health-care expenditures have reached an unsustainable percentage of the national gross domestic product; new payment systems are being implemented; the National Cancer Institute is proposing a consolidation of collaborative research programs; and proof of competence, proof of outcomes, and value-oriented medicine are being demanded across the board by society. Despite this seemingly unfavorable climate, there is little debate that imaging will maintain a central and indispensable role in future health-care delivery. Scientific progress will not abate, and future generations will experience personalized medicine, genomic molecular imaging, and personal biomarkers to predict risk of disease and response to treatment. The future of radiology will be secured by scientific and technological progress. The future of radiologists, however, will not be 2| Bulletin | January 2011 secure unless true added value is generated and proven. Lest radiologists become marginalized, we must think in new terms about our place in health-care delivery systems. I would advocate we create the concept of “radiology-centric medicine” as a means of recapturing and securing the center of the enterprise. A necessary component of radiology-centric medicine is “radiologistcentric medicine.” The future of radiology will be secured by scientific and technological progress. The future of radiologists, however, will not be secure unless true added value is generated and proven. If we continue to perpetuate behavior and practice patterns through which we are perceived as ancillary, we will never achieve our goal. Leaders in radiology have told us for decades that we need to emerge from our darkened reading rooms. That advice has never been more important than it is now. With a grass-roots commitment to recapture the center, our collective, creative storehouse will be able to produce a broad array of concepts that can be applied to the development of radiologist-centric medicine. The spectrum of these concepts should include practical applications of a renewed commitment to service, good citizenship, professionalism, introspection, and innovation. Longstanding models of practice business and staffing will need to be re-evaluated and revised to accommodate the process of recapturing the center. In this issue of the ACR Bulletin, three such concepts are described. For decades, the traditional radiology reporting system involved a radiologist dictating a report, a report being transcribed, the radiologist checking the report for errors, and finally, a printed copy of the report being sent to the medical record and the referring physician. This process was progressively streamlined to the point where it became an extremely efficient component of the radiologist’s workflow. However, depending on clerical resources, report distribution could be unduly delayed. The article on page 17, “Loud and Clear,” discusses the advantages and challenges of voicerecognition reporting systems — a tool that clearly can facilitate the enhancement of radiologist-centric medicine by proclaiming that the interests of the patient, through immediate report availability, are of primary concern to the radiologists central to their care. The article on page 11, “Right to Speak?” reinforces the radiologist-centric concept by exploring the process of radiologists delivering imaging results directly to patients. This would have been unacceptable to referring physicians 40 years ago, but their appreciation of radiologists’ ability to interact directly with patients has evolved through the efforts of mammographers and interventional radiologists. Direct reporting to patients is another opportunity to create radiologist-centric medicine. Imaging is also central and critical to the diagnosis and management of trauma. The article on page 14, “Tackling Trauma,” discusses the need to effectively manage trauma through streamlined care. Here is another area in which the personal involvement of radiologists can solidify our role in radiologist-centric medicine. Stepping up in our role as true consultants and not mere followers of orders will enhance our stature in the minds of our medical colleagues and our patients. The opportunities to create a brighter future for radiologists are there. It’s up to each of us to use them. // dispatches NEWS BRIEFS FROM THE ACR AND AROUND THE STATES. IT’S NOT TOO LATE TO MEET CMS MANDATES The deadline for MIPPA/CMS accreditation is approaching. Beginning Jan. 1, 2012, the CMS will not reimburse facilities without full accreditation in CT, MRI, breast MRI, PET, and nuclear medicine that bill the technical component under Medicare, Part B. Additionally, the CMS will not recognize “under review” status. As an ACR member, please help spread the word that your College is the right choice for accreditation. Advantages of ACR accreditation include: • No pre-accreditation on-site survey • Multisite pricing • Easy online application • Flexible time frames • Accreditation generally within 90 days of image submission Apply now by calling 800-770-0145 or visiting www.acr.org. For ACR breast-imaging accreditation, call the hotline at 800-227-6440. PREPARE NOW FOR CHAPTER RECOGNITION AWARDS The 2011 award cycle of the ACR Chapter Recognition Program has begun. Chapters can submit information on activities until Jan. 15, 2012, for awards to be presented during the 2012 AMCLC. The recognition program began in 2003 with two goals: to formally recognize chapter successes and to facilitate sharing ideas among chapters. Since the program’s inception, more than half of the ACR chapters have been recognized for their efforts. Honors are provided in these categories: communications, government relations, meetings and education, and membership. In addition, a chapter may receive an Overall Excellence Award for demonstrating exemplary activity in all categories. Within each award category are specific forms and types of information that chapters may submit to participate. Most of these submissions can be made online, and winning chapters will be notified this spring. Awards for the 2010 award cycle will be presented during 2011 AMCLC, held May 14–18, at the Washington Hilton in Washington, D.C. Check for more information on the upcoming meeting as it becomes available at http://bit.ly/aovlj5. For award criteria and to view samples of submissions from previous years, visit www.acr.org/chapterawards. To learn more about the program, please contact the Office of Chapter and Volunteer Development at [email protected] or 800-227-5463, ext. 4496. ACR Bulletin (ISSN 0098-6070) is published monthly, with combined issues for July/August and November/December, by the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4326. Opinions expressed in the ACR Bulletin are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher. No information contained in this issue should be construed as medical or legal advice or as an endorsement of a particular product or service. From annual membership dues of $795, $12 is allocated to the ACR Bulletin annual subscription price. The subscription price for nonmembers is $90. Application for periodical mailing privileges is pending at Reston, Va., and additional mailing offices. POSTMASTER: Send address changes to ACR Bulletin, 1891 Preston White Drive, Reston, VA 20191-4326 or e-mail to [email protected]. Copyright ©2011 by the American College of Radiology. Printed in the U.S.A. The ACR logo is a registered service mark of the American College of Radiology. For information on how to join the College, visit www.acr.org, or contact staff in membership services at [email protected] or 800-347-7748. For comments, information on advertising, or to order reprints of the ACR Bulletin, contact [email protected]. ACR Bulletin is published 10 times a year to keep radiologists informed on current research, advocacy efforts, the latest technology,Advocacy relevant education • Economics • Education • Clinical Research • Quality & Safety courses and programs, and ACR products and services. | 3 dispatches ANNOUNCING THE 2011 GOLD MEDALISTS AND HONORARY FELLOWS At the September meeting of the Board of Chancellors (BOC), board members cast their votes for the 2011 ACR Gold Medalists and Honorary Fellows. Gold medals are awarded to individual members for their distinguished service to the College and the field of radiology through teaching, basic research, clinical investigation, or radiologic statesmanship. Honorary fellows are elected by the BOC in recognition of their contributions to radiology. Only individuals who are not eligible for admission as members of the ACR can receive this honor. The gold medalists and honorary fellows listed below will receive their awards at the 2011 AMCLC in Washington, D.C. Look for more information about each recipient’s service and commitment to the specialty in next month’s edition of the ACR Bulletin. Gold Medalists: • Lawrence W. Bassett, M.D., FACR, Iris Cantor professor of breast imaging, David Geffen School of Medicine at UCLA in Los Angeles • Leonard Berlin, M.D., FACR, professor of radiology at Rush University in Chicago and vice chair of radiology at Skokie Hospital in Skokie, Ill. • Arl Van Moore Jr., M.D., FACR, president of Charlotte Radiology in Charlotte, N.C. FRANCE TESTS NATIONWIDE PACS INITIATIVE According to a Sept. 2010 AuntMinnie.com article, France may be the next European nation to pursue a large-scale initiative to increase the use of PACS. Currently, the country conducts more than 61 million radiology exams each year, yet only 20 percent of academic institutions have PACS to read these images. The proposal would create a national imaging archive, save money, and streamline storage. Estimated savings would total 70 million Euros per year. France implemented a pilot program last May in 24 hospitals near Paris. The program will last five years and test the “PACS software-as-service-model on a large-scale basis, handling 1.3 million images per year,” the article explains. Though the initiative would not require all radiology facilities to join, public funding would only be provided to those practices that take part. To read the full article, visit http://bit.ly/ccC5dG. 4| Bulletin | January 2011 Isaac Sanders, M.D., FACR (right), accepts his 2010 ACR Gold Medal at AMCLC. Honorary Fellows: • Andreas Adam, M.B., B.S., professor of interventional radiology at St Thomas’ Hospital in London, England • Byung Ihn Choi, M.D., from Seoul National University in Seoul, Korea • Lawrence Shu-Wing Lau, M.D., chair of the International Radiology Quality Network from Victoria, Australia RENEW YOUR MEMBERSHIP ONLINE ACR membership provides important benefits, including subscriptions to the JACR and the ACR Bulletin, discounts on educational products, and invaluable online resources to help enhance your practice. Don’t forget to renew your membership for 2011, which is a snap with the online renewal system. To complete your renewal, follow these simple steps: 1.Go to www.acr.org. 2.Click on “My Profile” (located on the top blue bar). 3.Log in using your username and password. Your 2011 dues order information will appear (for reinstatement or payment of past dues, please contact the ACR membership department using the information below). 4.Follow the prompts to complete your renewal and submit payment. For login assistance or dues questions, contact the ACR Membership Department at 800-347-7748 or [email protected]. Online renewal for 2011 closes July 1, 2011. For more information about making the most of your ACR member benefits, visit http://bit.ly/cvN4L1. IMPROVE YOUR BREAST-IMAGING SKILLS If you’d like to hone your breast-imaging skills, the ACR’s Mammography Case Review Series provides five CD-ROMs that can help. You’ll receive immediate feedback, rationales, and scoring, as well as up to 43 AMA PRA Category 1 Credits™ and 6 SAM credits. You can order each CD individually or the full set of five. Each CD is independent from the others and can be completed in any sequence. The full set is available to members for $475 ($950 for nonmembers). For more information, visit www.acr.org/mcr. If you’re looking for other opportunities to advance your breast-imaging skills, consider the ACR BI-RADS® Atlas — a comprehensive guide to standardized breast-imaging terminology, report organization, and assessment structure. The classification system features mammography, ultrasound, and breast MR, as well as sample reports, illustrated cases, statistical definitions, and explanations for mammography audits. The atlas is available for $175 for members ($300 for nonmembers). To order, visit http://bit.ly/djciN9. And don’t forget to check out upcoming ACR Education Center courses on breast imaging. Sign up for Breast Imaging Boot Camp on April 28–30, 2011, and Breast MR With Guided Biopsy on May 9–10, 2011. Visit http://bit.ly/aGwqou for course information or to register. JACR AWARDS BEST ARTICLES OF 2010 The JACR’s Editorial Board annually recognizes four articles, one in each of the journal’s areas of interest, for their lucidity of presentation and importance to the specialty. The winning articles for 2010, selected by committees of the board members, are featured below: Clinical Practice • “Radiation Exposure From Medical Imaging in Patients With Chronic and Recurrent Conditions,” by Evan G. Stein, M.D., Ph.D.; Linda B. Haramati, M.D., M.S., FACR; Eran Bellin, M.D.; Lori Ashton, B.A.; Gus Mitsopoulos, M.D.; Alan Schoenfeld, M.S.; and E. Stephen Amis Jr., M.D., FACR, published in May 2010, available at http://bit.ly/9Z3lHz Practice Management • “Trend in the Utilization of CT for Adolescents Admitted to an Adult Level I Trauma Center,” by Bahman Roudsari, M.D., Ph.D.; Daniel S. Moore, M.D.; and Jeffrey G. Jarvik, M.D., M.P.H., published in Oct. 2010, available at http://bit.ly/d8QJ5x Health Services Research and Policy • “Analysis of Appropriateness of Outpatient CT and MRI Referred From Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved Decision Support?” by Bruce E. Lehnert, M.D., and Robert L. Bree, M.D., M.H.S.A., FACR, published in March 2010, available at http://bit.ly/dg1FoW Education • “Resident Duty Hour Limits: Recommendations by the IOM and the Response From the Radiology Community,” by Martha B. Mainiero, M.D.; Lawrence P. Davis, M.D., FACR; and Jocelyn D. Chertoff, M.D., M.S., FACR, published in Jan. 2010, available at http://bit.ly/amN8FF RADIOLOGYINFO.ORG RECEIVES 2010 WEBAWARD The jointly run RSNA-ACR website, RadiologyInfo.org, received a 2010 Web Marketing Association “WebAward” for Outstanding Achievement in Web Development. Since 1997, these awards have set the standard for excellence in site development. Judged by experts from around the world, 96 industries are reviewed. RadiologyInfo.org received recognition in the category, “Medical Standard of Excellence.” The website is a resource hub about imaging for patients. Debuting a new look for its 10-year anniversary in 2010, the site has been refreshed and reorganized for viewers’ benefit. It also includes understandable descriptions of complex radiology procedures, as well as information about how to prepare for and what to expect from these tests. RadiologyInfo.org averages 550,000 visits per month. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 5 dispatches MEMBER RESPONDS TO NORWEGIAN MAMMOGRAPHY STUDY In response to the New England Journal of Medicine article, “Effect of Screening Mammography on Breast-Cancer Mortality in Norway,” published in the September 2010 edition,1 Daniel B. Kopans, M.D., FACR, chair of breast imaging at Massachusetts General Hospital and professor of radiology at Harvard Medical School, writes, “It is time to accept that screening, beginning at the age of 40, is saving tens of thousands of lives.” The Norwegian study asserts that mammography, along with comprehensive treatment, only reduced the mortality rate in women by 10 percent. The article further reports that mammograms alone were shown to reduce the rate by as low as 2 percent, whereas older studies cited reduced mortality rates of up to 25 percent. In Kopans’ reply, which was featured //Calendar/ January 24 American Institute for Radiologic Pathology (course begins), Silver Spring, Md. on ACR’s website, he explains that the number of noncompliant patients reduces the impact of screening. Furthermore, he indicates that the authors’ short Daniel B. Kopans, follow-up period likely swayed M.D., FACR, their results as well. Kopans encourages annual also writes, “The Norway mammograms for results are based on screening women over 40. women ages 50–69 every two years. In the United States, women are encouraged to be screened every year.” He continues, “Clearly more lives will be saved by giving breast cancer less time to grow between screens. Even the United States Preventive Services Task Force agrees that screening every two years results in deaths that could have been averted by screening every year.” ENDNOTE 1. Kalager M., et. al. “Effect of Screening Mammography on BreastCancer Mortality in Norway.” N Engl J Med 2010; 363:1203–1210. Available at: http://bit.ly/93SeHj. March 6–11 Radiology Resident Review, San Francisco 28–30 Society for Pediatric Radiology: Advances 7 American Institute for Radiologic Pathology in Fetal and Neonatal Imaging, Orlando, Fla. (course begins), Silver Spring, Md. 29–30 Society of Breast Imaging: Practical 18–20 ACR-SPR Pediatric Cardiac MR, Breast MRI, Miami 30–Feb. 4 Leadership Strategies for Radiology: Taking Your Practice to the Next Level, Vail, Colo. February 4–6 North Carolina Radiological Society: Vascular Ultrasound Weekend Review Course, Charlotte, N.C. 7–8 Breast MR With Guided Biopsy, Reston, Va. 7–10 Emergency Radiology, Palm Beach, Fla. 6 | Bulletin | January 2011 Reston, Va. April 5–6 SPR’s ALARA — Advances in CT, Dallas 6–9 Society of Thoracic Radiology 2011 Annual Meeting, Bonita Springs, Fla. 9 Texas Radiological Society Meeting, Austin, Texas // // CLINICAL EYEBROW RESEARCH Innovation in Imaging Research and Tools ACRIN® PRESENTS RESEARCH RESULTS AND UNVEILS IMAGE-MARKUP TOOL AT RSNA ANNUAL CONFERENCE. By By Nancy Fredericks Lesion 1 Area: 6.052 cm2 Mean: 76.291 SDev: 33.108 Total: 97576 Min: -50.000 Max: 171.000 Length: 9.680 cm In secondary analyses from this trial, findings from the study’s participants were identified and prospectively recorded using standard BI-RADS® terminology. These statistics also included an additional descriptor for multiple bilateral masses to note similar benignappearing findings in both breasts. Trial researchers also compared similar masses detected with mammography and whole-breast ultrasound with isolated, unilateral lesions. Among the 2,662 at-risk participants who underwent three rounds of screening with mammography and whole-breast ultrasound, no malignancies were identified among multiple bilateral, benign-appearing masses by either screening method. When using mammography alone, rates of malignancy were higher for isolated circumscribed or obscured masses Courtesy ACR Clinical Research Center Imaging Core Laboratory N ew and emerging clinical research findings from ACRIN® were well represented among the 2,600 scientific paper and poster presentations at RSNA’s 96th Scientific Assembly and Annual meeting. The conference also gave members of the ACRIN Biomedical Imaging Informatics Committee the opportunity to showcase their newest initiative — a novel annotated image-markup tool. ACRIN investigators delivered two presentations that featured data analysis from the ACRIN trial, “Screening Breast Ultrasound in High-Risk Women.” Wendie A. Berg, M.D., Ph.D., led this multicenter study that focused on determining the role of using breast ultrasound to screen for cancer and the associated risk of an unnecessary biopsy. In this image depicting the graphical interface of the image Physician Annotation Device (iPAD),* the reader has circumscribed a lesion in an image of the liver (left) and is using the reporting template to completely describe the visual features of that lesion (right). Each imaging observation, including the lesion name, is automatically prompted by the iPAD tool. 8 | Bulletin | January 2011 than for similar multiple bilateral masses. When analyzing mammographic findings and determining management, trial researchers discovered that morphology and distribution of calcifications should also be considered, as well as whether the finding is multiple, bilateral, or similar. When using ultrasound for screening, the descriptive categories between round and oval masses allowed for further refinement in the classification of benign and benign-appearing masses. Data from ACRIN’s “Digital Mammographic Imaging Screening Trial” (DMIST) were used in a secondary analysis led by Kathryn P. Lowry, B.S. In the analysis, a Markov Monte Carlo model was used to evaluate the comparative effectiveness of annual breast-cancer screening in women with BRCA-1 gene mutations when using mammography alone, digital mammography (DM) alone, or a combination of the two with MRI. Additionally, clinical surveillance without imaging was compared with six screening-strategy variations that started at four different ages (25, 30, 35, and 40) with the goal of projecting outcome for life expectancy. When mammographyinduced risk of breast cancer was taken into account, the optimal strategy involved MRI beginning at age 25 and alternating DM/MRI at six-month intervals beginning at age 30. Data from the “National Lung Screening Trial” were also presented at the annual conference by Randell L. Kruger, Ph.D., which focused on the effectiveness of radiation dose associated with chest Xray examinations. Retrospective data from 67,641 chest X-ray examinations were included in the assessment. Acquisition parameters at the 33 screening sites and participant-specific characteristics were considered in calculating the effective dose for each chest X-ray examination. The median participant effective dose (0.0344 NLST DATA SUPPORT LOW-DOSE CT USE FOR LUNG-CANCER SCREENING Lung cancer is the leading cause of cancer-related deaths in the United States. With more than 94 million current and former smokers in the United States, lung cancer is expected to claim 157,300 American lives in 2010. The National Cancer Institute (NCI) recently announced that initial results of the “National Lung Screening Trial (NLST)” — the largest randomized study of lung-cancer screening in high-risk In this axial CT image of the lung populations to date — have the of an NLST participant (from the potential to impact hundreds of second of three screening visits), thousands of individuals. the arrow points to a tumor in the posterior right lower lobe. The trial, sponsored by the NCI and conducted by ACRIN® and the NCI’s Lung Screening Study group, enrolled more than 53,000 current and former heavy smokers between 55 and 74 beginning in August 2002 at 33 sites across the country. Each participant was randomly assigned to receive three annual screens with either low-dose helical CT or a chest X-ray. In addition, 15 NLST ACRIN sites collected and banked specimens of blood, sputum, and urine. Tissue of trial participants’ lung cancer was also collected across most sites. These specimens will provide a rich resource to validate molecular markers that may complement imaging to detect early lung cancer. The NCI’s decision to announce the initial findings from the NLST was made after the trial’s independent Data and Safety Monitoring Board notified NCI Director Harold E. Varmus, M.D., that the accumulated data now provide a statistically convincing answer to the study’s primary question and that the trial should therefore be stopped. Comparing the effects of lung-cancer screening with CT and X-ray, the trial found that 20 percent fewer deaths occurred among participants screened with low-dose helical CT. The study’s design and methods were recently published online in Radiology.1 Courtesy Drew Torigian mSv) was consistent with prior studies, providing more detailed information about the potential for increased risk of cancer associated with CT or chest X-ray. A third presentation shared data from a central review of brain MRI scans. This research was obtained during the ACRIN 6677 clinical trial, with the aim of addressing the difficulty associated with the assessment of tumor progression in patients treated with the anti-VEGF antibody bevacizumab. Led by the trial’s principal investigator A. Gregory Sorensen, M.D., the central review involved two readers and an adjudicator. They were trained using a customized presentation and tested for comprehension prior to performing a WHO-style bidimensional radiographic assessment of progression and assessment of serial 3-D volume (both on T1-weighted measures for post-contrast images), as well as 3-D volume assessments for T2-weighted images. Researchers concluded that training and testing improve agreement in central radiologic review and that the addition of T2 imaging increases detection of progression rates in patients with recurrent glioblastoma who are being treated with anti-VEGF therapy. Another innovative development showcased in the RSNA Quantitative Imaging Reading Room featured a demonstration of the image Physician Annotation Device (iPAD)* from ACRIN in conjunction with Stanford University. iPAD, an open-source tool that links the semantic content of a radiologic image with the image itself, enables physicians to annotate images so that descriptions are recorded into the computer in a machineaccessible way. Currently, when radiologists annotate the same images differently, it is difficult to compare findings with different readers. Because iPAD stores data in a quantitative manner, it automatically provides a standard annotation vocabulary across the image repository and between readers. Readers are prompted to annotate lesions consistently and to use similar terms to describe the same features. This tool was developed by the Annotated and Image Markup Project, directed by Daniel L. Rubin, M.D., M.S., and supported by Mark A. Rosen, M.D., ENDNOTE 1. Gatsonis C.A. “The National Lung Screening Trial: Overview and Design.” Radiology 2010. Available at: http://bit.ly/dhAXx5. Ph.D., with programming assistance interns from the Princeton Internships in Civic Service Program. RSNA attendees were also presented with information about ACRIN’s expanding clinical trials portfolio and how they might participate in ACRIN research that will likely be featured at future meetings. // *Editor’s Note: Rubin’s team coined the term “iPAD” well before the introduction of the Apple product; however, they are currently considering new names for the annotation tool. Nancy Fredericks, M.B.A., (nfredericks@ acr.org) is communications director, ACR Clinical Research Center. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 9 >> NEWS FROM THE COUNCIL By Alan D. Kaye, M.D., FACR Speaker, ACR Council Preserving Tradition, Expanding Opportunity SKETCHING THE BLUEPRINTS FOR THIS YEAR’S AMCLC. T he 2011 AMCLC will provide a unique opportunity for ACR members to influence the policy and direction of the College. Preparations have begun, deadlines have been set, and the Council Steering Committee (CSC) anticipates a vibrant meeting in Washington, D.C., from May 14–18. The conference brings together councilors and representatives from 54 state chapters and 25 radiology subspecialty societies with diverse demographics and practice settings. These differing perspectives enhance the CSC’s discussions and debates about the issues facing our specialty in these turbulent times. A goal of my tenure as speaker is to empower the council to make policy, which is mostly accomplished by passage of resolutions at this meeting. To that aim, the council has approved a new document drafted by CSC member Katie D. Lozano, M.D., which provides a primer on how to introduce a resolution for the council’s 10 | Bulletin | January 2011 consideration. The document, which will be posted on the ACR AMCLC web portal at http://amclc.acr.org, will provide links to members of the CSC and the Board of Chancellors (BOC) as well as contact information for chapters and subspecialty societies. (Individuals can also visit http://amclc. acr.org/ContactCSC.aspx for more information about the CSC members.) I recommend that you contact me or any of these individuals or groups to facilitate the consideration of issues you think the ACR should address. In addition, the orientation session for new councilors will be expanded and all interested councilors will be invited. The orientation is designed to tion on meeting meaningful use criteria for electronic records so radiologists can take advantage of potential federal subsidies. Shay Pratt, managing director of the Advisory Board Co. — a national consulting group for hospitals — will discuss the evolving nature of radiologisthospital relations. With all of the challenges we face as radiologists, members surely have thoughts on where our specialty must go and how the ACR can help us get there. While I have not yet chosen the topics for the open microphone sessions, I have a few potential topics in mind that will give you the chance to listen to your fellow councilors and be heard by the ACR leaders. With all of the challenges we face as radiologists, members surely have thoughts on where our specialty must go and how the ACR can help us get there. ... We want to hear your opinions. improve awareness of the governance processes of the ACR and the council, and make the annual meeting less daunting for new councilors and enhance the effectiveness of experienced councilors. We want to hear your opinions. Meeting Plans Take Shape Our regular program for the 2011 AMCLC is supplemented with important lectures and discussions about the challenges our members and specialty face. This year, we invited Donald M. Berwick, M.D., CMS administrator, to deliver Monday’s Robert D. Moreton Lecture. Other featured speakers will include informatics expert Keith J. Dreyer, D.O., Ph.D., from Massachusetts General Hospital in Boston, who will deliver the Tuesday lunch presenta- Continuing our tradition of providing clinical education for attendees, the pre-meeting educational symposia on Saturday, May 14, “Radiation Dose and CT Scanning: Perspectives on the Problem and Potential Solutions,” will be co-sponsored by the ACR and the American Roentgen Ray Society. The 2011 AMCLC promises to be an outstanding opportunity for ACR members to participate in the policymaking process, stellar educational sessions, federal health-care advocacy, and discussions of issues critical to the future of the profession. For more information about the conference, visit http://amclc.acr.org. To learn about the CSC, volunteerism, or ACR state chapters, contact Brad Short, senior director of member services, at 800-227-5463, ext. 4795, or [email protected]. // THE RIGHT TO SPEAK? EXPERTS WEIGH IN ON GIVING IMAGING RESULTS DIRECTLY TO PATIENTS. By Leah Lakins R adiologists have traditionally served as the “strong, silent type” in the health-care arena. Although they are a critical bridge between the patient and the referring physician, their voices were often unheard or deemed unnecessary. But in this new era — where patients are educated, informed, and ready to litigate — radiologists can no longer afford to keep their silence. Today’s professionals must be willing to stand in the gap between the patient and referring physician and, as needed, be an active, vocal partner, ensuring patients receive superior care. So, how do radiologists determine when they should speak up? Advocacy • Economics • Education • Clinical Research • Quality & Safety | 11 The first step toward charting the communication waters begins with understanding one of the most trusted documents on the issue: The ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Now in its fifth revision, the guideline has been mentioned in legal cases for and against radiologists and as a foundation for communication standards throughout the radiologic community. The guideline remains a hotly contested topic among radiologists, accruing 110 comments since its creation in 1991. Despite garnering four times the feedback for a typical ACR standard,1 this document continues to be beneficial for today’s practicing professionals. “Overall, the guidelines have more pluses than minuses,” says Leonard L. Lucey, J.D., LL.M., legal counsel and senior director for the ACR Department of Quality and Safety. While the federal Mammography Quality Standards Act already mandates that radiologists deliver mammography results directly to patients, the revised ACR standard recommends direct communication to the referring physician for findings that require immediate intervention. In the most extreme or life-threatening cases, radiologists can report results directly to the patient when the patient’s physician cannot be reached. These cases include urgent imaging results from emergency and surgical departments, second interpretations that are significantly different from the first and may change a course of treatment, and any findings for which the imager believes a delay in communication will be seriously adverse to the patient’s health. The guideline also states, “Regardless of the source of the referral, the interpreting physician has an ethical responsibility to ensure communication of unexpected or serious findings to the patient. Therefore, in certain situations the interpreting physician may feel it is appropriate to communicate the findings directly to the patient.”2 While these new recommendations gave radiologists more license to speak up if needed, many were uncomfortable with circumventing the traditional reporting systems and rapport with referring physicians. “Not all radiologists are good 12 | Bulletin | January 2011 at speaking to patients,” says Richard N. Taxin, M.D., FACR, from Southeast Radiology Ltd. in Chester, Pa., and vice chairman of radiology at the Crozier Chester Medical Center in Upland, Pa. “[Also] patients may get things wrong when they hear things, and they may miss out on a lot. This can lead to all kinds of complications.” Armed Patients Regardless of a medical professional’s preference or comfort level, today’s patients are demanding more from all of their health-care professionals — including radiologists. With the increasing popularity of medical websites like WebMD.com and MedicineNet.com, patients have more access to diagnostic information than ever before. Gone are the days of simply accepting a medical diagnosis without question or explanation. Instead, patients are well informed and want to partner with their medical professionals. “Historically, radiologists did not communicate directly with patients,” says Leonard Berlin, M.D., FACR, vice chair of radiology at Northshore University HealthSystem at Skokie Hospital in Skokie, Ill., and radiology professor at Rush University Medical College in Chicago. “Radiologists would make sure the X-ray was done, write up a report for the referring physician, and send it back,” Berlin continues. “Now, we are beyond the age of ‘paternalism’ in medicine where the doctors are the ultimate authority. We are now in an age of ‘consumerism’ where patients are very involved and want to know about their treatment options.” Empowering patients is an important principle for Harley J. Hammerman, M.D., CEO of Metro Imaging in St. Louis. When local physicians in his area began acquiring their own imaging equipment, Hammerman made the decision to provide imaging results directly to his patients. Although there was some grumbling from his fellow physicians, Hammerman believes that immediately giving his patients their results provides peace of mind and helps them make better decisions. Richard N. Taxin, M.D., FACR, states that referring physicians should deliver imaging results to patients. “I believe that patients are best served by their referring physicians, who can explain the intricacies of a diagnosis with more detail.” — Richard N. Taxin, M.D., FACR Leonard Berlin, M.D., FACR, says that radiologists have a legal and moral obligation to provide results to patients in a timely manner. “Now, we are beyond the age of ‘paternalism’ in medicine where the doctors are the ultimate authority. We are now in an age of ‘consumerism,’ where patients are very involved and want to know about their treatment options.” — Leonard Berlin, M.D., FACR Harley J. Hammerman, M.D., delivers image results to patients as soon as possible. “Patients don’t want to spend weeks being worried or concerned. They would rather hear and know [their results]. This gives patients the time to do their research and be better prepared to have a discussion with their physician.” — Harley J. Hammerman, M.D. PATIENT RADIOLOGIST REFERRING PHYSICIAN PATIENT CARE TRIANGLE + “Patients don’t want to spend weeks being worried or concerned,” he says. “They would rather hear and know [their results]. This gives patients the time to do their research and be better prepared to have a discussion with their physician.” Berlin similarly advocates for keeping patients in the loop. He says, “If I saw something on a patient’s film, I couldn’t bring myself not to tell him or her about it. [Delivering results] to my patients never worked against me, and it helped me build up a nice relationship with them.” While Taxin believes direct communication is a great courtesy to extend to patients, he argues that it takes a lot of time. “Our practice reviews more than 365,000 examinations every year,” he says. “While [we are required by law] to discuss diagnostic mammography results with every patient, we wouldn’t have time to provide this service for every patient. I believe that, in general, patients are best served by their referring physicians, who can explain the intricacies of a diagnosis with more detail.” When the Law Intervenes The decision to cross the communication divide with patients is more than just a professional preference; it also comes with legal considerations. While the ACR guideline states, “the ultimate judgment … of any procedure or course of action must be made by the physician or medical physicist,” several prominent court cases, including Phillips v. Good Samaritan Hospital, Jenoff v. Gleason, Stanley v. McCarver, and Williams v. Lee, have also made radiologists equally responsible for the patient’s ultimate well-being. “Imagine having to stand before a jury and defend why you didn’t tell a patient that you saw a potential cancer in his screening,” Berlin says. “If you were to simply say, ‘It wasn’t my job to deliver those results,’ and the patient dies because they didn’t receive the news in a timely manner, that’s a very hard thing to defend legally and morally.” If a radiologist has to stand on trial, Hammerman believes that developing a relationship with patients will be beneficial. He says, “Most of the physicians who are sued don’t have a relationship with their patients. When we take the time to develop a relationship with them, if something goes wrong, we are less likely to be sued.” Even if radiologists aren’t comfortable delivering critical medical news to a patient, they are still obligated to ensure that image results get to the referring physician quickly and efficiently. “Courts generally hold radiologists responsible for getting a report where it needs to be and making sure that it is acted upon,” Lucey notes. “Although, the communication guideline does also emphasize that referring physicians share in the responsibility of obtaining results of imaging studies they order,” he adds. While many radiologists are still divided about communication, the next cue may come from patients. “The trend is moving in the direction of providing [imaging] reports directly to patients,” says Berlin. “It’s the right thing to do and I believe it is eventually going to happen.” Regardless of where you stand on the issue of communication, the ultimate responsibility is clear — every radiologist must make decisions to ensure the health, safety, and well-being of patients. // ENDNOTES 1. Lucey L et al. “The ACR Guideline on Communication: To Be or Not to Be, That Is the Question.” Journal of the American College of Radiology 2010;7:109−114. 2. ACR Practice Guideline for Communication of Diagnostic Imaging Findings. American College of Radiology, Reston, Va., 2005. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 13 TACKLING TRAUMA + RADIOLOGISTS ACT FAST, THINK SMART TO STREAMLINE CARE IN THE EMERGENCY DEPARTMENT. BY ALYSSA MARTINO 14 | Bulletin | January 2011 +++++++++++++++++++++++++++++++++++++++++++++++++++++++ Susan D. John, M.D., chose emergency department radiology because she enjoys the physician interaction and intimate atmosphere. As current president of the American Society of Emergency Radiology, Stephen F. Hatem, M.D., believes standardizing image transfer protocols will help improve emergency care. A ll hospitals maintain one department unlike all the rest: the emergency department (ED). It’s a place where the pressure to provide fast, effective care is rivaled only by the number of acute injuries and illnesses witnessed each day. In the ED, radiologists play a vital role in saving lives. As Marty Khatib, J.D., RT(R), writes in Radiology Today, “Although many service lines support the ED, diagnostic imaging is arguably one of the most critical areas.” Khatib adds that 44.2 percent of ED patients have imaging procedures ordered, as found in a National Center for Health Statistics study.1 “Some individuals can train for this lifestyle and others have it built into their personality and thus gravitate toward it,” explains Susan D. John, M.D., vice president of the American Society of Emergency Radiology (ASER) and professor of radiology at the University of Texas Medical School in Houston. Although this one-of-a-kind job is extreme in tension levels and pace, emergency radiologists face many of the same challenges as other subspecialists — from making decisions and triage to communication and patient safety. Urgency, Efficiency, and Turf Issues ED physicians — radiologists included — face at least one major variation in their patient care: “There’s a sense of urgency,” says John. In general medicine, “treatment is usually ongoing. In the ED, you’re dealing with problems that have to be handled immediately.” John, who practices both pediatric and emergency radiology, prefers the ED’s climate because it’s very interactive and close-knit and requires a team-like atmosphere, she explains. Stephen F. Hatem, M.D., 2010–2011 president of ASER and radiologist at the Cleveland Clinic in Ohio, made the decision to become an emergency radiologist after completing residency at a level 1 trauma center. “It’s an eye-opening experience,” he says. “You feel integral to patient management. You have to be prepared to deal with multiple organ systems and multiple imaging modalities.” “You feel integral to patient management. You have to be prepared to deal with multiple organ systems and multiple imaging modalities.” — Stephen F. Hatem, M.D. Referring physicians in the ED also need diagnostic answers as soon as possible, which amplifies the role radiologists play in imaging decisions. “I think that all practices work differently,” says Hatem. “But in mine, [radiologists have] taken a fairly active role in triaging the requests we receive.” John agrees: “We see many more patients in a day, so we need to be very efficient with processes. [ED radiologists] sometimes need to decide which patients take precedence based on how life-threatening a situation may be. We use trauma codes 1, 2, 3, [etc.] to help with this.” Advocacy • Economics • Education • Clinical Research • Quality & Safety | 15 ++++++++++++++++++++++++++++ Another issue radiologists face in the ED is “turf wars.” For example, in the March 2005 JACR article, “Turf Wars in Radiology: Emergency Department Ultrasound and Radiography,” co-authors David C. Levin, M.D., and Vijay M. Rao, M.D., argued against physician imaging, writing that “the training offered to emergency medicine residents is far less rigorous than that provided to radiology residents.”2 John believes that while some physicians have taken on imaging responsibilities in the ED, they still rely heavily on radiologists. “Some physicians and trauma surgeons have begun to use ultrasound as a bedside tool to obtain focused information they really need, such as whether there’s free fluid in the abdomen,” she says. John adds that it’s challenging for radiologists to provide this information rapidly because often they’re in the reading room, not the trauma room. Bridges of Communication Though imagers have stepped up in the ED, they must still communicate and work with referring physicians to avoid duplicate studies and ensure the smooth transfer of images — both notorious problems in emergency medicine. In the past several years, technology, including PACS, has sped up the overall processes of communicating findings. “In the old days, when we had hard copy film, you had one copy [of an image] that everybody needed to see,” says John. “It was messy and horrible. Once PACS came into existence, multiple people could view images from various places without running all over the hospital. This has been the biggest step toward improving efficiency.” In other arenas, however, more advances are necessary to ensure efficient care. Currently, CD-ROMs with a patient’s radiologic images are transferred from other hospitals, which can pose further obstacles. “Unfortunately, there aren’t really standards for these CDs,” says Hatem. “You receive data in all different formats, which can be cumbersome and frustrating. “I definitely support standardization of this process — which, I believe, the ACR is working on.” ACR’s system for the 16 | Bulletin | January 2011 Transfer of Images and Data is helping fulfill this goal by tracking and managing the collection and transfer of images, scans, and more. (To learn more, visit https://triad.acr.org.) John notes that although PACS has definitely improved image transfer, the technology still needs refining. “The ability to dictate is lagging,” she says. “If a department uses a transcription company, typists listen and type dictations — this is a moderately slow process. Now, with voice recognition, radiologists become the typists. However, this means we also have to correct any mistakes the system incorrectly hears.” (For more on voice recognition software, read “Loud and Clear” on page 17). Communicating findings is also challenging during off hours. Hatem explains, “More frequent utilization of teleradiology has increased access to expert radiologic interpretations — both in academic and private practice.” John’s department is also at the helm of implementing a new “critical value” system to communicate the most vital of findings — those needed to save lives immediately. “We’re looking for pieces of information that are very valuable in the treatment and welfare of a patient,” she says. “For those, we’ll have a special way of contacting the referring physician immediately.” Protecting Patients In this fast-paced, high-stress environment, one question is not overlooked: how do ED radiologists remain mindful of patient safety? John believes there are two ways to prioritize safety. “The first facet is on the technical side — setting up department protocols based on patient size so we don’t use the same dose when we image a 60-year-old to image a 2-year-old,” she says. This, she adds, includes making sure equipment is current and that the appropriate parts of the body are imaged. John also notes that the Image Gently™ and Image Wisely™ campaigns are important efforts to oversee safer imaging. For more information and resources, visit www.imagegently.com and www.imagewisely.com. ++++ + “The tendency is to want to do a lot of imaging quickly. It’s easy to over-image in those circumstances.” — Susan D. John, M.D. The second piece of protecting ED patients is related to physician responsibility. “We need to make sure we’re only doing studies that are necessary based on the clinical problem,” John explains. “This is a difficult process because clinicians are under a lot of pressure, and many patients have potentially serious conditions that could be life threatening,” she continues. “The tendency is to want to do a lot of imaging quickly. It’s easy to over-image in those circumstances.” Hatem also agrees that radiation dose and safety are important priorities; however, he doesn’t believe these issues require a higher level of awareness and commitment from ED radiologists alone. “I think [radiation safety] should be on the forefront of all radiologists’ minds,” he says. “We should all strive to minimize radiation dose and ensure appropriate utilization.” // ENDNOTES 1. Khatib, M. “Improving Emergency Department and Imaging Throughput.” Radiology Today Nov. 16, 2009. Available at: http://bit.ly/9iJ0t9. 2. Levin, D.C. et al. “Turf Wars in Radiology: Emergency Department Ultrasound and Radiography.” JACR 2005;3:271–273. + Radiologists articulate the advantages and challenges of speech-recognition software. By James Brice R adiologists have adjusted to many new technologies, but few have posed a bigger challenge than speech recognition (SR). Using computers to aid in translating speech into text, SR strikes at the heart of radiology practice and work routine. SR performs its primary function precisely at the moment radiologists perform theirs. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 17 radiology department that continues to rely mainly on traditional transcription, notes Arun Krishnaraj, M.D., M.P.H., clinical fellow at Massachusetts General Hospital and Harvard Medical School, who studied SR practices at the University of North Carolina. Medium-sized acute care hospitals are adopting SR swiftly, and small hospitals and freestanding imaging services have much to gain. “I would suspect the improvement in report turnaround that you get with speech recognition would be even greater with small practice groups and hospitals,” Krishnaraj says. Bountiful Experience One group with a positive SR experience is Radiology Consultants of Iowa (RCI) in Cedar Rapids, Iowa. RCI first applied the concept in 2005 as part of a wide-area network PACS/RIS implementation for 12 small, rural hospitals. The goal was to view images and dictate reports any time, any place, says RCI partner John L. Floyd, M.D., FACR. In fact, senior partner W. Jay Friesen, M.D., uses the system to dictate reports during frequent visits to his second home in Arizona. The new configuration delivered on RCI’s promise to its rural hospitals for report turnaround times as short as those at its large facilities in Cedar Rapids. Courtesy Hoag Hospital Newport Beach Many radiologists dislike SR and prefer the reassuring backup of a medical transcriptionist. In fact, SR forces radiologists to correct mistakes and edit their work, which sometimes makes interpretation more time-consuming. They are also wary because of SR’s tendency to make rare, but dangerous, mistakes. Nonetheless, the service has evolved, and the most recently released software’s error rates have fallen to about 2.5 percent. Although radiologists still debate SR’s merits, many hospital administrators are convinced it saves money — often hundreds of thousands of dollars annually in reduced medical-transcription expenses. Vendors typically promise a positive return-on-investment in about a year. SR also dramatically cuts imagingreport turnaround times, creating goodwill among referring physicians whose loyalty and patients are key to a hospital’s financial success. Recent product developments are designed to capitalize on SR as a workflow tool to automatically load information, boost productivity, and draw data from the system for billing, patient management, and quality control. Despite the misgivings, SR is on its way to becoming as ubiquitous as digital workstations in reading rooms. Indeed, it’s hard to find a U.S. academic William J. Van Dalsem, M.D., demonstrates Hoag Hospital’s approach to radiology dictation assisted with speech-recognition software. 18 | Bulletin | January 2011 With the exception of emergency CT transmitted via rudimentary teleradiology, the rural sites were accustomed to turnaround times as long as five days. After installation, however, most studies were signed and transmitted back in less than two hours. RCI then took steps to collaborate on proposed SR installations with its two largest clients, Mercy Medical Center and St. Luke’s Hospital, both in Cedar Rapids. Software was installed at Mercy after the group contracted to manage the facility’s in-house transcription service and promised to charge the hospital less per report than it paid when operating the service itself. The hospital continued to manage its own PACS and RIS. St. Luke’s came on board in January 2007 when Floyd showed its management how SR was dramatically improving report turnaround times for its nearby competitor. The change at St. Luke’s was impressive. Previously, only 20 percent of reports had been available to referring physicians in less than two hours after imaging. After implementation, 90 percent arrived in less than two hours, says Dennis E. Winders Jr., St. Luke’s director of imaging services. Since mid-2008, mean turnaround time for final reports for ER imaging has been less than 15 minutes. Improvements were especially evident in the ICU. “Physicians who arrived in the mornings to make rounds among ICU patients found that their radiology reports were waiting for them,” Floyd says. “When they came in to make afternoon rounds, imaging reports were sometimes showing up in patients’ records before the patients returned to their rooms.” Referring physicians were especially pleased with the improved performance, notes Kathy Epley, RCI’s chief administrative officer. A Press-Ganey survey conducted a year after implementation found that St. Luke’s and Mercy scored with the top 1 percent of U.S. hospitals for referring-physician satisfaction with report turnaround times. Radiologists also benefitted professionally and financially from the new SR system. Faster turnaround led to fewer interruptions for wet reads, Floyd reports. Attending radiologists were more likely to be available to field questions when referring physicians read the findings. And RCI’s transcription services at both hospitals made a profit. Like many SR implementations, Floyd notes that his group’s effort started acrimoniously. Deep divisions emerged from initial discussions about RCI’s strategy. “Now, you won’t find any radiologist in our group who would prefer to return to traditional transcription, mainly because of the backend benefits of immediate filing,” he says. Dispelling Doubt Michael N. Brant-Zawadzki, M.D., FACR, tells a similar story about his group’s initial skepticism and eventual acceptance of SR at Hoag Hospital in Newport Beach, Calif., in 2005. To overcome resistance, Brant-Zawadzki argued that self-editing improved on traditional transcription methods. “Before SR, reports at Hoag Hospital were dictated in a stream-of-consciousness fashion without a conscientious attempt by the radiologist to structure them properly,” he says. Most reports were accurately transcribed, but there was no guarantee that the transcriptionist understood crucial details, so errors could find their way to the referring physician. Confirming clinical results was nearly impossible because of the way work was organized, Brant-Zawadzki adds. Now, about 80 percent of the reports are self-edited after SR implementation. This extra step forces radiologists to invest 10 to 20 percent more time into each report, but it also delegates responsibility for correcting errors to the person most qualified to find them, according to William J. Van Dalsem, M.D., Hoag Hospital’s medical director of radiology. While Van Dalsem doubts that every radiology group will embrace SR, he is committed to the self-editing concept. “The style and quality of our group’s reports are generally much improved,” he shares. New Features Save Time Despite some lingering skepticism, labor-saving upgrades are encouraging broader use of SR. Radiology reports are now frequently prepopulated with demographic and clinical history, as well as imaging protocol data from RIS and PACS. Other time-savers include a growing library of report templates providing shortcuts to reporting normal findings, and dictation that can be limited to exceptions only, such as the presence, size, and location of abnormalities. And, the source of all material in a report can be color-coded before self-editing so radiologists can focus on critical sections where significant errors may reside. Newer software also helps radiologists more accurately structure reports, add punctuation, and correct bad grammar, which means less editing time. Another key advantage is that SR users can be guided by master work lists that alert them of the status of studies awaiting interpretations at multiple hospitals and imaging centers served by the practice. New, computer-assisted coding engines that draw data from the final report for automatic coding and insurance billing can provide additional efficiencies. These tools can also mine PACS, RIS, and electronic medical records for data to assist administrative management-by-exception reporting. And, future enhancements may even support structured reporting. Although new features continue to improve SR, it may take time for radiologists to fully embrace it; in the meantime, case studies such as those in Iowa and California can help illuminate its value and future ways to refine its implementation. // James Brice (jamesbrice@medicalwrite. net) is a freelance writer. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 19 // TESTING The Art of the Question NEW REFORMS CREATE DEMAND FOR SKILLED ITEM WRITERS. By James Brice W ell-prepared residents fly through them in less than a minute. They read the question, consider the options, choose an answer, and move on. They are multiple-choice questions, and there is nothing quick or easy about writing good ones. The question writer — called an item writer in the field of exam writing — spends hours formulating just Gary J. Becker, M.D., FACR, believes that diplomates of the ABR can rely on cognitive exams to determine who is qualified for clinical practice. 20 | Bulletin | January 2011 one question to measure the test taker’s clinical knowledge and diagnostic skill. But the effort is considered time well spent. Under the guidance of the National Board of Medical Examiners (NBME), many professional medical societies, including the American College of Radiology and the American Roentgen Ray Society, have become increasingly involved in promoting sound medical testing practices. “Valid testing has a very important role to play,” says Mark R. Raymond, Ph.D., NBME’s principal assessment scientist. “If the tests are done right, the public is well served. If the questions are not well designed, they can allow people who really don’t know the subject matter to get a passing grade.” Diplomates of the ABR also deserve to know that cognitive exams are a reliable way to determine who is qualified for clinical practice, notes ABR Executive Director Gary J. Becker, M.D., FACR. “Most [diplomates] do not know that the evidence base is solid and growing behind the correlation between their performance on certifying cognitive examinations and performance in practice,” he says. Good questions, and the item writers required to create them, are in demand — particularly in radiology because its certification programs are in a state of flux. New committees are developing test questions for the ABR’s new core and certification exams for radiology residents. The question areas Janette Collins, M.D., M.Ed., FCCP, FACR, notes that anyone can learn to become a good item writer. include medical physics, patient safety, 10 categories of organ systems, and six imaging modalities. The new core exam will have 600–700 questions, and the certifying exam will have approximately 300. Each committee member who is helping develop the new computer-based exams has been asked to submit 20 cases for each of the next four years to create a sufficient pool of items for the test. (See October 2010 ACR Bulletin for related article, “Introducing the New Boards.”) Each case has one or more items. So, what is promoting this emerging market, and what does it take to become a good item writer? Jeffrey P. Kanne, M.D., says that question ideas are drawn from relevant subject matter, personal clinical experience, and review articles. Effect of MOC The ABR’s Maintenance of Certification (MOC) program is one area fueling demand for talented item writers. Lifetime board certification was discontinued in 2002 in favor of a 10-year certification cycle that requires ABR diplomates, who were first certified after 2001, to pass a cognitive recertification exam every 10 years. ABR diplomates are also required to earn 250 AMA PRA Category 1 Credits™ every 10 years and to complete two self-assessment modules (SAMs) annually. More than 200 SAMs, which each include a multiple-choice exam to test comprehension, are needed to accommodate the diplomates’ varied professional needs. Continuous professional development and MOC testing are necessary because of published evidence showing that a physician’s professional performance is likely to deteriorate over time, according to Becker. “The facts have tremendous bearing on the mandate for continuous professional development and on the need for MOC as a framework to accomplish it,” he says. radiology, radiation oncology, or medical physics, as well as willingness to learn the mechanics of good item writing are key requirements, she says. The process begins with framing an objective, according to Jeffrey P. Kanne, M.D., associate professor of radiology at the University of Wisconsin, Madison, and member of ABR’s Thoracic Certifying Committee. For questions designed for Good questions, and the item writers required to create them, are in demand — particularly in radiology. Developing Good Questions Though academic radiologists will meet most of the demand for this field, anyone can learn to become a good item writer, says Janette Collins, M.D., M.Ed., FCCP, FACR, chair of radiology at the University of Cincinnati College of Medicine in Ohio. Mastery over a particular dimension of diagnostic the ABR, Kanne selects subject matter that an individual seeking certification is expected to know after completing residency training. Question ideas are also drawn from personal clinical experience and review articles. “Skilled item writers overcome the tendency [to only write] multiple-choice questions that require test takers to ANATOMY OF A GOOD QUESTION A 62-year-old man presents with a 3.2-cm peripheral right upper-lobe lung adenocarcinoma and bilateral mediastinal lymph node metastases. What is the most appropriate treatment? A. Surgery and chemotherapy B. Surgery and radiation therapy C. Radiation therapy and chemotherapy D. Chemotherapy only Correct answer: C. This patient has T2N3M0 lung cancer (Stage III-b). Standard treatment is a combination of chemotherapy and radiation therapy. This question tests a single concept — lung-cancer treatment. However, it requires a higher level of thinking because the examinee has to know the current lung-cancer staging system and standard treatment for each stage to arrive at the correct answer. This is a good test question because it is linear, complete, and clear; provides all the information needed to answer (i.e., a knowledgeable person can answer the item before seeing the choices); focuses on a single concept; is worded positively; and is clinically relevant but not controversial. (Source: J. Kanne) Advocacy • Economics • Education • Clinical Research • Quality & Safety | 21 recall memorized material,” Collins says. “Writers should draw from Bloom’s taxonomy, a pyramid of increasingly sophisticated intellectual behaviors important in learning. Higher levels of learning can be tested with properly formed questions. For example, the item writer could provide a mammogram showing a cluster of calcifications and ask about the next logical step for the patient’s management.” Raymond advises item writers to keep the question format as simple as possible. He prefers “single best answer” multiplechoice questions where a concise question, often referred to as “the stem,” precedes four or five possible options with one correct answer. Another critical element for item writers to develop carefully is the lead-in. This element is the last sentence of the question’s stem. According to Steven A. Haist, M.D., an internist and associate vice president of test development at NBME, item writers need to create a focused lead-in, structuring it as a question to produce a better item. Developing alternate responses is also a vital skill for item writers. “Inventing wrong multiple-choice answers, also called distractors, [can be] the hardest 22 | Bulletin | January 2011 “A distractor must be plausible enough to become the choice for some test takers, but it must be implausible enough to lead wellinformed test takers to still select the right answer.” — Jeffrey P. Kanne, M.D. part of item writing,” Kanne says. “A distractor must be plausible enough to become the choice for some test takers, but it must be implausible enough to lead well-informed test takers to still select the right answer.” Other pitfalls for item writing include: • Stating a question in the negative (e.g., “Which of the following is not … ”). These statements are often harder for test takers to understand than questions stated in the positive. • Using “always,” “never,” or “sometimes.” These terms rarely appear in the correct answer. • Writing correct answers that are longer than the distractors. • Repeating key words in the correct answer that are used in the stem. • Creating distractors that are grammatically inconsistent with the stem. Overall, item-writing is both a science and an art, Kanne notes. Newcomers may assume that item writing will be easy. However, the challenge of preparing a good question becomes apparent when an item writer tries to write one. “That is where the art comes in,” he says. // James Brice (jamesbrice@medicalwrite. net) is a freelance writer. RESOURCES Case S.M., Swanson D.B. Constructing Written Test Questions for the Basic and Clinical Sciences. National Board of Medical Examiners. 2001; third edition (revised). Raymond M., Neiers R.B., Reid J.B. “Test-Item Development for Radiologic Technology.” American Registry of Radiologic Technologists 2003. Collins J. “Writing multiple choice questions for continuing medical education activities and self-assessment modules.” RadioGraphics 2006; 26:543–551. Frey G.D., Ibbott G., Morin R. et al. “The Life of ABR Physics Examination Questions.” The Beam. Available at: http://theabr.org/4beam/question.pdf. Spring 2009. // SCHOLARLY PUBLISHING Tapping Into Rich Resources JACR LAUNCHES NEW WEBSITE, CONTINUES TO PROVIDE INVALUABLE TOOLS AND CONTENT. By Leah Lakins W hy should you take the time to read the Journal of the American College of Radiology (JACR) every month? What makes it so special? The journal is an informative, trustworthy resource for radiologists to use in daily practice. Each issue is full of timely, cutting-edge research and practice-management strategies that can help improve your individual skills and general practice. While JACR is a fairly new addition to the gamut of radiology journals — it was founded in 2004 — it provides equally indispensable content that directly influences how radiologists approach their daily reads and interactions with their patients. Also known as the “blue journal,” the JACR has carved a distinctive niche among radiology journals with its mix of research and opinion pieces. JACR readers can find articles on specific topics like coding for radiologic services and content of a broader nature, such as cost-effective strategies for building and maintaining your practice. For a fairly new scholarly publication, Bruce J. Hillman, M.D., FACR, editor-in-chief of the JACR and chair of radiology at the University of Virginia in Charlottesville, Va., is Bruce J. Hillman, proud of the quality and M.D., FACR number of submissions received. And the JACR recently earned the distinction of being ranked number one in readership among radiology journals, according to the 2010 Kantar Media report. “Every month, subscribers can expect to see a wide range of articles on topics, such as health services, education, policy, and practice management,” Hillman says. “They can also expect to hear from regular columnists who speak about their everyday, practical issues and help keep the profession in the forefront.” However, the journal’s value extends beyond practicing radiologists to residents as well. “The journals are often the only contact that residents have with the practice of radiology during their training,” says Hillman. “[The articles] give them insight into some of the issues they will be facing in the future.” As you enjoy your issues of JACR, you can also earn CME credits. You can easily view and keep track of your CME credits through the journal’s CME web page at http://bit.ly/b7BJQo. On the site, members can find a list of available CME articles, read the articles, take the corresponding tests, record and track their test scores, and print out certificates of completion. Same Content, New Website In addition to its useful content every month, JACR recently unveiled a new website with user-friendly tools and updates. The redesigned home page features horizontal navigation bars with easy-access and drop-down menus that display more content, allowing for easier browsing between articles. Readers can also view the “JACR in the News” section, which lists JACR articles cited in news sources and links to those stories. The new site also includes an updated interface for each article that gives readers more flexibility to easily switch among different sections and images. The page displays a fly-out reference box that provides readers immediate access to an article’s sources and the ability to add articles to their personal reading lists. Visitors can also use the revamped site to read past issues of JACR, sign up for the electronic alerts containing the table of contents, subscribe to JACR’s RSS feed, and check out the most-read and most-viewed articles for each quarter. Finally, the site allows readers to instantaneously share and comment on JACR articles via expanded bookmarking tools (including Digg, StumbleUpon, and Reddit). Readers can access the new JACR website either via the ACR home page or directly at www.jacr.org. If you have trouble logging in to the new site, visit http://bit.ly/bThnk4 for a quick, one-page instructional overview. Whether you’re new to the field of radiology or a seasoned professional, the JACR delivers quality resources that will help you improve your practice today and ensure the health of the profession tomorrow. // WEB EXCLUSIVE To discover more about the JACR, check out our video on ACR’s YouTube Channel at http://bit.ly/bHdZHR. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 23 >> RADLAW By Bill Shields, J.D., LL.M., CAE, and Tom Hoffman, J.D., CAE Protecting Your PeerReview Rights ACR’S COUNSEL ELABORATE ON LEGAL ISSUES WITHIN THE FEDERAL AND LOCAL PEER-REVIEW PROCESSES. Bill Shields Tom Hoffman T he ACR General Counsel’s Office and the Quality and Safety Department are often asked whether RADPEER™ materials can be subpoenaed or “discovered” in court. As with most legal matters, the answer is more complicated than a simple “yes” or “no.” The American Medical Association (AMA) and many other bodies take a narrow view of the medical peer-review process. The AMA defines it as “the process by which a professional review body considers whether a practitioner’s clinical privileges or membership in a professional society will be adversely affected by a physician’s competence or professional conduct.”1 While this definition may have sufficed in the initial uses of peer review within a hospital, the College and many states now take a much broader view. Peer review matters for the ACR because all sites initially applying for or renewing their accreditation must be active participants in a physician peer-review program. Thus, RADPEER, or an equivalent program, 24 | Bulletin | January 2011 is required for accreditation (except for mammography and image-guided biopsy programs). And because Medicare will require accreditation for advanced diagnostic imaging as of Jan. 1, 2012, the link between peer review and quality care is even more critical. Since the purpose of peer review is to assess competency and promote quality treatment and patient safety, logically, it should be conducted on a regular basis at lower levels and in many places other than the traditional hospital setting. For example, in radiology alone, freestanding diagnostic imaging, interventional treatment, and radiation oncology centers now provide many services that hospitals had previously exclusively provided. To ensure that participants in the peer-review process can express their opinions freely without fear that the peer whom they are reviewing will be able to retaliate against them or that a patient may use their peers’ comments or analysis for a claim or lawsuit against them, medical professionals have sought statutory protections against such uses of peer-review materials. Unfortunately, the key federal peer-review law, the Health Care Quality Improvement Act of 1986, only provides protection to members and staff of professional review bodies that meet certain requirements. Reviewing State and Local Law Protection for practice-level, peerreview activities is governed primarily by state law. At that level, most attention is properly focused on ensuring that the process is confidential and that the results are not subject to legal discovery or admissible in court. The College and its Virginia chapter were successful in placing language in the state’s peer-review law that specifically protects ACR peerreview programs and materials. The 2006 Virginia Code § 8.01-581.17 – Privileged communications of certain committees and entities, states that “… Additionally, for the purposes of this section, accreditation and peer-review records of the American College of Radiology and the Medical Society of Virginia are considered privileged communications.”2 This statement means that a Virginia court will normally not order disclosure of such information during a lawsuit. When a lawsuit is filed in another state seeking ACR peer-reviewed materials, that plaintiff may obtain a court order directing the College to disclose the information but then must ask a Virginia court to enforce that order. The Virginia court applies Virginia law and thus should refuse to enforce the other state’s order. We have succeeded with this strategy both in lawsuits filed in Virginia and those filed in other states’ courts that seek to enforce their disclosure orders against the College via the Virginia courts. However, with RADPEER, the ACR does not retain any physician or patient identifiable data, and once the plaintiffs’ attorneys realize this fact, they almost always drop their request for information. The problem may arise when a plaintiff files an action in your state seeking RADPEER materials in your possession. Depending on the wording of the law in your state, the courts may be able to order your practice to disclose such data. The same is true for information produced by other similar peer-review programs. The key factor in most cases is usually the scope of the state peer-review protection, not the specific program. The College has frequently championed peer review as a means of achieving safe, high-quality patient care and understands the necessity of protecting participants in this process. Now that many payers require participating physicians and practices to have peer-review programs, and the federal government will soon do so as well, the ACR is working with its state radiology societies, state medical societies, and the AMA to strengthen and enforce state and federal peer-review protections. // Bill Shields, J.D., LL.M., CAE (bshields@ acr.org), is ACR general counsel. Tom Hoffman, J.D., CAE (thoffman@acr. org), is ACR associate general counsel. ENDNOTES 1. American Medical Association. Medical Peer Review. Available at: http://bit.ly/bWpTLh. 2. Code of Virginia § 8.01-581.17. Available at: http://bit.ly/d52tem. The Congressional Forecast for Radiology 2 010 was another hectic year for the Economics and Government Relations Department. With the election of Sen. Scott Brown, R-Mass., to the U.S. Senate last January, many believed that comprehensive healthcare reform legislation could not be passed. However, at the Obama administration’s urging, the Patient Protection and Affordable Care Act, H.R. 3590 (PPACA), was enacted in March through the use of reconciliation, a legislative vehicle that circumvented a cloture vote in the Senate. Despite years of lobbying efforts, radiology was the only physician specialty targeted for reduced payments. Specifically, the equipment-usage assumption changed from 50 percent to 75 percent and the multiple-procedure payment reduction (MPPR) increased from 25 percent to 50 percent. Both of these reductions affect how the technical-component payment is calculated and will target physician-owned outpatient imaging centers and independent diagnostic testing facilities. The ACR worked extensively with Senate leaders to achieve a 65-percent equipment-usage assumption in its version of the bill, but, unfortunately, the House language on this issue prevailed. The health-care reform legislation failed to achieve many of organized medicine’s stated goals. Notably absent from the bill was a permanent fix for the sustainable growth-rate formula used to calculate the Medicare conversion factor. This has required a series of congressional “fixes” to prevent as much as a 23-percent cut in Medicare payments for all physicians. Without another congressional fix, the CMS projects an additional six-percent decrease in the conversion factor for 2011. Also absent from the legislation was meaningful tort reform. As a result of these issues, many state medical societies and some specialty societies have openly opposed the PPACA legislation. Additionally, the PPACA creates the Independent Payment Advisory Board (IPAB), which is authorized to recommend reductions in Medicare payments to providers. These recommendations will go into effect unless 60 percent (in Congress) vote to overturn the decision. The PPACA also authorizes governmental agencies, such as the U.S. Preventive Services Task Force (USPSTF), to create “evidence-based” policies to cover medical services. However, due to public and congressional outrage, the USPSTF 2009 recommendations for limiting screening mammography were excluded from the mandate by subsequent legislation. Due to the advocacy of government relations staff on behalf of our specialty, the final equipment-utilization assumption was less than both the White House’s proposed 95 percent and the initial House bill (75 percent). During the process, proposals were also submitted for a separate conversion factor for radiology and for prior authorization by radiology benefit management companies. However, as a result of our efforts, these proposals did not make it into the health-care legislation. The attention given to self-referral as part of the PPACA discussions prompted several House committee chairs to ask the Government Accountability Office to study the issue in more detail. As a result, the effect of self-referral on the growth of imaging was an important part of the Medicare Payment Advisory Commission’s September 2010 meeting. The process of moving from legislation to regulation began in June with ECONOMIC << CHAIRMAN’S REPORT By Bibb Allen Jr., M.D., FACR the Notice of Proposed Rule Making for the 2011 Physician Fee Schedule. In the proposed rule, the CMS went beyond the legislation and continues to specifically target radiology for additional payment reductions. The agency proposes applying the MPPR to noncontiguous body parts and across different modalities. Furthermore, the CMS is considering an MPPR for the professional component despite the work of the Relative Value Update Committee (RUC) and the Current Procedural Terminology® (CPT®) Editorial Panel to develop and value new CPT codes for bundled services. The agency proposed a lengthy list of radiology services for the RUC to review based on the legislative mandates. Finally, will the 2010 elections and the composition of the 112th Congress provide an opportunity for substantive legislative change? There will not be enough votes to overturn health-care reform; however, certain provisions, including the IPAB, may be reconsidered. In the absence of legislative backing, the executive branch will likely expand its use of regulatory processes to advance its agenda; correspondingly, look for the CMS to develop even more payment policies beyond the scope of legislative mandates. Simultaneously, Congress (especially House members) will probably use its oversight authority to potentially reign in some executive policies. We will continue to use our influence on Capitol Hill to help direct some of these oversight efforts to issues where the CMS may have overstepped the legislative mandates. However, a change in the balance of power will not be enough. Continued education for congressional members and more grassroots advocacy from our members will be needed to help advance our agenda in Congress. // Advocacy • Economics • Education • Clinical Research • Quality & Safety | 25 // FINANCIAL REPORT On Solid Ground THE COLLEGE MAINTAINS A STRONG POSITION DURING A TOUGH FINANCIAL YEAR. By Leah Lakins A s the economy slowly but surely climbs its way to higher ground, the College’s finances have also steadily improved. According to the 2009–2010 financial report from ACR Secretary-Treasurer Anne C. Roberts, M.D., FACR, in Fiscal Year 2010, the College maintained a strong financial position. As of June 30, 2010, the ACR had assets of $108.6 million and liabilities of $45.6 million, with net assets of $63 million. Net assets increased over- well. ACR CEO Harvey L. Neiman, M.D., FACR, and all the staff have been working to keep expenses down as much as possible and have succeeded admirably. Since the stock market has improved in the last year, our long-term investments are in a much better position. Through the leadership of Dr. Neiman and Ken Korotky, ACR’s chief financial officer, the College is in a good position, but we continue to watch our expenses and our income carefully. “We will continue to ensure that our members get value over and beyond what they pay for College membership.” — Anne C. Roberts, M.D., FACR all by $10 million in Fiscal Year 2010, with a positive bottom line from operations and investment earnings for the year. This surplus stemmed primarily from accreditation revenues, as it was a strong year for accreditation renewals in CT, PET, MRI, and nuclear medicine. The ACR’s long-term investment portfolio also produced an improved annual return for Fiscal Year 2010 of 14.6 percent. This performance exceeded the benchmark return of 12.37 percent for the year. The portfolio remains invested in a number of equity and fixed-income mutual funds with an allocation to stocks and bonds that is in line with the long-term objectives of capital appreciation. To get a more in-depth view of the College’s finances, the ACR Bulletin asked Roberts to elaborate on performance during the past fiscal year, as well as what’s to come. Bulletin: How has the College fared during the current economy? Roberts: The College’s finances are doing 26 | Bulletin | January 2011 Bulletin: How will the new healthcare reform act affect the ACR’s finances? Roberts: I don’t think we know yet. There will certainly be costs associated with our Capitol Hill efforts. We may have a better idea when the new session of Congress begins this month. Bulletin: How will the new accreditation mandates affect the College’s finances? Roberts: The CMS has designated three organizations for radiology accreditation for compliance with the Medicare Improvements for Patients and Providers Act of 2008. One is the ACR, which has the most well-developed accreditation system. The College’s accreditation looks at all the aspects of a radiology practice, including the images that are obtained. The other two entities are the Intersocietal Accreditation Commission (IAC) and The Joint Commission (TJC). The IAC accreditation process is very similar to the ACR model, whereas the TJC process is different. TJC does not have the emphasis on the imaging that one finds with the ACR and IAC processes. The cost of the TJC process may be less for some centers compared to the ACR. However, we have built a reputation over a number of years as having an outstanding program, and we know that we offer the best accreditation program for radiology practices and for the public. Bulletin: How do the College’s results for Fiscal Year 2010 compare to other medical societies? Roberts: It’s a challenge to compare the ACR to other medical societies, as we have a few very unique business lines, such as our own contract research organization, Image Metrix™. That being said, our 2010 results exceeded our budgeted expectations. We experienced a positive net from operations of $5.3 million plus an additional $4.7 million from long-term investments. Our reserve balance remains in line with industry averages as well. Bulletin: Are there any new fiscal benefits that members can expect for the next year? Roberts: At this time, we do not have anything concrete planned. We will continue to ensure that our members get value over and beyond what they pay for College membership. Bulletin: What are some of the ACR’s fiscal goals during Fiscal Year 2011? Roberts: The College’s most important goal is to continue to support our members and their practices. This will require ACR expenditures to fund political advocacy, standards, accreditation, education, and outreach. It’s important that we control our expenses as much as possible so that there are funds available for all of these efforts. // >>>> TRANSITIONS ARIZONA - TUCSON - Breast Imaging Radiology Ltd. seeks an additional fellowship-trained and/or experienced radiologist with mammography, breast biopsy, breast ultrasound, & breast MRI proficiency. Part-time/full-time partnershiptrack position available. Contact: Jackie Hand at 520-545-1966, by e-mail at jackie. [email protected], or mail CV to Radiology Ltd, Jackie Hand, Administration, 677 N. Wilmot Road, Tucson, AZ 85711. FLORIDA - HOLLYWOOD - Nighthawk Radiologist - Private practice seeks in-house BC radiologist for shift from 11 p.m. to 8 a.m.; CT, US, nuclear medicine, & plain films. Subspecialists backup call nightly. No mammo/interventional required. Contact: Jill Avendano, Radiology Associates of Hollywood at 954-437-4800, ext, 2148, by fax at 954-437-6628, by e-mail at jill.avendano@ rahmail.net, or mail to 9050 Pines Blvd., Suite 200, Pembroke Pines, FL 33024. CALIFORNIA - BISHOP - General Radiologist - Exciting partnership opportunity for outside enthusiast at a 25-bed critical access hospital. Enjoy the autonomy & challenge of developing a hospitalbased practice with the full support of an established radiology group with broad IT & teleradiology experience. Contact: Stephen Loos, M.D., at Stephen.loos@ greatbasinimaging.com. FLORIDA - PALM BEACH GARDENS Interventional Radiologist - Busy hospitalbased private practice seeks interventional radiologist or neuroradiologist comfortable with interventional procedures. Candidate with current training preferred. Must be willing to practice all aspects of radiology. Very desirable location. Contact: Dr. Singh at 561-625-5036 or by e-mail at [email protected]. CALIFORNIA - SAN MATEO - Women’s Imager - Part-time/full-time in busy outpatient practice. Must have breast imaging & US fellowship with OB-GYN US or equivalent experience. MRI experience preferred. Modalities include digital mammo, stereotactic biopsy, MRI, US, x-ray, & DEXA; 25,000 exams annually. ACR accredited for US & mammo. Health benefits/401k/education allowance/paid vacation. Contact: Send CV to [email protected]. CONNECTICUT - NEW LONDON - General Radiologist - 13-member group seeks BC general radiologist to replace retiring partner. Partnership-track position with comprehensive benefits package. Hospital based with 4 PACS integrated outpatient centers & state-of-theart equipment. Teleradiology night coverage. Fellowship training a plus, neuroradiology preferred. Contact: Tom Manning, M.D., by e-mail at [email protected]. CONNECTICUT - NORWALK - Part-time Breast Imager - ACR accredited Breast Center of Excellence seeks part-time breast imager. No call. State-of-the-art digital mammography, comprehensive breast biopsy service. Additional subspecialty skills & fellowship training a plus. Contact: Alan H. Richman M.D., President, Norwalk Radiology Consultants, P.C. at 203-852-2715 or by e-mail at [email protected]. FLORIDA - HOLLYWOOD - General Radiologist - Large radiology group seeks BC radiologist. Fellowship training in PET/ CT & nuclear medicine to support PET/ CT & radiology practice. ABR certification required. Contact: Jill Avendano at Radiology Associates of Hollywood at 954-437-4800, ext. 2148, by fax at 954-437-6628, by e-mail at jill.avendano@ rahmail.net, or mail to 9050 Pines Blvd., Suite 200, Pembroke Pines, FL 33024. INDIANA - FORT WAYNE - Diagnostic Radiologist - Outpatient imaging facility offering competitive salary/benefits, including 26 weeks’ vacation to qualified, experienced diagnostic radiologist willing to relocate. Imaging modalities include CT, MRI, mammography, US, & radiography. Image-guided biopsies (particularly breast biopsies), arthrography, & myelography also performed. Contact: Chris Conner at 260-436-7770, by fax at 260-436-3570, by e-mail at [email protected], or visit http://www.theimagingctr.com. MARYLAND - BALTIMORE Neuroradiologist - Academic practice seeks experienced interventional neuroradiologist. Weekly responsibilities: clinical coverage of ~ 2 days in interventional & ~ 2 days in diagnostic, with interventional call coverage & 1 day of academic time. Contact: William Regine, M.D., at 410-328-2326, by e-mail at [email protected], or send CV to Dept. of Diagnostic Radiology, University of Maryland Medical Center, 22 S. Green Street, Baltimore, MD 21201. MISSOURI - JEFFERSON CITY - General Radiologist - General radiologist position in a stable group with a busy outpatient imaging practice & hospital contract for over 40 years. First year $375,000; 10 weeks’ vacation; call 1/6; nighthawk at 7 p.m. Low cost of living/near major recreational lake area. Contact: Jeffrey Patrick, M.D., by e-mail at [email protected]. NEBRASKA - OMAHA - Neuroradiologist The neuroradiology section at University of Nebraska Medical Center seeks a candidate that has completed a neuroradiology fellowship & is ABR certified. Clinical expertise in head, neck, spine, & brain imaging is required. Individuals from diverse backgrounds are encouraged to apply. Contact: E-mail CV to Vickie Wrobleski at [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. NORTH CAROLINA - GASTONIA Nightshift Radiologist - Charlotte metro area, board-certified radiologist needed to work nightshift in 435-bed hospital. Competitive salary/partnership track with full benefits. Contact: Rick Keener at 704-852-9759 or by e-mail at keenerr@ gastonradiology.com. PENNSYLVANIA - CHAMBERSBURG General Radiologist - Subspecialized group of 12 radiologists with centralized PACS seeks new team member with complimentary skill sets. Partnership/employee track available. All fellowships welcomed. Generous salary/benefits. Close to both Washington and Baltimore beltway. Experience/interest with mammography & mammo-intervention skills required. Contact: Robert Pyatt Jr., M.D., at 717-264-4169 or by e-mail at [email protected]. TENNESSEE - NASHVILLE - Associate Medical Director - MedSolutions (an intelligent cost management company specializing in managing radiology, cardiology, ultrasound, & oncology services) seeks an associate medical director (radiation therapist/oncologist) to join its professional multidisciplinary medical management team. Contact: Leslie Thornton by e-mail at leslie@ physicianexecutive.com. Advocacy • Economics • Education • Clinical Research • Quality & Safety | 27 final read Rebecca E. Gerber, M.D. Diagnostic Radiology, PGY-3 Resident University of Virginia, Charlottesville, Va. TELL US ABOUT YOUR INTERNATIONAL ROTATION EXPERIENCE. D Courtesy Rebecca E. Gerber >> Rebecca E. Gerber, M.D., relaxes with some of the children during Friday activities at GAIA Vaccine Foundation’s Hope Center Clinic in Sikoro, Mali. uring my medical school and internship years at Brown University, I collaborated with my mentor Anne S. DeGroot, M.D., from the Global Alliance to Vaccinate Against AIDS, to identify, raise funds — Rebecca E. Gerber, for, and train medical professionals to use an ultrasound machine for a communitybased clinic in Sikoro, a slum of Bamako, Mali. In Mali, pregnancy and childbirth complications are responsible for one-third of the deaths of women aged 15 to 49. The goal was to use imaging to reduce pre- and perinatal morbidity and mortality. The ultrasound machine unexpectedly monopolized all the power in the village. I collaborated with the local engineer, electrician, pediatrician, medical director, and executive director to solve the issue, which was difficult because we all spoke different languages. After three weeks, we succeeded, demonstrating that “it takes a village.” It was a wonderful moment when we plugged in the machine and it finally worked. I also trained the local sonographer and pediatricians how to use the ultrasound machine to estimate delivery date and identify potential complications. Now, the village women have access to imaging as a routine part of their obstetric care, which is rare in Mali and Africa in general. This imaging tool, seemingly obsolete in the United States, may be an incredible boon in a more Rebecca E. Gerber, M.D. resource-poor community. Previously collecting dust in the hospital basement, it was viewed as a “gift from above” by the village chief. I humbly think that we all should value imaging’s role to such a degree. This project further solidified my commitment to coupling international health with radiology. // 28 | “Previously collecting dust in the hospital basement, it [ultrasound machine] was viewed as a ‘gift from above’ by the village chief.” Bulletin | January 2011 M.D. ACR 2011 CME Calendar of Events 1.800.373.2204 www.acr.org/educenter Education Center Complete 2011 schedule now available at acr.org. Neuroradiology coming in May 2011. Cardiac and Peripheral Vascular MR CT Colonography This course is designed to optimize clinical practice skills by providing intense training in interpreting cardiac MR examinations. Jan. 10–11 ACR Education Center, Reston, VA March 4–6 ACR Education Center, Reston, VA CME: 30.75 AMA PRA Category 1 Credits and 4 SAM Credits TM Learn the technique, performance and interpretation of CTC through the supervised review of a minimum of 50 cases. CME: 21.5 AMA PRA Category 1 Credits and 4 SAM Credits TM Body and Pelvic MR – New for 2011 – Pelvic module added Jan. 14–16 ACR Education Center, Reston, VA This intensive, practical course on abdominal and pelvic MR image interpretation focuses on the most common current indications for abdominal and pelvic MRI. CME: 35 AMA PRA Category 1 Credits and 4 SAM Credits TM Musculoskeletal MR ACR-SPR Pediatric Cardiac MR March 18–20 ACR Education Center, Reston, VA Optimize clinical practice skills with intense training in interpreting pediatric cardiac MR examinations under expert supervision. CME: 33.25 AMA PRA Category 1 Credits TM ACR-Dartmouth PET/CT Course March 29–31 ACR Education Center, Reston, VA In this course you’ll interpret in a frontline fashion more than 150 PET/CT scans covering all clinical applications. CME: 34 AMA PRA Category 1 Credits and 4 SAM Credits Jan. 28–30 ACR Education Center, Reston, VA TM This 100-case course provides intensive experience in the technique and interpretation of MR imaging of the knee, shoulder, ankle, foot and hip. CME: 34.75 AMA PRA Category 1 Credits and 4 SAM Credits Education On the Go TM 88th ACR Annual Meeting and Chapter Leadership Conference Breast Imaging Boot Camp Feb. 3–5 ACR Education Center, Reston, VA Develop your expertise in interpreting mammography studies through hands-on interpretation of more than 240 digital screening and diagnostic mammograms. CME: 34.25 AMA PRA Category 1 Credits May 14–18 Hilton Washington Hotel, Washington, DC Save the date for the ACR annual meeting to attend educational sessions, participate in ACR elections and discuss the future of radiology. TM Breast MR With Guided Biopsy Feb. 7–8 ACR Education Center, Reston, VA s Meet MR st ion Bread at it Accreirements Requ This 100-case course provides practicing radiologists with intensive, hands-on experience reading breast MRI under expert supervision. CME: 21 AMA PRA Category 1 Credits and 4 SAM Credits TM 5th Annual Body MRI Update Course June 9–11 Hyatt Regency Atlanta, Atlanta, GA Save the date for this state-of-the-art update and review of advanced methods for disease detection. Learn more at acr.org, “Meetings and Events”. Coronary CT Angiography Feb. 18–20 ACR Education Center, Reston, VA Optimize your clinical practice skills in this intensive training course interpreting coronary CTA exams. CME: 33.25 AMA PRA Category 1 Credits and 4 SAM Credits TM Accreditation Statement: The American College of Radiology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation Statement: The American College of Radiology designates these educational activities for AMA PRA Category 1 Credits™ and SAM Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. The ACR Education Center courses were qualified by the American Board of Radiology in meeting the criteria for self-assessment toward the purpose of fulfilling requirements in the ABR Maintenance of Certification Program. Breast MR includes 4 SAM Credits approved July 13, 2009; CT Colonography and PET/CT include 4 SAM Credits approved Aug. 6, 2009; Coronary CT Angiography includes 4 SAM Credits approved Nov. 5, 2009; Body MR includes 4 SAM Credits approved Dec. 8, 2009; MSK MR includes 4 SAM Credits approved Dec. 17, 2009; Cardiac and Peripheral Vascular MR includes 4 SAM Credits approved April 27, 2010. MKT CODE: CAL0111BUL 7639 01.11 PERIODICALS ACR BULLETIN 1891 Preston White Drive Reston, VA 20191-4326 ARRS Annual Scholarship Program ® now accepting nominations Investing in the Future of Radiology The American Roentgen Ray Society (ARRS) and The Roentgen Fund® invite medical schools, affiliated hospitals and clinical research institutions to nominate one candidate for the 2011 ARRS Annual Scholarship Program. CPT Codes Got You Down? ACR makes it easier for you and your staff to comply with Current Procedural Terminology (CPT®) coding. Starting January 2011, radiology practices will be required to report valid codes at the time of service. There is Each year, up to two $140,000 scholarships are awarded to no grace period to implement new codes ... young investigators, educators and/or administrators to support studies willACR prepare them resources for leadershiptoday! positions … So get that your coding in academic radiology. FREE 2011 CPT® Code Update Scholarships through a generousACR grantRadiology from Find it inare thefunded September–October Coding Source.™ Bookmark it! Visit www.acr.org/rcs. ® The Roentgen Fund . The 2011 Online Coding Update for Interventional Radiology is also FREE to members (nonmembers – $199) Theand general requirements forchanges candidates includes significant to are: the lower extremity revascularization and atherectomy family of codes. ■ MD or DO from an accredited institution ■ InCompletion all new required residency, fellowship or equivalent ASTRO-ACR Guide totraining Radiation Oncology Coding 2011 (online-only version) is available to addition,ofthe ■ ACR Certification by the American Board of Radiology or equivalent members ($75) and nonmembers ($225). ■ Full-time faculty appointment as a lecturer, instructor, assistant professor or equivalent for no more than five years beyond Radiology edAppointment Coders —must EarnbeCEU Credits of radiology, nuclear medicine, or an associated department in completion ofCertifi training; in a department the radiological sciences of a medical school teaching hospital in the U.S. or Canada ■ Candidate must be a member of the ARRS at the time the application is submitted and for the duration of the award To order your ACR coding resources, visit www.acr.org/coding. For more information about the scholarship program and application procedures, visit www.arrs.org or call 1-800-227-5463 or 703-648-8900. 2010 Nuclear Medicine Coding User’s Guide — Promo-code: NUCMED10 2010 Coding User’s Guide Promo-code: ULTRASOUND10 The deadline for submission of Ultrasound applications is November 19,— 2010. 10% off! 7639.3 01.11 No 2011 Updates