Author Archives: Mary M. Saltz, MD

About Mary M. Saltz, MD

I am a Radiologist with many years of practice behind me, and lots of ideas! I would like to share my vision for our future, based on my experiences, taking Quality to the next level.

Radiogenomics— on the Road to Personalized Radiology

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An odd tumor of the pancreas, held in the hand, a death-the history of watery profuse diarrhea. Why, what, how?  That was the gross pathology of discovery, a window to disease. The year was 1958, the pathologist, my father Duke, giving another discovery in medicine to the world[i]. A discovery made from the history, and the course of the disease, combined with information gleaned post mortem-holding in hand the organs, weighing the pancreas, observing the masses and finally looking under the microscope…A syndrome described…Verner-Morrison syndrome-yet what was it and why? WDHA[ii], pancreatic cholera[iii]…An islet cell tumor…Vasoactive intestinal peptide was discovered, a molecular cause determined. Now the gene sequence is analyzed.  Going deeper and deeper into the root cause of disease is what we do, and when we think we might understand, we realize there is yet another layer of knowledge to gain.

Today we stand at the intersection of genetics and radiology: radiogenomics.  We are the de facto gross pathologists of the age, wielding our imaging scalpels to cut through the body swiftly to diagnose, to treat and to follow.  As medical knowledge explodes, we are there to discover, to guide and to direct therapy.  Often it is we who first discover a mass-but is it cancer or not? We use now tried and true guidelines to decide further action. Is that pancreatic tumor big or small, cystic or solid, enhancing or not, single? Multiple? Encasing the vessels?  With this knowledge in-hand decisions are made and care given, often a biopsy obtained. If we don’t think the results are what we expect.  We say go back, get more tissue, do it again!  What if we know not only the cell type but the genetic expression of the tumor?  Could we help more? Give better guidance?  What if we could combine the big picture we see with ever more specific data-delving into not only the pathology but beyond, into specific expressions of tumor genetics?  Not only to see the gross pathology but to combine magnetic resonance spectroscopy, molecular imaging, microscopic pathology and genetic information. What a powerful tool this could be-taking imaging and cancer treatment to the next level, many steps beyond Virchow, beyond WDHA and into the new world of radiogenomics, correlating genetic information with radiology images.

Imagine starting with a breast MR, swooping down to see the digital pathology slide, and yet again through higher and higher powered resolution and more—down to the sub-cellular level. 

A Google maps for the body… Yesterday we had gross pathology, a surgical specimen or an autopsy, yielding an organ to hold in the hand, to weigh and to dissect.   Next the pathologic glass slide, carefully prepared, stained and ready to examine. These findings, in the setting of the patient’s history, their signs and symptoms, gave us the basis to diagnose and treat.  Today we have gone digital—and have replaced the touch and feel of the organs with the dynamic non-invasive gross pathology—the CT scan, the MRI…We have added functional molecular imaging, MR spectroscopy, fusion imaging…The virtual microscope, first invented at Hopkins in 1997[iv], gave us a digital version of the glass slide.  Today this technology allows us to zoom in and out, and to move through a block of tissue, virtually.  Now we are able to add the genetic information, in a “mark-up”—placing it in three-dimensional space.  We know that combining genetic information about tumors and their radiologic appearance adds valuable information[v] and that MR spectroscopy is more powerful when combined with molecular genomics[vi]. This is the beginning of an information explosion, and we must prepare as imagers and physicians to lead our medical colleagues through this journey.

As those most able to visualize and integrate imaging data, radiologists are uniquely poised on the edge of the new imaging frontier, where placing genetic information in three-dimensional space is now possible…disease rediscovered…Combining information across modalities, then going down to the next level of resolution, then the next, will yield a wealth of knowledge. Using our current understanding of disease, based on centuries of science, while leveraging state-of-the-art advances, will bring us to the cutting edge of patient care, providing novel and personalized therapies.  As imagers we will be able to see and monitor these interventions in a new way—personalized radiology of the future, here today.  Let us seize this opportunity as imagers, and take it to the next level.  What do you think?

Mary

Mary M. Saltz, M.D.
CMO, Hospital Radiology Partners 

 

The French Radiologist Scandal! Radiologist Loses Arms—French Pioneer Makes New Sacrifice for Research

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That was in 1941[i] …. Have people really changed since then? Do doctors want to harm patients? What about William Hope Fowler… a Radiologist who died in 1933 at age 57, losing one finger after another to the ravages of radiation, finally losing and arm and succumbing to radiation poisoning[ii]? It was not that long ago radiologists used screens to amplify radiation while staring directly at the beam… A big improvement came with mirrors to reflect the images, and after that, image intensifiers… Yet we have always been willing to sacrifice our own well being for the patient’s good…. The physicians who deal with radiation and medicine have long been known as radiologists—now in our country the name radiologist is more closely associated with diagnostic radiology, and not curing cancer through radiation therapy—yet we share a common history, and are two parts of the same whole.

Did our French colleague, sent to jail for his mistakes [iii] in overdosing patients actually act of malevolent ill will? I cannot ask him, and do not know—but I doubt it. One does not become a member of a valiant profession to harm patients, and yet how often do we have to have tragic mistakes to do something definitive to make sure it cannot happen again?

How many of you have ever heard of the Riverside Radiation Tragedy? In the mid 1970’s nearly 400 patients in a prestigious central Ohio hospital were seriously over radiated during Cobalt cancer therapy [iv] —many with crippling side effects—some thought to have died because of, rather than in spite of their treatment. There was a scandal and a cover-up, but the real issue… Human error. Preventable error…

Systems, systems and more systems… we are not smarter than a good system, because it is not about being smart, it is about safety, checklists and procedures.

In Scotland in 2006-headlines again: a teenage cancer patient was seriously harmed in by over radiation for brain tumor [v]. In 2007 two patients hit front page news in New York for serious radiation therapy overdose, one rendered deaf, unable to swallow and finally unable to breathe, the second had a hole burned in her chest [vi]. In 2009 the Philadelphia VA released information delineating incorrect radiation doses were administered to 92 veterans treated for prostate cancer [vii].

Catastrophes of radiation overdose are not limited to our radiation oncology colleagues. In 2009 California hit the news—sky-high radiation doses accrued for routine diagnostic testing? If it can happen at Cedar Sinai, LA County USC Medical Center and Bakersfield Memorial Hospital [viii], it can happen at your hospital! Why did patients get up to eight times the planned radiation dose during head CT? The radiologists bypassed the usual safety net put in place by the machine manufacturers to calibrate and control dosage, to do a customized state of the art stroke protocol. A worthy goal, but they did not double check to make sure that they first did no harm.

Information overload is also at fault—too many numbers, too much information, and after a while no one looks at it. Actually the radiation dose was automatically reported in every CT – information given both to the technologists and the radiologists—but no one saw it. We all recognize this phenomenon—the ICU monitors all going off, while the team chats about their weekend, or the upcoming game…

What about the technologist who CT’d a toddler for over an hour, while his father held him in the scanner—leaving burn marks on the child’s skin [ix]? How could that happen?

Human error is very real, we are fallible and we all recognize that. What can we do to not make this sort of tragic mistake again? First we must understand the power of radiation and the danger inherent in its use. Familiarity makes us perhaps underestimate that we are working with danger, to do good, but danger nonetheless. We need to really understand that our Radiation Safety committees are valuable and real, and not here only to rubber-stamp policies and procedures long in place. We need to develop mechanisms to ensure that we measure, track and report radiation doses per case, and accumulated doses over a lifetime. We need to make sure that in our desire to customize imaging, we do not circumvent built in safety nets, and we need to avoid information overload. We can do this—through developing and maintaining checklists, by flagging important numbers for review, and by making sure that each time a test is done, we make sure that there are no red flags.

We cannot even approach safer practice before we agree that to err is human, and that wanting to do good for our patients is not enough. We must change the way we work, and put systems in place to help us prevent error, not fix it once it has happened. This involves changing the way we think, and the way we practice, and it is not easy to change our collective culture. Technology can help put design safer systems, help us to flag important anomalies, measure and track radiation doses and create a safer environment for our patients, but it cannot change our attitude that we are too good to need this help. Hubris is our enemy, humility our friend. Until we realize this we are doomed to err again, and again. What do you think?

Mary

Mary M. Saltz, MD
CMO, Hospital Radiology Partners
_____________________________

[i] http://query.nytimes.com/mem/archive/pdf?res=F40B13FF395F1A7A93C5A91783D85F458485F9

[ii] http://query.nytimes.com/mem/archive/pdf?res=FB0A15FB3E541A7A93C4A9178BD95F478385F9

[iii] http://www.auntminnieeurope.com/index.aspx?sec=nws&sub=rad&pag=dis&ItemID=607680

[iv] http://www.columbusmonthly.com/October-2010/The-Riverside-Radiation-Tragedy/

[v] http://www.auntminnieeurope.com/index.aspx?sec=sup&sub=imc&pag=dis&ItemID=603657  

[vi] http://www.nytimes.com/2010/01/24/health/24radiation.html?pagewanted=all

[vii] http://www.nbcphiladelphia.com/news/local/Philly-VA-Treats-92-with-Incorrect-Doses-of-Radiation-Reports.html

[viii] http://articles.latimes.com/2010/aug/03/local/la-me-stroke-scans-20100803-http://www.nytimes.com/2009/10/16/us/16radiation.html

[ix] http://www.times-standard.com/ci_10962540

Once Upon a Time…An X-ray jacket—the Radiology Wiki that was

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Mornings were rough, but Sylvia was right there with a cup of coffee, just the way I liked it, lots of milk-no sugar.  That was pretty special, a mark of importance, because she did not bring coffee to just anyone—after all she was the lynchpin of the department.  Why?  She ran the file-room…She knew every crevice of the place, and could spot a misfiled jacket in a heartbeat.  She knew every doctor both radiologist and not, and made sure things were the way we liked them—maybe sometimes gave the tougher cases to someone she did not like so much…Who said she had to be fair?  Cross her at your peril…You needed to ensure someone got a message—Sylvia would make it happen.  Maybe running a few minutes late? She had your back.  She was the keeper of all information—the old films and the jacket.

Of course the old films were important—and of course we need to compare cases-image by image, but the jacket itself was very important.  Inside it held the old reports, and outside our scribbled notes.  The outside of the jacket was where we wrote notes to each other—our Radiologist brethren, so they would know what we know, and have the benefit of knowledge already gained.  Making sure to note—“Bx canc ­ abnl INR”… or perhaps “pt. no show.”  These cryptic notes spoke volumes—they gave history, or told us something our colleague had learned or summarized the key finding.  We could read them easily, they were handy, as the jacket was never far from its films, and told us things not in the formal record, and possibly not in the report.

Communication is key to quality—and hand-offs are especially vulnerable to mistakes.  Each time a new radiologist looks at a patient, it is essentially a hand-off, and a time of potential peril.  Moving into a digital age, we have lost some of the safeguards we once had.  It’s not so easy to examine an entire EMR to learn a couple of salient points, already discovered by our partner—the last guy who read a case on our patient.  It is not enough to mandate that one should look at the entire record—it is fine to say, but in practice impracticle to scour the record each time to retrieve the same information.   Not only that, the personal, to the point, salient information, distilled by a peer, is unlikely to be reproduced by natural language  processing in the near-term.  How can we recreate the hand written note on the outside of the jacket?  The key things we want our partner to know when they look at a case?  Effectively and easily transmit our knowledge to the next physician, where it might make a difference to what happens to the patient.  Maybe we would like to know that their son is a Radiologist or their husband the hospital CEO?  That has no place in the formal medical record, nor in a report, but it can be good to know.

Can we bring back the x-ray Jacket?  Well perhaps in a virtual sense—what about a radiology wiki?  A place where we can easily enter a few thoughts about a case, passing key information to the next doctor.  A wiki is defined as a web site developed collaboratively by a community of users, allowing any user to add and edit content[i] … What if we had a wiki for each patient—a place we could jot quick virtual notes about the patient?  There is a lot of attention paid to the handoff  in medicine, because it is clearly identified as a barrier to optimal patient care[ii], a place where a slip may occur, a chasm to cross.

Yet if adding a step, it must be true value added, and not an extra step on which to trip… Not a burden, but an advantage, to us and to quality of care.  The wiki should be easy to use, pop up automatically when we open a case… Be easily updated with voice recognition software that really works, and add otherwise intangible information, that which we might have jotted down on the x-ray jacket once upon a time….

It would be important to make sure that this was not just one more thing to do…another form to fill out, another requirement in a long and growing list.  We would have to make sure that it was carefully crafted to allow real usability.

We have lost our file rooms, and the folks who ran them- some of the glue that held radiology departments  together, but we have not lost the ability to communicate.  The decline of the X-ray jacket is the rise of other forms of interaction, but we must be careful to remember the importance of the human touch, even if it comes though the digital world. Staying in touch with our colleagues is critical- to quality of care, and to remaining connected with our partners, our teammates, our fellow radiologists. Couldn’t a well designed radiology Wiki, tied to the PACs help? A virtual note note on the jacket? What do you think?

Mary

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

[i] More info – Wikipedia – Dictionary.com – Answers.com – Merriam-Webster More info – Wikipedia – Dictionary.com – Answers.com – Merriam-Webster

[ii] http://virtualmentor.ama-assn.org/2012/05/medu1-1205.html

The Eye of the Needle — Patient Centered Interventional Radiology

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Is it harder to pass through the eye of a needle than for radiologists to regain control of interventional radiology?

As a child I liked to sew, making an idea a three-dimensional a concept. Threading the needle to bring a cloth to life. Taking a flat fabric to make a suit, complete with lining, interlining, shoulder pads, batting and of course matching the plaid across the entire ensemble. This was roundly seen as silly by the world of scientists and healers in which I lived, and yet was a harbinger of my profession. Taking the two dimensional and understanding three dimensional reality is what radiologists do, all day long every day-all the more so when we thread a catheter into a distal artery, imagining the final destination. Reaching the terminus, with success – first illuminating the problem and finally rendering the solution. Thinking fast on our feet to process the information, from the history, the previous imaging and what is on the screen on front of us. Taking this complex data, integrated on the fly, and doing that which is needed to gather the sample, or place the stent or sometimes more importantly, retreat before harm is done.

Our turf is threatened today as it has been for decades by those who control patient access and patient flow[i]. The vascular surgeons and the cardiologists nibble around the edges of our practice, and in many cases, have taken the whole ball of wax, leaving us with PICC line placements and after hours filter placements… Why? You and I appreciate we are better at manipulating catheters, better at understanding anatomy, better at knowing how to get from the groin to a tiny sprig of a far away artery. Yet why have we lost ground?

Maybe because we can’t do what we have to do to take care of the whole patient.. It is too much trouble? No… Not really. We are perhaps scared… Not learning how to take care of patients, we are afraid to their diabetes, or maybe terrified of their chest pain… Worried about what to do for hypertension…and anyway what is their BP usually? So we punt, and take care of only the procedure, and not the whole patient. That is why we are losing and we need to win! Take back our advantage, by being better in the 3D world and being competent to care for the whole patient.

We need to win, not for us, but because I really believe we are better at most procedures, have better ideas of the spatial resolution of the body, and how the body parts fit together than other do others. Our training targeted to reconstructing the three dimensional body as represented by two-dimensional images is unparalleled. No surgeon or cardiologist has our training, nor our bent for understanding the whole body as represented in two dimensions. That is what we do, and we do it well. 3-D anatomy is radiology; we are the bridge between the image and the patient… Yet we drop the ball. As doctors, not only imagers… We must remember what it means to be a doctor…

By failing to embrace the whole patient we have given up too much already and will continue to give up more and more.

How can we change this pattern? First we must decide that we want to do so… Teach residents a little bit about patient care during their Radiology training, not relying on the stuff they surely picked up in the internship year…We must collect metrics to show that our results are excellent… But most importantly, we must change the way we practice.

How many of us still evaluate pre-procedure consults in a cubby somewhere near the reading room… confidence inspiring? We need to have an office, in which we see patients in consultation, arrange for the appropriate procedure and see them again afterwards. We can assess the efficacy of our intervention, and build a database to assess our performance. How can we say we are good, if we don’t keep score? We need to act the part, and take charge of the patient, in order to keep IR in the Radiology family! The practices who do this, may have a chance, and those where we do it the old way are probably not doing it at all… We have lost so much market share to other specialties that the trend may not actually be reversible[ii]… And of course there is marketing—not usually a Radiologist’s strong suit—but that is for another day…

What do you think? Is it too late?

Mary

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

[i] http://www.diagnosticimaging.com/display/article/113619/1364476

[ii] http://www.newswise.com/articles/vascular-surgeons-perform-most-peripheral-arterial-interventions

Is the Private Practice Radiologist Extinct? Or merely an endangered species?

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Once, a baby shower marked a step to acceptance, a tribute to unity. I had joined a big, powerful private practice as a green Radiologist just out of training, and it was not easy to get a footing in that world, far from everything familiar. The first woman, young, scared and really not ready to shoulder the load of partnership. I did make partner, but not until the guys threw that shower, did I know I was really “in.” They all came, all with boxes wrapped in ribbons, all to wish me the best. Not griping because I got to take my vacation all at once, as my maternity leave, not complaining I was taking two more weeks without pay, not worrying about whether or not I would really be able to pull my weight after the baby, but there to celebrate and support the birth of new kin.

Back when I finished training, after the boards, and after a fellowship, most really strong residents went out and sought the best private practice opportunities—good groups with a sure path to partnership. Why? Sure money was part of it[i], but by no means the only reason. Community and a feeling of belonging was also a strong driver. A group was like family—working together for the collective common good. A place where your best friends were your partners, and where in order to thrive you had to all give your best, and in return get ownership of the success and a full and equal share of the profits, or losses… But of course there were the “bad” groups too…

The path for those who stayed in Academics was quite different, and often more challenging than for those who left. A few were destined to fame and greatness—superstars, leaders among leaders, international lecture circuits, an ante-room with a secretary, adoring residents, rafts of ribbons at RSNA… At the top, Academic salaries weren’t too bad, and anyway if you could invent a catheter or a device, publish a book or who knows, become a TV doctor, well life was good and the money was fine.

But for sure, not everyone who stayed in Academics was on the path to fame and fortune… Many stayed waiting for a great private sector job, others because it was easier to stay than to leave, and others remained because they needed to be in a certain specific geographic region, and it was the only thing they could find in the area[ii]. Boston was a key example of that!

Yet how is it today? Groups have grown, and the easy camaraderie possible with 20, is impossible with 75! Size is not the only thing that has changed groups… Our medical culture is changing too. The freewheeling days of the 1980’s where Top Gun glorified Chuck Yeager and his individualistic rule-breaking path to personally winning against the odds, are being replaced by a culture in which we recognize the importance of systems, rules and checklists[iii][iv]. Our new heroes are more like John Glenn—a member of a cadre of well-trained astronauts, any one of whom could be called on to do the job, relying on well defined standards not at all on personal colorful exuberance.

This attitude, along with the increased need for hierarchy and structure imposed by increasing group size renders that rather freewheeling world of private practice radiology a relic. Corporate structure is now a necessity, and the old easy familiarity is really no more. Not everyone is equal, there are well-defined leaders and there is no certain path to the top.

Academic practice has changed as well, claiming their fair market share, spreading their logo to hospitals large and small, near and far. The line between what is an academic hospital and a private practice hospital has blurred, and continues to become less distinct. Service provided to these far-flung hospitals is in actuality more like private practice than not. Subspecialty reads are given by far-away experts, 24/7 coverage provided by teleradiology groups—often the same ones used by the non-academic hospitals[v]! Medical schools are beginning to recognize clinical service as important for promotion[vi], giving recognition for clinical service and not only for academic contributions. The salary distinctions are eroding—the chapter of high pay in private practice is closing, and no longer does the academic pay scale seem as unfair, coming as it does with relative job security and increasing recognition of clinical work at the institutional level.

Academic and non-academic hospitals have increasingly similar salaries, challenges and hierarchies. This metamorphosis will inevitably change the face of radiology. As the distinctions between academics and the “real world” blur, the brain drain to private practice may well be over. What do you think?

 

Mary

 

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

 

[i] http://www.acr.org/~/media/ACR/Documents/PDF/Membership/Legal%20Business/Group%20Practice/APPA/The%20Manpower%20Crisis%20in%20Academic%20Radiology.pdf

[ii] http://www.appliedradiology.com/Issues/2008/06/Editorials/Guest-Editorial–To-be-or-not-to-be-an-academic-radiologist-.aspx

[iii] http://en.wikipedia.org/wiki/Atul_Gawande

[iv] http://davisliumd.blogspot.com/2010/11/why-doctors-need-to-be-less-like-chuck.html

[v] personal work experience and observation

[vi] http://med.emory.edu/main/administration/faculty_affairs_dev/appointments_promotions_tenure.html

Timing is Everything-Radiology Scheduling meets Queuing Theory and Discrete-Event Simulation

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A whimper and a cry, an evening interrupted. Medical help was not near, nothing I had considered before picking our vacation spot-a popular island in the Great Lakes.  Pushing to the front of the raucous crowd of partying day trippers heading home a wee bit worse for the wear from their Saturday night, the last ferry out…  I pushed to the front of the fray, knowing that time was of the essence, and if my 8 year old needed a doctor right away, we could not miss that ferry.  The ticket taker was not impressed by my tale, and suggested that we go to the paramedics and if they agreed I could go on the next ferry- in the morning…  I insisted and by force of desperation, pushed our way on board.

Yet how can one actually decide what constitutes a true medical emergency? Not every case can be emergent—not every procedure stat… Resource management is an important tool to cost control, and expensive imaging procedures will be under increasing scrutiny.

It is not enough to do the right test, but it must be done at the right time.  Defining the right time is complex—sometimes things must be done at once, right away, immediately—to make a swift and critical diagnosis in a time sensitive matter.  Is there an epidural hematoma, or is there not?  Important AND urgent!

PET/CT for cancer follow-up—important for sure, but NOT urgent…  Really it is not critical exactly when it is done, so long as it is within a certain time window of days or weeks, but not hours.

How can we decide when to do which test—to make sure that the important and urgent studies do not wait, but there are minimal unused slots on the schedule? 

In practice, the best system I have ever seen was the now, all but defunct, dedicated Radiology scheduler. This lynch-pin of the department knew what each and every procedure was, and could take into account which doctor was going to be there that day, and whether or not we could squeeze in an add-on from our biggest referrer or how to juggle things when the ED had just gone crazy… Intelligent scheduling…  Now gone, with the hopes that centralized scheduling would bring efficiency.

Yet hope may be around the corner…

While there has been resistance to applying industrial models to healthcare, tools are available to help us manage resources in a cost effective manner, and used appropriately will help us decide how to do which test, and when to do so.  While a hospital is not a factory, lessons learned in other arenas can well be applied to our issues.

Since 1909, when the first queuing theory paper was published by Earlang[i] we have been trying to model resources needed to provide service. The word queue comes, via French, from the Latin cauda, meaning tail[ii]. Queueing theory is the mathematical theory of waiting lines, or queues[iii].  The earliest work was on telephone systems, at the Copenhagen Telephone Company,[iv] but by 1976 these principles were applied to healthcare[v].  Queuing system models provide insight into the big picture– and can be used to look at how to best configure healthcare systems to optimize resource utilization and help us to understand how to flex staffing for the best results, or how to best configure healthcare systems for efficiency

But is the big picture enough?  Can we refine this?  As computing capacity has increased there has been a parallel interest in other ways to model healthcare.  Simulation of what really happens day-to-day in complex healthcare systems is now increasing possible using discrete-event simulation (DES). This is a data intensive, data driven process, which needs a lot of accurate information about each patient and each event to have a chance of accurate predictions.  A challenge, but one we can meet.  This necessitates integration of large-scale information, across health systems, bridging multiple electronic health records (EHR), Radiology Information Systems (RIS) and PACs, to capture a moment in the life of a patient, and help determine how to best schedule their exam-when, where and why.  

This system cannot be static; it must learn from itself what works and what does not. Our best attempts to initially instruct the system can only be an approximation of optimal performance. Taking all the information available and feeding it back again and again, will allow continuous improvement over time, rather than a static system mired in time. 

This and more is possible today, with the right systems, intelligently deployed.  We can create a need-based, smart scheduling system combining the best qualities of the old fashioned departmental scheduler with a large scale, efficient, data-driven system capable of handling the challenges of doing the right imaging exams, in the right sequence, at the right time, across a large scale healthcare system. 

And next– how about a smart phone scheduling app for our patients???

Mary

Mary M. Saltz, MD
CMO, Hospital Radiology Partners 

Powerful pivot point – why effective Radiology management is key to the new medical paradigm

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I had the nightmare of diagnosing my mother’s terminal cancer myself, and she was dead within the week. This was after months of state-of-the-art care rendered by doctors at an esteemed academic medical center. I figured she must be in trouble when she let her daughter have anything to do with her care! As the MRI images came up in the screen, with a huge mediastinal mass, her spine destroyed, and paraspinal masses everywhere, I had to figure out how to tell her she was dying, and had to face it myself. I had an educated hunch that an MRI would be the key to unlock her diagnosis, but her doctors did not think it necessary- too expensive?

How could this have happened in this millennium?

Poor communication of information, poor communication and ineffective use of available technology…Had the spine MRI been done earlier, that would have been enough to make a diagnosis, make her comfortable and allow us all some precious time to say goodbye. The multiple specialist visits, extensive testing, and endless doctor visits could have been circumvented by spending the money up front to do the right imaging test — the expensive MRI could have saved a lot of healthcare dollars, and a lot of pain and suffering too…

Radiology has a bad rap — got to cut down on expensive testing…can’t afford it any more…Maybe we need to think differently about it, and ponder how to maximize the strategic effect of doing the right test early. Patient care today pivots around imaging, and yes it is expensive. But judicious imaging can and does improve care — knowing when to do which test is not easy, and formulaic decision trees are a start but not good enough. Doctors have resisted automated decision support because it often does not help, but is rather an unwelcome barrier, which provides little advantage. We cannot reduce each patient to fit those constrained boxes, and march forward like automatons.

How can we do better? Can we all get smarter, or maybe just work harder? More CME cruises?

Or is there more we can do to leverage technology to help us? As physicians we rely on our education, our intelligence and our experience to deliver the best possible care to our patients. But as long as we may live and practice, we will never have the experience of treating a whole population. What if the wisdom and experience gleaned from a population were available to help guide and support us in care delivery?

What if rather than flat out discouraging the expensive tests, making doctors jump through hoops to get an MRI on a patient, we had a way to support doing the right test at the right time, even if it means spending more money up front? Or give us the support we need to defend NOT doing a test that is often done, but we don’t think is needed…

The pivotal role of imaging is clear…. We need to make sure we do the right test, at the right time, get the right results and use it to make the right decisions. Double back to make sure we did not miss something, or maybe help us think of an option we might not have considered. Replacing doctors with computers is not possible, but integrating sophisticated state-of-the-art technology to help us make informed decisions is critical. Giving care providers the tools to help decide what test should be done first, what to skip, when to circle back and repeat a study, or maybe have the results reviewed because they just don’t fit…

Radiologists should have the information they need about a patient before interpreting an exam. We don’t have time to identify the critical information from the medical record for each case…As done today, a link to the EMR is a double-edged sword — who has time to find the information and read the whole thing? Maybe in an academic setting with residents, but I can’t remember the last time I read the whole EMR, even though it IS linked to PACs…Yet we are “responsible” for the whole record. Yet when we do get the pertinent data, we can make a much better interpretation[1]…What if the pertinent history were automatically culled for every case?

Using all the information available to decide how to treat a patient is much more powerful than using the smaller sub segment usually available to us. Information is knowledge, knowledge power. Seizing the power of information is our job as physicians of this millennium, and technology is here to stay. Who says doing the MRI first is not allowed? We need to decide what is allowed, and have the data to support us. Let’s start with low-hanging fruit — expensive imaging, and make it work for us, and work for our patients today and tomorrow.

What do you think?

 

Mary

 

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

 

[1] http://bjr.birjournals.org/content/73/874/1052.short

Christopher Robin in 2013 – decision support for the wheezles

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Christopher Robin
Had wheezles
And sneezles,
They bundled him
Into
His bed.
They gave him what goes
With a cold in the nose,
And some more for a cold
In the head.[i]

Did he have CTA chest?  D-dimer? Or even a CXR?  Perhaps less may be more, and as we all recall he was fine in the morning!  Would he have been better served by more testing?

Not long ago, at our family’s house in Glenarm, where the Mull of Kintyre can be seen on a clear day, off the rocky coast, across the sea to Scotland, I learned a lesson about patient centered care.  There in the North of Ireland, one of us was stuck down with terrible facial pain, and we suspected shingles… A combination of high tech and low tech yielded a treatment course very different from what would have happened in the US, and for pennies. The internet led us to contact the right clinic, where a friendly nurse used computer aided decision support to agree that we were probably right about the shingles, and told us to hop into the car and be seen.  By midnight, after a tense trip in the dark, across the twisting and dark road of the Co. Antrim hills, driving on the left-hand side, we arrived at the Ballymena “Urgent Care.” A dashing doctor came out to greet us, and took us back at once–no registration, no nurse. He did a quick exam, declared shingles, and gave us one tablet of acyclovir, a codeine pill and 500 mg. of ibuprofen.  There was no record begun, and no notes made.  The total cost the UK health service was under one US dollar[ii].

Closer to home, such an adventure would have been more time consuming, less personal and way way way more expensive-with no better outcome!  Imagine the ED waiting room—packed…  The insurance cards—scanned and returned, the wait… finally seeing the doctor after having told the story at least twice before.  Well—don’t forget the blood work, and maybe even a head CT—just for good measure… The average cost for a visit to an emergency department in the US for a headache is between $3,000-$4,000.[iii]

This is unsustainable—and now with ACO’s and other shared cost models, change will come.  Using technology to optimize our medical world is key—but done elegantly.  Our interaction with the health system in the UK showed that the intersection of commonsense and technology optimized patient care– bringing the human touch to computerized decision support, and, at the discretion of the physician, eschewing the need for obsessive documentation.

Intelligent use of information technology will bring us the best of both worlds.  As Radiologists, working closely with our healthcare systems, we can build and select the tools to make sure the right tests are done correctly the first time, to make sure we are aware, in real time, of how much radiation our patients are getting, that our reports make sense, and that critical findings are delivered to the right people.  If we let these systems be constructed without us, if we don’t take time from our mission of patient care, the wrong systems will be built.  We need to be involved from the ground up, as champions of the new—to allow sensible and practical solutions that work for us, and work for our patients.  No one but Radiologists knows how we work, and what should be done to optimize our workflow.  Once the system is bought and installed—we will have to adapt, it is too late to change… 

Yet we cannot lose the personal touch, reaching our directly to our patients, to our referring physicians—letting the world know who we are, what we do and why. 

I learned a lot about caring, effective, inexpensive health-care delivery in Ballymena, Northern Ireland.  That IT support does not preclude the human touch but that sometimes the best EMR is no EMR at all..

What do you think?

 

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

 

Patient Portals – Portending Problems or a Patient First Solution?

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It’s simple right?  A patient has a right to know their results—of COURSE they do…  Well yes—but really?  Unfiltered, technical, cold, hard reports—how do we manage this? Some patients want to have online access—some don’t.i   The Mammography community has already walked the walkii, and standard letters have been devised to alert women to findings in a gentle and careful manner.  Even in this atmosphere of patient involvement and participation, the actual mammography report is generally not shared directly –not unless her doctor or the radiologist cares to do so, and that is almost always in person.  Meaningful use says we need to share patient’s health records with them electronicallyiii –but exactly what this means and how it will be implemented is not yet defined.

How will we best do this in Radiology?

Is it appropriate for a patient to be given very bad news, perhaps while at Starbucks, grabbing a coffee and having a quick peek at the recent CAT scan report?  “Widespread metastatic cancer is almost certainly present—tissue diagnosis strongly suggested…..”

Consider the ambiguous report—the “I really think this is nothing, but I sure better cover all bases—just in case.”  You know the report:  it goes something like this…”while this hepatic low-density, well circumscribed lesion is likely a cyst, the possibility of a slight irregularity in the wall is such that six month follow up is suggested—differential diagnosis includes benign cyst, atypical cyst, infectious process, cystic tumor, necrotic tumor.  Is there history of exposure or possible exposure to cystocercosis?  Unusual travel history?  Is there a known pre-existing underlying malignancy?”

Suddenly, the lines of international communication begin to light up…  They call their sister in London, their best friend who is a doctor, in NYC, the babysitter, just in case they will need to be hospitalized soon…  And they do NOT call their father in the Nursing home—they don’t want to worry him—at least until he really needs to know. 

And all we meant was—I think this is probably a cyst, but I better make sure I am right…  That nuance can be much better communicated in person—no?

What about the normal report, which gives a patient a false sense of security that they are fine, when they are anything but?

So how do we make it happen?  Make a patient appropriate report available, in a timely fashion?   Have notifications for all radiology reports—something along the mammography model?  Have the referring physician release reports to the patient, but only after they have seen them in follow-up and discussed the findings?  Do we have to step up to the plate and engage in direct patient contact?   Is that realistic?  How?  We are not now paid for time spent talking to patients… do we want to be?

Some help may come to us from systems that will be able to directly translate the Radiologist’s report into a patient friendly version…  We are not there yet, but with structured reporting and the use of natural language processing and the right ontologies, we can use technology to simplify our reports; allowing patients to understand them, without having to actually generate two reportsiv.   That does not address the case of how to deliver bad news, but does address a bit of how to put things in words a person will understand. 

A picture can speak volumes… do we include key images imbedded in the report?

This helps our referring clinicians understand our report betterv, so maybe patients would like that as well?

Will we link our patient portal reports to health information sites such as WebMDvi or brew our own sites? 

I think we will need a combination of changing expectations, both on our parts and the patients, about what it means to have patient centered care in Radiology.  We need the help and support of our clinical colleagues to make this transition.  Technology makes this all possible, by creating ways for patients to quickly and directly access their own information.  Technology can be leveraged to make this happen well, and with little extra hands-on work for the Radiologist in the trenches, fighting hard to do the best possible job, day in and day out!

As we move into the next era of Radiology, and step out from behind the curtain of Oz, we want to think carefully about how to bring Radiology to the patient—charting new waters, and moving beyond our old comfort zone out into the world of patients, perhaps one portal at a time!

 

What do you think?

 

Mary

 

Mary M. Saltz, MD

CMO, Hospital Radiology Partners

      i.        J Am Coll Radiol. 2012 Apr;9(4):256-63. doi: 10.1016/j.jacr.2011.12.023

     ii.        http://www.fda.gov/downloads/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/ucm114151.pdf

    iii.        http://www.informationweek.com/healthcare/patient/patient-portal-isnt-only-road-to-meaning/240007750

    iv.        Charles Kahn, M.D. Radiology Grand Rounds, Emory University school of Medicine, 9/26/1012

     v.        http://www.ncbi.nlm.nih.gov/pubmed/20193926

    vi.        http://www.webmd.com

 

Falling off the cliff—can Radiology Informatics break the fall?

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OK-just because it is on the internet, it does not make it true—but look at the chart[i] I found… 

As doctors we know we are pretty smart, and for sure have worked hard to make something of our careers.  We really do care about patients—even though we get a lot of bad press.  I know I care, and care a lot.   I know we all do.  As Radiologists we are in the top of our medical school class, elite among elite.  Look at what applicants to Radiology face…

As Donna Magid, MD, MEd, program director for Radiology at  Johns Hopkins School of Medicine, says “Only the academically extremely strong should even think about this [Radiology]. USMLE scores must soar well above 230s/mid 90s, transcripts groan under the weight of A’s, Honors and applause; accepted publications bend your mailbox from sheer volume; whole communities praise you as their savior; and your letters must make you appear likely to qualify for instant sainthood. On top of that, you must present a sparkling and error-free ERAS, a compelling Pulitzer-level Personal Statement, and project the vivid and charismatic presence of a talk-show host. A successful, articulate one.“[ii]

So now we have crossed that hurdle, passed our boards and are ready to enjoy a long and engaging career…but wait…. Don’t fall, careful of the cliff…

I remember Hilary Care, just as I was starting out…  I thought …. All that work, and now what…  yet I have had a fantastic career since… Change is coming this time—for SURE. 

Change is not all bad, and when challenged the fit can climb to the top of the mountain.  As a profession, we should be ready to change, and to drive that change to our advantage.  As some of the most well trained physicians, we should lead this change.

We rode the excitement of the development of ever improving technologies—the first CT scan, the first MR…  Miracles that allow us to see inside people in a way previously reserved for the autopsy.  My Dad was a Pathologist—and today we still have his knife[iii]—the one he used to cut brains…  Creepy, but the only way there was to see within, and learn about the effects of disease on our body.   As he grew old in the era of CT—he remained amazed by our ability to see inside the body, and image the impossible, visualize the unseen…

We became the gross pathologists of living people—medical voyeurs. Beyond shadows into millimeter precision.  The excitement of the field grew until we became prisoners of our own success.  Reading too many images, too much information, too fast, running to keep up.  Running flat out to process all that ever-growing information.  Fused imaging—PET CT= PET MR, Functional brain MRI.. Fascinating—amazing—hard to grasp, hard to keep up.

And now we are about to free-fall off the fiscal cliff—into what?  More hard work for less pay?  Scrambling every more to asymptotically reach our goal.  Forever stuck pushing our burden uphill, to never reaching the top?  Never having read enough cases?  Always running always stressed, never enough time?  Paid less and less, spiraling downwards…

Yet the cliff looms, and our fall may be broken this time or the next time, but not forever.  You and I know that medical spending must be cut, and cut it will be.  We may not like it, but that much is sure.  My question is-can we find a way to work smarter-not harder?  Can we leverage technology to provide better care for less?

Just as the demand for more cars, cheaper and faster created new manufacturing methods and a new paradigm in car manufacturing, so will the demand for better quality healthcare cheaper change our world.  Using technology to improve care delivery is where we can make smart change. 

What if we figure out how to condense our images into only the important ones.  Use more volume rendering, for example?  Employ CAD to help us screen CTs, and concentrate on looking at the important images—not EVERY image.  Oh—but what about malpractice—oh you may ask…. We are responsible for the whole case, for every image, and thus must look at every image…  Standards will change as we drive them…  do you really think that anyone can actually carefully scrutinize thousands and thousands of images a day (really)?  We rely on pattern recognition, and a quick look to help us, and then target the specific question at hand and the history.  That influences how we read a case—that is why it is so important for us to know what the clinician is looking for. 

So if we could skip to the chase and have those images presented first, with the right history—how much better a job could we do?  Way better… 

What if many more of our cases were actually abnormal—so we are not lulled into normal…next…normal…next…  A more fruitful use of our time, one where our opinion really made a clinical difference?

We, who have always ridden the technology wave, and learned to surf on its crest, must do so again, and make technology work for us.  We cannot afford to lament the fall without working to place a good strong trampoline at the bottom of the cliff so we bounce back stronger than ever.  If we don’t take this change and make it work for us, we will stand to lose our advantage.  Just how well we can do if we stop working harder, and start working smarter?

What do you think?

Mary

 

Mary M. Saltz, MD
CMO, Hospital Radiology Partners

[i] http://www.woosk.com/wp-content/uploads/2008/11/iq.jpg

[ii] http://www.uth.tmc.edu/radiology/radiology-match-guide/index.html

[iii] http://www.pk.all.biz/brain-knivesl-is-a-very-sharp-knife-used-primarily-g17590