The future workforce in academic radiology: gender, generational, and cultural influences

The acute shortage of academic radiologists in the United States, and in fact across the world, is a multifactorial issue. A review of the recent literature suggests a number of influences that discourage radiology residents from remaining in academics, including cultural and generational values and their gender roles in our society. This article discusses the influence of gender, generational, and cultural issues on the current and future workforce in academic radiology.

Web-based results distribution: new channels of communication from radiologists to patients

Radiologists face substantial challenges in the timely and appropriate communication of diagnostic test results. As with other systems in health care delivery, the radiology reporting system is not designed to be optimally safe, timely, and patient centered. To improve the quality of care, there must be a new commitment to organizing services around patients' needs, including the reporting of diagnostic test results directly from radiologists to patients. The rationale for this change is that if both referring physicians and patients are given imaging examination results from radiologists immediately after their interpretation, it would be less likely that important diagnostic information would be lost or overlooked. The results would be provided to all stakeholders in a more timely fashion, the potential for important information to "fall through the cracks" would be diminished, and safety would be improved. Providing these results to patients directly online would also allow radiologists to facilitate increased patient satisfaction and patient-centered care by treating patients as "co-customers" and equal partners with referring physicians with regard to access to information and shared decision making.

High-attenuation mucus plugs on MDCT in a child with cystic fibrosis: potential cause and differential diagnosis

High-attenuation mucus plugging is a rare finding in both adults and children. When it occurs, the field of differential diagnoses is typically quite small and includes acute hemorrhage, aspiration of radiodense material, and allergic bronchopulmonary aspergillosis (ABPA). The last of these three diagnoses is the most difficult to make, although ABPA is more commonly seen in children with cystic fibrosis (CF) or asthma. ABPA is radiographically characterized by recurrent mucus plugging, atelectasis, and central bronchiectasis. Thus far, high-attenuation mucus plugs have only been reported in adults. We report a rare case of a child with CF who had high-attenuation mucus plugs and atelectasis that raised the possibility of ABPA. We discuss the differential diagnoses of this finding and the role of multidetector CT in these children.

American College of Radiology white paper on radiation dose in medicine

The benefits of diagnostic imaging are immense and have revolutionized the practice of medicine. The increased sophistication and clinical efficacy of imaging have resulted in its dramatic growth over the past quarter century. Although data derived from the atomic bomb survivors in Japan and other events suggest that the expanding use of imaging modalities using ionizing radiation may eventually result in an increased incidence of cancer in the exposed population, this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing studies that are performed to obtain the best image quality with the lowest radiation dose. The ACR, which has been an advocate for radiation safety since its inception in 1924, convened the ACR Blue Ribbon Panel on Radiation Dose in Medicine to address these issues. This white paper details a proposed action plan for the college derived from the deliberations of that panel.

The role of pelvic magnetic resonance in evaluating nonhip sources of infection in children with acute nontraumatic hip pain

We retrospectively identified all children with acute hip pain who underwent pelvic magnetic resonance (MR). Children with septic hip or history of trauma were excluded; the remaining children with signs of infection (fever, >38 degrees C; leukocytosis, >12 x 10(9)/L; or elevated erythrocyte sedimentation rate [ESR], >30 mm/h) comprised the study group. Thirty-three children (9 girls; age, 0.8-15.8 years) were identified. On MR examination, 18 (55%) of 33 children had hip joint effusion, whereas 19 (58%) of 33 children had other abnormalities, including pyomyositis (n=15), osteomyelitis (n=12), and sacroiliitis (n=3). Staphylococcus aureus was cultured from 13 (68%) of these 19 children. Compared with MR, sensitivity for bone and soft tissue abnormalities was 30% for pelvic radiography (n=26) and 71% for bone scintigraphy (n=8). Elevated ESR (>30 mm/h) was the clinical finding that best predicted pelvic osteomyelitis or pyomyositis. Pelvic MR should be performed to rule out pelvic osteomyelitis or pyomyositis in children with acute hip pain, ESR of more than 30 mm/h, and no evidence of septic hip.

Quality—A Radiology Imperative: Report of the 2006 Intersociety Conference

Recent publications by the Institute of Medicine have pointed out the many medical errors that occur and the adverse effect of those errors on patient outcomes. These errors are often the result of problems within our health care systems. In an effort to improve patient care outcomes, many health care providers have developed improved policies and practices. Third-party payers are encouraging participation in quality efforts through a variety of mechanisms, including pay for performance, pay for participation, and the creation of centers of excellence. If the quality of health care is to be improved and monitored, appropriate metrics must be developed. Such metrics must be within the control of providers, measurable, and likely to improve patient outcomes. The participants of the 2006 Intersociety Conference developed 49 metrics, which are offered for adoption by health care networks, payers, and regulation agencies.

Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series

Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially life-threatening complication. An evaluation for malrotation is part of every upper gastrointestinal (GI) tract examination in pediatric patients, particularly neonates and infants. Although the diagnosis of malrotation is often straightforward, the imaging features in approximately 15% of upper GI tract examinations are equivocal and lead to a false-positive or false-negative interpretation. The clinical manifestations and upper GI tract findings of malrotation in older children and adults are less specific than are those in younger patients, and for this reason diagnosis of the condition may be more difficult. Successful differentiation between a normal variant and malrotation requires the use of optimal techniques in acquiring and interpreting the upper GI series. Familiarity with the upper GI series appearance of both normal and abnormal anatomic variants allows the radiologist to increase both diagnostic accuracy and confidence in the diagnosis of malrotation.

Acute pyomyositis of the pelvis: the spectrum of clinical presentations and MR findings

BACKGROUND

Acute pelvic pyomyositis is uncommon in non-tropical areas.

OBJECTIVE

To summarize the clinical and MR findings in children with acute pelvic pyomyositis.

MATERIALS AND METHODS

We retrospectively identified 20 children (mean age 9.4 years) who were evaluated by MR and diagnosed with acute pelvis pyomyositis during the time period between January 2002 and June 2005. We reviewed clinical, laboratory, and imaging findings.

RESULTS

Fifteen of the 20 children had secondary pyomyositis associated with osteomyelitis (n=13), septic hip (n=4) or sacroiliitis (n=4); all were previously healthy except for one child with leukemia. Seven of the children with secondary pyomyositis underwent bone scintigraphy; three (43%) did not show pelvic abnormalities. Staphylococcus aureus was cultured in 13 of the 15 (87%) children. Five of the 20 children had primary pyomyositis. Three had underlying disease and two others were engaged in vigorous physical activity. Bone scintigraphies (n=2) were negative. Cultures were positive for S. aureus in three of the five (60%) children.

CONCLUSION

Septic hip should be the first diagnostic consideration in children with fever and acute hip pain. Pyomyositis should be considered if arthrocentesis is negative or there is clinical suspicion of infection outside the hip joint. MR is the preferred imaging modality for evaluating foci of pyomyositis, muscle abscesses, and additional foci of infection within the pelvis.

Managing risk: threat or opportunity?

OBJECTIVE

Radiologists often regard risk management as a burden or even a threat. This article examines some of the most important reasons every radiologist should regard managing risk as an opportunity.

CONCLUSION

There are short-term risks and costs to a program of risk management, but they are far less than the long-range costs of inaction. More importantly, managing risk well is an opportunity to excel as a physician and leader.

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

OBJECTIVE

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

CONCLUSION

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.

Mesenteric lymph nodes in children: what is normal?

BACKGROUND

Enlarged mesenteric lymph nodes (MLN) are frequently seen in children with abdominal pain and, in the absence of other disorders, have been attributed to primary mesenteric lymphadenitis.

OBJECTIVE

To evaluate the prevalence of enlarged MLN (short axis>or=5 mm) as detected by abdominal CT in children with a low likelihood for mesenteric lymphadenopathy.

MATERIALS AND METHODS

During a 14-month period, we identified all non-contrast abdominal CT examinations performed at a tertiary care pediatric hospital for evaluation of suspected or known renal stones. Two radiologists reviewed the examinations and recognized all enlarged MLN, measured the short-axis diameter, and noted the quadrant location.

RESULTS

Sixty-one children were identified who met entry criteria; mean age was 10.7 years (range 1.1-17.3 years). Enlarged MLN were found in 33 (54%) of the 61 children; the largest enlarged MLN was most frequently in the right lower quadrant (RLQ) (29 of 33, 88%). Seventeen of the 61 children (28%) had three or more enlarged MLN; all were in the RLQ. The largest short-axis diameter measured was 10 mm.

SUMMARY

MLN with a short-axis diameter of >5-10 mm are commonly found on abdominal CT examination of children with a low likelihood for mesenteric lymphadenopathy and should be considered a non-specific finding. A short-axis diameter of 8 mm might better define the upper limit of normal mesenteric lymph node size in children.

Improving the quality of radiology reporting: A physician survey to define the target

PURPOSE

Our long-term goal is to improve the quality of reports in radiology imaging interpretation. The rationale for this project focused on identifying the characteristics of a high-quality report from the perspective of referring physicians and radiologists.

METHODS

We undertook a survey of physician faculty at a large Midwestern academic medical center (including university, children's, veteran's, county and private practice hospitals) regarding radiology report quality concepts.

RESULTS

Using a 5-point Likert scale, >95% of respondents indicated the highest importance rating (score=5) for radiology report characteristic "Accurate," with mean score of 4.94. Seventy-eight to 83% of respondents considered "Clear," "Complete" and "Timely" to have the highest importance rating, with means of these scores between 4.73 and 4.79. Somewhat less desirable characteristics included "Well-organized" and "Mentions pertinent negatives"-though radiologists tended to think the latter was less important than did all other categories of physician respondents. The single greatest problem area in reporting is lack of timeliness. Using a 10-point Likert scale, respondents gave a median score of seven for overall satisfaction with current reporting.

CONCLUSIONS

For high-quality radiology reporting, accuracy is most important. Clarity, completeness and timeliness are also very important. Radiologists tend to consider mentioning pertinent negatives as less important than do referring physicians; otherwise, respondents from different specialties largely agreed on which characteristics are most important for high-quality reports. There is room for improvement in physician satisfaction with radiology reporting.

The likely effects of radiologist extenders on radiology training

Manpower shortages have led many radiologists to consider using radiologist extenders, and the American Society of Radiological Technologists and the ACR have responded by formulating the radiology assistant (RA) program. There is no doubt that the RA program is becoming a reality or that it can be a boon to radiologists and physician radiologist trainees in freeing up faculty members' time, freeing trainees from repetitive tasks, and providing limited instruction in RAs' areas of expertise. Patients will likely accept RAs and trainee physicians equally. A financial analysis of using residents and physician extenders in anesthesia suggests that residents may be a cheaper labor source in those institutions not at the cap for resident positions.

Continuous quality improvement for radiologists1

Continuous quality improvement methods provide a relatively new way to improve quality in healthcare by using a systems approach with key features of customer-mindedness, data collection, experimentation, and teamwork. CQI is not meant to solve simple problems but is increasingly applied in our complex healthcare organizations. In fact, CQI is as much philosophy as it is both a qualitative and quantitative method to assess quality. This review describes the general methods and potential application for radiologists.

Technology Assessment for Radiologists

Health technology assessment is the systematic and quantitative evaluation of the safety, efficacy, and cost of health care interventions. This article outlines aspects of technology assessment of diagnostic imaging. First, it presents a conceptual framework of a hierarchy of levels of efficacy that should guide thinking about imaging test evaluation. In particular, the framework shows how the question answered by most evaluations of imaging tests, "How well does this test distinguish disease from the nondiseased state?" relates to the fundamental questions for all health technology assessment, "How much does this intervention improve the health of people?" and "What is the cost of that improvement?" Second, it describes decision analysis and cost-effectiveness analysis, which are quantitative modeling techniques usually used to answer the two core questions for imaging. Third, it outlines design and operational considerations that are vital if researchers who are conducting an experimental study are to make a quality contribution to technology assessment, either directly through their findings or as an input into decision analyses. Finally, it includes a separate discussion of screening--that is, the application of diagnostic tests to nonsymptomatic populations--because the requirements for good screening tests are different from those for diagnostic tests of symptomatic patients and because the appropriate evaluation methods also differ.

Hypothesis testing III: counts and medians

Radiology research involves comparisons that deal with the presence or absence of various imaging signs and the accuracy of a diagnosis. In this article, the authors describe the statistical tests that should be used when the data are not distributed normally or when they are categorical variables. These nonparametric tests are used to analyze a 2 x 2 contingency table of categorical data. The tests include the chi2 test, Fisher exact test, and McNemar test. When the data are continuous, different nonparametric tests are used to compare paired samples, such as the Mann-Whitney U test (equivalent to the Wilcoxon rank sum test), the Wilcoxon signed rank test, and the sign test. These nonparametric tests are considered alternatives to the parametric t tests, especially in circumstances in which the assumptions of t tests are not valid. For radiologists to properly weigh the evidence in the literature, they must have a basic understanding of the purpose, assumptions, and limitations of each of these statistical tests.

Imaging of acute appendicitis in children

Acute appendicitis is the most common acute abdominal condition that results in surgical intervention in childhood. The clinical diagnosis of acute appendicitis in children can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed nonoperatively. Complications associated with delayed diagnosis of this condition include perforation, abscess formation, peritonitis, sepsis, bowel obstruction, infertility, and death. The use of cross sectional imaging has proven useful for the evaluation of suspected acute appendicitis in children. Both graded compression sonography and CT have been widely utilized in the imaging assessment of the condition. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to assess ovarian pathology that can often mimic acute appendicitis in female patients. The principal advantages of CT include less operator dependency than sonography as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in perforated appendicitis.

An introduction to biostatistics

This introduction to biostatistics and measurement is the first in a series of articles designed to provide Radiology readers with a basic understanding of statistical concepts. Although most readers of the radiology literature know that application of study results to their practice requires an understanding of statistical issues, many may not be fully conversant with how to interpret statistics. The goal of this series is to enhance the ability of radiologists to evaluate the literature competently and critically, not make them into statisticians.

Spiral CT scanning technique in the detection of aspiration of LEGO foreign bodies

BACKGROUND

Radiolucent foreign bodies (FBs) such as plastic objects and toys remain difficult to identify on conventional radiographs of the neck and chest. Children may present with a variety of respiratory complaints, which may or may not be due to a FB.

OBJECTIVE

To determine whether radiolucent FBs such as plastic LEGOs and peanuts can be seen in the tracheobronchial tree or esophagus using low-dose spiral CT, and, if visible, to determine the optimal CT imaging technique.

MATERIALS AND METHODS

Multiple spiral sequences were performed while varying the CT parameters and the presence and location of FBs in either the trachea or the esophagus first on a neck phantom and then a cadaver. Sequences were rated by three radiologists blinded to the presence of a FB using a single scoring system.

RESULTS

The LEGO was well visualized in the trachea by all three readers (both lung and soft-tissue windowing: combined sensitivity 89 %, combined specificity 89 %) and to a lesser extent in the esophagus (combined sensitivity 31 %, combined specificity 100 %). The peanut was not well visualized (combined sensitivity < 35 %). The optimal technique for visualizing the LEGO was 120 kV, 90 mA, 3-mm collimation, 0.75 s/revolution, and 2.0 pitch. This allowed for coverage of the cadaver tracheobronchial tree (approximately 11 cm) in about 18 s. Although statistical power was low for detecting significant differences, all three readers noted higher average confidence ratings with lung windowing among 18 LEGO-in-trachea scans.

CONCLUSION

Rapid, low-dose spiral CT may be used to visualize LEGO FBs in the airway or esophagus. Peanuts were not well visualized.

Assessing physicians' accuracy in diagnosing paediatric patients with acute abdominal pain: measuring accuracy for multiple diseases

In evaluating the accuracy of diagnostic tests there are many situations where the true disease status can be one of multiple disorders. For example, when paediatric patients suffer acute abdominal pain, the underlying diagnosis could be appendicitis, intestinal obstruction, gastroenteritis, urinary tract infection, etc. In this paper we describe a format for collecting data for the case of multiple truth states. This new format allows one to make pairwise comparisons of the diagnostic accuracy between all of the different truth states. We propose a summary measure of accuracy which is a weighted average of the pairwise estimates of accuracy. Estimators are derived for the variance and covariance of the estimated summary accuracy. The small sample properties of the estimators are evaluated in a Monte Carlo simulation study. The new data collection format and summary measure were used in a paediatric acute abdominal pain study; data from this study are used to illustrate the methods.

The "differential diagnosis" for multiple diseases: comparison with the binary-truth state experiment in two empirical studies

RATIONALE AND OBJECTIVES

In practice readers must often choose between multiple diagnoses. For assessing reader accuracy in these settings. Obuchowski et al have proposed the "differential diagnosis" method, which derives all pairwise estimates of accuracy for the various diagnoses, along with summary measures of accuracy. The current study assessed the correspondence between the differential diagnosis method and conventional binary-truth state experiments.

MATERIALS AND METHODS

Two empirical studies were conducted at two institutions with different readers and diagnostic tests. Readers used the differential diagnosis format to interpret a set of cases. In subsequent readings they interpreted the cases in binary-truth state experiments. Spearman rank correlation coefficients and the percentages of agreement in scores were computed, and the areas under the receiver operating characteristic curves were estimated and compared.

RESULTS

The between-format Spearman rank correlation coefficients were 0.697-0.718 and 0.750-0.780 for the two studies; the between-reader correlations were 0.417 and 0.792, respectively. The percentages of agreement between formats for the two studies were 50.0%-51.7% and 72.9%-78.8%; the percentages of agreement between readers were 45.0% and 80%, respectively. In the first study there were several significant differences in the areas under receiver operating characteristic curves; in the second study these differences were small.

CONCLUSION

The differences observed between the two formats can be attributed to within-reader variability and inherent differences in the questions posed to readers in the multiple-diagnoses versus binary-truth state reading sessions. The differential diagnosis format is useful for estimating accuracy when there are multiple possible diagnoses.