Estimating the effects of informal radiology resident teaching on radiologist productivity: what is the cost of teaching?

The Big Squeeze: Factors Contributing to Moral Distress Among Radiologist Clinician-Educators

Moral distress is a term used to describe the cognitive-emotional dissonance that is experienced when one is compelled to act contrary to one's moral requirements. This occurs as a result of systemic constraints that prevent an individual from taking actions that they perceive as morally right, resulting in a perceived violation of one's core values and duties. There has been a growing interest in the prevalence of moral distress in healthcare, particularly as a root cause of burnout. A recent national survey on moral distress in radiology found that 98% of respondents experienced at least some degree of moral distress with 18% of respondents having left a position due to moral distress. One of the scenarios associated with the highest degree of moral distress related to the conflict that arises when one feels unable to fulfill teaching responsibilities due to high clinical demands. Now more than ever, clinician-educators are asked to do more with less time, fewer resources, and in an increasingly demanding work environment that is often discordant with providing quality education to their learners. In this manuscript, we aim to discuss the factors contributing to moral distress in radiologist clinician-educators as a framework to better understand the implications of these drivers, and to offer our perspective on potential mitigating measures.

Peer learning is both preferable and less expensive than score-based peer review: Initial experience at a tertiary academic center

PURPOSE

To examine radiologist experiences and perceptions during a transition from score-based peer review to a peer learning program, and to assess differences in time-cost efficiency between the two models of quality improvement.

METHODS

Differences in Likert scale survey responses from radiologists (N = 27) in a multispecialty group at a single tertiary academic center before and following intervention were evaluated by Mann-Whitney U test. Multiple variable linear regression analysis assessed independent variables and program preference.

RESULTS

All positive impacts rated significantly higher for the peer learning program. Workflow disruption for the peer learning program rated significantly lower. 70.4 % (19 of 27) preferred the new program, and 25.9 % (7 of 27) preferred the old program. Only the "worth investment" questionnaire score demonstrated a significant correlation to program preference and with an effect that was greatest among all variables (Beta = 1.11, p = 0.02). There was a significantly decreased amount of time per month used to complete peer learning exercises (0.76 ± 0.45 h, N = 27) versus peer review exercises (1.71 ± 1.84 h, N = 34, p = 0.011). The result was a difference of 0.95 ± 1.89 h/month (11.4 ± 22.7 h/year), translating to an estimated direct salary time-cost saving of $1653.68/year/radiologists and a direct productivity time-cost saving of $3469.39/year/radiologist when utilizing the peer learning program.

CONCLUSIONS

There was a strongly positive perception of the new peer learning program. There was a substantial implied direct time-cost saving from the transition to the peer learning program.

PRECIS

The peer learning model emphasizes learning from errors via feedback in a non-punitive environment. This model was positively perceived and demonstrated substantial implied direct time-cost saving.

Prevalence of burnout syndrome in Spanish radiologists

BACKGROUND AND AIMS

The primary objective was to analyze the prevalence and degree of professional burnout in radiologists in Spain. Secondary objectives were to identify possible factors that increase or decrease the risk of burnout to enable preventive and corrective measures, decrease the stress associated with this condition, and thereby increase radiologists' performance and satisfaction at work.

MATERIAL AND METHODS

This cross-sectional observational study used a voluntary, anonymous online survey of attending radiologists and residents through Google Forms®. The survey was structured into three sections: a qualitative assessment of the degree of professional burnout with the Maslach Burnout Inventory Human Services Survey (MBI-HSS), a series of sociodemographic and work-related questions, and a final section centered on possible causes of stress and improvements to the working environment. The results of the survey were analyzed statistically to determine which variables were associated with burnout syndrome as well as to identify possible risk factors and protective factors.

RESULTS

After disseminating the survey through social networks and email contacts, we received a total of 226 responses (175 from attending radiologists and 51 from residents; 52% men; mean age, 41 ± 11 years; age range, 25-68). The prevalence of the syndrome was 33%, without significant differences between attending radiologists and residents. No risk factors associated with burnout were identified. Teaching in the workplace was the only protective factor.

CONCLUSIONS

One-third of the respondents had burnout syndrome. Because the consequences of this syndrome can affect professionals' personal life and their ability to do their jobs, early detection and intervention should be prioritized.

Assessing Physician Resident Contributions to Outpatient Clinical Workload

BACKGROUND

Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics.

OBJECTIVE

Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners.

RESEARCH DESIGN

VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units.

MEASURES

Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity.

RESULTS

Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care).

CONCLUSIONS

Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.

Radiological 'SATs' monitor: The use of 'study ascribable times' to assess the impact of clinical workload on resident training in a resource-limited setting

INTRODUCTION

Globally, increasing clinical demands threaten postgraduate radiology training programmes. Time-based assessment of clinical workload is optimal in the academic environment, where an estimated 30% of consultant time should ideally be devoted to non-reporting activities. There has been limited analysis of the academic radiologist workload in low- and middle-income countries.

METHODS

Departmental staffing and clinical statistics were reviewed for 2008 and 2017. The Royal Australian and New Zealand College of Radiologists 'study ascribable times' (RANZCR-SATs) for primary consultant reporting were used with the Royal College of Radiologists (RCR) 2012 guidelines for secondary review of resident reports, to estimate the total consultant-hours required for each year's clinical workload. Analyses were stratified by type of investigation (plain-film vs. special) and expressed as a proportion of the total annual available consultant working hours.

RESULTS

Reporting all investigations required 90% and 100%, while reporting special investigations alone, demanded 53% and 69% of annual consultant working hours in 2008 and 2017, respectively. Between 2008 and 2017, the proportion of consultant time available for plain-film reporting decreased from 17% to 1%, while preserving 30% for non-reporting activities.

CONCLUSION

A time-based analysis of the academic radiologist's clinical workload, utilizing the RANZCR-SATs and RCR 2012 guidelines for primary and secondary reporting, respectively, provides a reasonably accurate reflection of the service pressures in resource-constrained environments and has potential international applicability.

The Integration of Active Learning Teaching Strategies Into a Radiology Rotation for Medical Students Improves Radiological Interpretation Skills and Attitudes Toward Radiology

PURPOSE

In recent years, there has been increased recognition of the benefits of teaching by active learning. However, there is a paucity of experimental studies utilizing active learning in undergraduate radiology rotations, which is traditionally a passive learning experience. We designed a new radiology rotation that integrated teaching by active learning. We prospectively examined the efficacy of this new rotation compared to our standard rotation in terms of students' radiological competency and attitudes toward radiology, as well as impact on departmental efficiency.

METHODS

This was a prospective cohort study involving fourth year medical students completing a 1-week radiology rotation at our department between January and April 2018. One cohort completed a rotational model which incorporated active learning sessions (integrated cohort) while the remainder were taught using traditional passive learning methods (standard cohort). All participants completed a radiology examination before and after the rotation and were surveyed on their attitudes toward radiology.

RESULTS

A total of 105 students enrolled in the study. The mean postrotation competency score obtained by the integrated cohort was significantly higher than that obtained by the standard cohort (82% vs 62%; P < 0.001). The integrated rotation freed up 7 hours of radiologists' time per week. While the students completing the integrated rotation had a more positive perception of radiology, they were no more likely to express a desire to pursue a career in radiology.

CONCLUSIONS

The integration of active learning sessions into an undergraduate radiology rotation results in an improvement in students' postrotation radiological competency and attitudes toward radiology.

Predictors for Failing the American Board of Radiology Core Examination

OBJECTIVE. Since the American Board of Radiology (ABR) instituted its new board certification pathway, our residency program has had more residents fail the core examination than was typical with the prior pathway. We performed a single-center retrospective study to evaluate predictors of ABR core examination failure. MATERIALS AND METHODS. Data regarding U.S. Medical Licensing Examination (USMLE) steps 1 and 2, ACR diagnostic radiology in-training examinations, the number of image interpretations, academic degree (doctor of medicine or doctor of osteopathy), status as an American or foreign medical graduate, and Alpha Omega Alpha national medical honor society status were gathered and evaluated through logistic regression and generalized additive logistic regression. Data were gathered for all residents who took the ABR core examination from 2013 to 2017. RESULTS. Six of 30 residents (20%) failed the ABR core examination on the first attempt. The ACR in-training examination scores for 1st- and 3rd-year residents were significantly related to ABR core examination failure (p = 0.027 and p = 0.035, respectively), with significant nonlinearity (p = 0.037 and p = 0.033, respectively). The suggested baseline percentile score was the 30th percentile for 1st-year residents and the 20th percentile for 3rd-year residents. USMLE step 1 and 2 scores were significantly related to ABR core examination failure (p = 0.041 and p = 0.043, respectively), without significant nonlinearity (p = 0.35 and p = 0.09, respectively). However, residents with scores of less than 220 on USMLE steps 1 and 2 seemed to be at risk. CONCLUSION. Low scores on USMLE steps 1 and 2 and 1st- and 3rd-year ACR in-training examinations were associated with ABR core examination failure. If validated more broadly, these cutoffs may serve as predictors of ABR core examination failure and may facilitate identification and remediation of at-risk residents.

Radiology Education in the 21st Century: Threats and Opportunities

Over the past 25 years, radiology has seen tremendous growth in interpretive demands, including increasing imaging volumes and shorter turnaround times, as well as increased noninterpretive demands often targeting value-adding opportunities. These mounting pressures have led to increased burnout among radiologists nationwide and, in the academic setting, have begun to threaten the core educational mission. Despite these threats, radiology has also proven itself over the years to be a leader when it comes to innovation, and as such, no other field is better suited to confront these challenges with innovative solutions. This article explores the impact these workload trends have had on radiology education and educators, as well as opportunities to confront these challenges.

Impact of formal training on agreement of videofluoroscopic swallowing study interpretation across and within disciplines

PURPOSE

Formal agreement studies on interpretation of the videofluoroscopic swallowing study (VFSS) procedure among speech-language pathologists, radiology house officers, and staff radiologists have not been pursued. Each of these professions participates in the procedure, interprets the examination, and writes separate reports on the findings. The aim of this study was to determine reliability of interpretation between and within the disciplines and to determine if structured training improved reliability.

METHODS

Thirteen speech-language pathologists (SLPs), ten diagnostic radiologists (RADs) and twenty-one diagnostic radiology house officers (HOs) participated in this study. Each group viewed 24 VFSS samples and rated the presence or absence of seven aberrant swallowing features as well as the presence of dysphagia and identification of oral dysphagia, pharyngeal dysphagia, or both. During part two, the groups were provided with a training session on normal and abnormal swallowing, using different VFSS samples from those in part one, followed by re-rating of the original 24 VFSS samples. A generalized estimating equations (GEE) approach with a binomial link function was used to examine each question separately. For each cluster of tests, as example, all pairwise comparisons between the three groups in the pretraining period, a Hochberg's correction for multiple testing was used to determine significance. A GEE approach with a binomial link function was used to compare the premeasure to postmeasure for each of the three groups of raters stratified by experience.

RESULTS

The primary result revealed that the HO group scored significantly lower than the SLP and RAD group on identification of the presence of dysphagia (p = 0.008; p = 0.001, respectively), identification of oral phase dysphagia (p = 0.003; p = 0.001, respectively), and identification of both oral and pharyngeal phase dysphagia, (p = 0.014, p = 0.001, respectively) pretraining. Post training there was no statistically significant difference between the three groups on identification of dysphagia and identification of combined oral and pharyngeal dysphagia.

CONCLUSIONS

Formal training to identify oropharyngeal dysphagia characteristics appears to improve accuracy of interpretation of the VFSS procedure for radiology house officers. Consideration to include formal training in this area for radiology residency training programs is recommended.

What it means 'to teach' as a radiologist in the modern era: a personal perspective

Whether employed in a private practice, a community or academic setting, or even a hybrid practice, radiologists fill many roles in the course of a day. Teaching is one of the most important roles in the dissemination of knowledge and the continued renewal of the health, vibrancy and advancement of our field. In this article the author reviews some of the various facets of what radiology teaching and learning look like in the current era. Highlighted topics include workstation teaching, workshop and small group education, interdisciplinary activities and mentorship.

Resident Perspectives of an Interactive Case Review Following Independent Didactic Study as a Method of Teaching a Pediatric Imaging Curriculum

PURPOSE

The ABR has recently changed the format of the board examination, in which the oral examination was replaced by a computer based multiple-choice test. The purpose of this study was to determine resident's perceptions of a new conference resembling the new ABR format.

METHODS

Residents were requested to review a series of didactic pediatric imaging presentations prior to attending case conference. During conference, unknown cases reflecting the subject matter from the didactic presentations were presented along with multiple-choice questions. We then surveyed resident perspectives after each case conference.

RESULTS

Between 14 and 18 residents were surveyed at the end of each subspecialty case review presentation. About 94% of resident respondents felt that the independent didactic study followed by an interactive case review session would better prepare them for the ABR certification exams, compared to didactic lectures alone. Furthermore, 95% of the respondents indicated that they preferred the independent didactic review followed by interactive case review versus didactic lecture alone. Most the respondents (85%) felt that combining independent didactic review with interactive unknown case sessions made the material more interesting and provided greater understanding of the material. There was no statistically significant difference in the distribution of answers across the subspecialty sessions (p > .05).

CONCLUSION

Radiology residents favorably reviewed the combination of independent review of didactic material prior to interactive case review. Material presented in this fashion is felt to be more interesting and is thought to result in enhanced understanding of pediatric radiology material.

Effect of Radiology Study Flow on Report Turnaround Time

OBJECTIVE

The purpose of this study was to assess the importance of relative value unit (RVU) flow and other factors in report turnaround time (TAT) in emergency radiologic operations.

MATERIALS AND METHODS

RVU flow was defined as the normalized (to 60 minutes) total work RVUs for studies performed in a given time interval of 30 minutes (RVU flow 30) or 60 minutes (RVU flow 60). Twenty-five weekday emergency radiology shifts each for four radiologists were randomly selected. The institutional radiology search engine was queried to obtain the following data for each study: study completion time, work RVU, attending radiologist, and report TAT. RVU flow 30, RVU flow 60, presence of resident, and number of hours since start of shift were computed. Two separate multiple linear regression analyses were performed with RVU flow 30 or RVU flow 60 and other factors as independent variables and TAT as the dependent variable.

RESULTS

The study included 7378 radiology studies from 100 weekday shifts, from which 1537 RVU flow 30 and 792 RVU flow 60 data points were generated. RVU flow 60 (p = 0.0026) and RVU flow 30 (< 0.0001) were significantly associated with radiology report TAT. One attending radiologist had statistically significant lower TAT 30 and TAT 60, whereas another had a lower TAT 30 but not TAT 60. The presence of a resident was significantly associated with reduced TAT 30 (p = 0.0005) and TAT 60 (p = 0.0028).

CONCLUSION

RVU flow 60, RVU flow 30, specific attending radiologist, and presence of a resident are significantly correlated with radiology report TAT. RVU flow should be considered when evaluating radiologist and overall system performance with respect to report TAT.

Academic and private practice partnerships in veterinary radiology residency training

As veterinary radiologists devote greater time to telemedicine consultation, residency training must evolve to reflect the skills of these services. The contribution of private practice/consultant radiologists to residency training has traditionally been minimal but academic and private practice partnerships in education and research can provide the framework for a well-rounded residency. These partnerships can also lessen the impact of workforce shortages in academia and provide financial compensation to academicians through external consultation. The purpose of this commentary is to review existing collaborative interactions between academic and private practice veterinary radiologists; with a focus on ways to sustain, improve, and cautiously increase the number of veterinary radiology training programs.

Quality metrics currently used in academic radiology departments: results of the QUALMET survey

OBJECTIVE

We present the results of the 2015 quality metrics (QUALMET) survey, which was designed to assess the commonalities and variability of selected quality and productivity metrics currently employed by a large sample of academic radiology departments representing all regions in the USA.

METHODS

The survey of key radiology metrics was distributed in March-April of 2015 via personal e-mail to 112 academic radiology departments.

RESULTS

There was a 34.8% institutional response rate. We found that most academic departments of radiology commonly utilize metrics of hand hygiene, report turn around time (RTAT), relative value unit (RVU) productivity, patient satisfaction and participation in peer review. RTAT targets were found to vary widely. The implementation of radiology peer review and the variety of ways in which peer review results are used within academic radiology departments, the use of clinical decision support tools and requirements for radiologist participation in Maintenance of Certification also varied. Policies for hand hygiene and critical results communication were very similar across all institutions reporting, and most departments utilized some form of missed case/difficult case conference as part of their quality and safety programme, as well as some form of periodic radiologist performance reviews.

CONCLUSION

Results of the QUALMET survey suggest many similarities in tracking and utilization of the selected quality and productivity metrics included in our survey. Use of quality indicators is not a fully standardized process among academic radiology departments. Advances in knowledge: This article examines the current quality and productivity metrics in academic radiology.

Learning, technology and intellectual property: a survey of the philosophies and preferences of our trainees and peers

BACKGROUND

Increasing workloads threaten the quality of teaching in academic radiology practices. There is a wealth of unfiltered educational resources for radiology on the internet. As a digital native, today's radiology trainee may have differing opinions from teachers about learning and intellectual property.

OBJECTIVE

To identify the preferences and philosophies regarding learning, technology and intellectual property toward the future development of an innovative radiology curriculum.

MATERIALS AND METHODS

An electronic survey with 22 questions was sent to 2,010 members of the Society for Pediatric Radiology and 100 radiology trainees.

RESULTS

Three hundred sixty-one of the 2,110 surveys were returned. All questions were completed in 342 surveys. Fifty-three respondents were trainees (residents and fellows) and 289 respondents were radiologists (teachers). Time needed for a single learning activity in both groups is <30 min, but teachers spend less time (P=0.007). The preferred learning environments were point-of-care and outside work hours for both groups. Ideal lecture durations were 31-45 min for trainees and 21-30 min for teachers (P=0.001). Adoption of new technology showed late majority and laggard trends for both groups (P=0.296). Interest in gadgets was greater in trainees (17%) than teachers (2%) (P<0.001). Interest in lecture recording was greater in trainees (84%) than teachers (61%) (P=0.008). More trainees (61%) than teachers (42%) would not charge money for educational materials (P=0.028); 27% versus 13%, respectively, disagreed with dissemination of those materials beyond the institution (P=0.013).

CONCLUSION

While millennial trainees are adult learners with a stronger comfort with technology, learning styles of trainees and teachers are more similar than was previously believed. Trainees and teachers hold conflicting philosophies about intellectual property. Results herein speak favorably for revising our teaching portfolio to include practical learning materials of short duration available at point-of-care.

Workload of consultant radiologists in a large DGH and how it compares to international benchmarks

AIM

To measure radiologist workloads in a UK radiology department using relative value units (RVUs), and compared these data to current international standards from Australia and Ireland.

MATERIALS AND METHODS

Data on reporting throughput was gathered for 13.5 whole-time equivalent (WTE) consultants at the DGHs of East Lancashire Hospitals Trust (ELHT) between April 2010 to March 2011. RVUs were assigned to the reported imaging studies to create a crude RVU/WTE score. This was compared to benchmarks from Australia and results from a similar study in Ireland. Time spent on teaching, multidisciplinary teams, and administration was factored in to create a net RVU/WTE score, more accurately assessing workload.

RESULTS

Radiologists in ELHT reported 110,315 imaging studies, producing a total of 649,617 RVUs. Crude reporting workloads were 48,119.78 RVUs/WTE, and net workloads were 83,674.00 RVUs/WTE (with consultants spending 42.49% of their time on non-reporting commitments). These crude and net workloads are far above the Australian maximum reporting benchmark of 45,000 RVUs.

CONCLUSION

The workload is much higher than international benchmarks, indicating high-quality service and excellent value for money, but also highlights understaffing. Foreign RVU systems do not accurately reflect current UK practices and a UK-specific RVU system should be developed to assess staffing and analyse performance.

What program directors think: results of the 2011 annual survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) conducts an annual survey to monitor and evaluate issues pertaining to radiology residents' educational experiences, work responsibilities, and benefits. Data are used to identify emerging trends and patterns of change to plan and provide resources that support radiology residency programs and their directors.

MATERIALS AND METHODS

The APDR Annual Survey Committee selected 59 items for an observational, cross-sectional study using a Web-based survey. Topics of interest included program director satisfaction, resident recruitment, social media, program requirements, curriculum, the new American Board of Radiology exam process, call, and residents-as-teachers programs. All active APDR members (n = 296) were invited to participate in survey between February 20 and March 11, 2011.

RESULTS

The response rate was 47% (140 of 296). Descriptive results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 59th annual meeting of the Association of University Radiologists.

CONCLUSIONS

Data generated by the annual survey enable the APDR to accrue data pertaining to residents' real-time educational experiences. In 2011, program directors were satisfied with their jobs but not convinced that competency-based program requirements had positive effect on residency training. Programs plan to use the Radiological Society of North America and American Association of Physicists in Medicine Web-based physics training modules. Most radiology programs do not have residents-as-teachers programs, nor do they plan to initiate them. During recruitment, programs use an applicant's location as a proxy for true interest in the program, and interest in the program is important for granting interviews and final ranking. Qualified international medical graduate applicants have access to radiology training in the United States and Canada. Almost half of radiology programs have in-house reading by attending radiologists with residents on call. Residency programs have been slow to embrace social media.

Measuring Consultant Radiologist workload: method and results from a national survey

Objectives

The role of the Consultant Radiologist has changed substantially in recent decades, yet manpower planning is often based on older inappropriate methods of measuring Radiologist workload. We report a nationwide survey of Consultant Radiologist workload in Ireland in 2009.

Methods

Relative value units (RVUs) were assigned to easily countable studies. Hospitals’ activity was collated for the full calendar year of 2009. Radiologist time engaged in activities not easily counted (interventional and procedural work, multi-disciplinary meetings, teaching, administration, etc.) was separately measured.

Results

Data were obtained from 28 of 38 public hospital radiology departments. Mean Consultant Radiologist workload across all hospitals was 57,659.1 crude RVUs/WTE and 103,987 net RVUs/WTE. A mean of 32.47% of WTEs are engaged in non-countable activity. Means of 85.35% and 65.73% of the required numbers of WTEs were available in 2009 to achieve respectively annual crude and net RVU/WTE figures of 45,000. Excluding Specialist Centres, plain films accounted for 28–41% of recorded activity, mammography for 0.8–5.8%, US for 16–20%, CT for 27–32% and MR for 5.9–15.8%.

Conclusions

Irish Consultant Radiologist staffing levels are well below appropriate international benchmarks for the current workload. Approximately one-third of radiologist time is engaged in activity not easily counted in study numbers.

[Financing and control of surgical training]

The present analyses of different surgical training systems show that training of surgical residents significantly contributes to hospital costs. These are predominantly caused by prolonged operation times of residents with increased work load for other staff members in the operating room. In addition, the productivity of surgical residents is less compared to experienced surgeons. On the other hand, hospital managements save money by the lower standard wages paid to the residents. The amount of educational costs is difficult to determine because surgical training takes place as on the job training. Therefore, from an economic point of view, the two products patient care and surgical training are difficult to separate. There are no reliable cost analyses available for the German training system. At present surgical training is indirectly financed by the DRG (diagnosis-related groups) flat rates of the health insurance. Possible options of financing the surgical training are additional funding from the health department or redistribution with supplemental payment for those surgical departments which contribute significantly more to the residents' training. Statements of medical associations, health departments and health insurances demonstrate the difficulty to come to an agreement concerning the finances of the training system. Despite this controversial discussion it should be taken into consideration that there is no alternative to a high quality surgical training as this is the basis for an effective health system.

A cost-efficiency analysis to increase clinician staffing in an academic emergency department

PURPOSE

To develop a software-based model to determine which combination of attendings working with/without residents and/or midlevel providers (MLP) was most cost-efficient for incremental staffing in an academic emergency department (ED).

METHOD

A decision tree model using standard decision analysis software was created to compare different staffing configurations for the Rhode Island Hospital ED. The productivity, salary, and working hour data of different staffing configurations were determined using data from the ED, reported productivity data, and assumptions based on the authors' experience. Attending physician productivity alone was assumed to be 2.1 patients per hour, and each additional resident and/or MLP was assumed to add smaller net productivity gains (the first one adds 0.75 patients/hour; the second, 0.5 patients/hour; the third, 0.33 patients/hour). Resident and MLP productivity were assumed to be equivalent in the base case and varied during subsequent analysis. Noneconomic variables were not included in the model.

RESULTS

The lowest base case cost option is to pair one attending with one resident; all other approaches are more expensive. The difference between most options is less than $5/patient. Only at extremes of variables do overall choices differ.

CONCLUSIONS

Incrementally staffing an academic ED with a ratio of one attending per resident achieves the lowest cost, but other models are minimally more expensive. The model allows an ED administrator to determine the costs of different models.

MRI interpretation proficiency of musculoskeletal fellows in training

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the magnetic resonance imaging (MRI) interpretation proficiency of musculoskeletal fellows in training.

MATERIALS AND METHODS

Between July 2003 and June 2007, 14 musculoskeletal fellows were independently tested with 20 MRI studies of the knee and shoulder at four separate time points during their fellowship years. Trends in true-positive and false-positive interpretation results were evaluated. Fellows who completed their residencies at the fellowship institution (internal fellows) were compared with those from other residencies (external fellows).

RESULTS

There was a significant improvement in proficiency between the initial and final (9-month) evaluations (P < .0001). At the initial evaluation, there was a mean of 52.8% (41.7 of 79) true-positive results (range, 32-51); at 9 months, there was a mean of 71.0% (56.1 of 79; range, 40-72). The number of false-positive results also declined during this time period from a mean of 8.1 (range, 2-13) at initial evaluation to 4.7 (range, 2-8) at 9 months (P < .001). External fellows had more incorrect diagnoses initially but showed greater improvement than internal fellows at 9 months.

CONCLUSION

Fellows continued to improve their MRI interpretation skills throughout the first 9 months of their fellowships. External fellows were slightly less proficient at the start of their fellowships but slightly more proficient at 9 months compared to internal fellows.

Evaluating the effect of resident involvement on physician productivity in an academic general internal medicine practice

PURPOSE

To estimate the effect of resident involvement across three years of resident training in a general internal medicine practice on the productivity of faculty physicians at Rush University Medical Center.

METHOD

Productivity was measured by work relative value units (RVUs) per clinical full-time equivalent attending physician generated in the ambulatory practice between July 2004 and June 2005. Random-effects linear regression models were used to estimate the impact of resident involvement by year of resident on attending physician productivity, controlling for faculty physician demographic characteristics.

RESULTS

Resident involvement significantly reduced physician productivity. Each first-year resident was associated with a loss of 0.81 work RVUs per attending physician per four-hour clinic session. Each second-year and third-year resident was associated with a loss of 0.88 work RVUs and 0.49 work RVUs per attending physician per session, respectively. The loss per resident per session translated into a loss of 2,447 work RVUs for the year for the practice.

CONCLUSIONS

Physician productivity significantly decreased with resident involvement, but the impact varied across resident training years. The loss in productivity for the year was $164,000 in revenue or $49 per resident per session. Results of this study provide insight into the importance of considering teaching responsibilities when establishing productivity targets, particularly in practices where the level of teaching involvement varies across faculty physicians. External benchmarks with other general internal medicine practices would be more accurate when resident teaching responsibilities are accounted for.

Whither hospital and academic psychiatry?

If psychiatrists are to bring value to the health care team, training a renewable force of such psychiatrists is essential. Have psychiatrists been trained to bring maximal value to the health care team? Is such training being provided now? Given the current health care climate, will sufficient funding be available to train this renewable force optimally? This article addresses these questions from an historical-developmental perspective, identifies current challenges, and outlines opportunities for further growth and development.

Challenges to radiology resident education in the new era

Over the past decade, there have been many developments that have changed the practice of radiology and the education of radiology residents. These include workforce issues, the institution of the Accreditation Council for Graduate Medical Education duty-hours restrictions, the increased use of night float systems, and the implementation of picture archiving and communication systems as well as voice recognition. This article reviews the impact on resident education, summarizes potential problems introduced by these changes, and examines proposed solutions.

The needs of an educator

A medical educator has needs that are specific to educators and needs that are common to all medical faculty members. An educator needs time to perform educational duties; space to carry out educational activities; and money to buy time, space, and other resources. Just as important as time, space, and money are to the success of an educator is having an infrastructure that supports the educator and the educational mission. Such an infrastructure includes a system that provides educational leadership opportunities, institutional support for medical education, opportunities and funding for medical education research, students, feedback from students and peers, faculty development and mentoring, national societal support for education, and an institutional agenda that values education to the degree that it values patient care and investigative research.

The Academic RVU: A System for Measuring Academic Productivity

Despite the importance of teaching, research, and related activities to the mission of academic medical departments, no useful and widely agreed-on metrics exist with which to assess the value of individual faculty members' contributions in these areas. Taking the concept of the clinical relative value unit (RVU) as a model, the authors describe the development of an academic RVU (aRVU) system that assigns weights to and creates formulas for assessing productivity in publications, teaching, administrative and community service, and research. The resulting aRVU schema was implemented on a Web-based system that incorporates a number of novel tools, including a curriculum vitae manager that automatically maintains and calculates total aRVU scores and breaks out component elements for each individual and for the department as a whole. The benefits and limitations of this system are discussed, as well as the potential advantages in sharing this approach with other radiology departments and other medical disciplines. Wide acceptance and implementation would make the aRVU the appropriate counterpoint to the clinical work RVU in academic medicine.

Funding for Graduate Medical Education

The education of radiology residents and fellows is a vitally important but costly process. This paper reviews the most common methods of funding graduate medical education. The majority of graduate medical education in the United States is funded by Medicare, but there are caps on the number of trainees allowed, and the government is cutting payments. Academic medicine, particularly academic radiology, is at a point of crisis today if new methods to provide additional support are not found.

Financing Radiology Graduate Medical Education: Today’s Challenges

Radiology graduate medical education (GME) is exposed to huge financial challenges. First, there is a continuous increase in demand for imaging services by referring doctors and the general population, aggravating the staff shortage. Second, there has been an important decline in reimbursements. Third and probably most important is the progressive reduction of federal funds subsidizing GME. Medicare is the largest single contributor to GME. The Balanced Budget Act (BBA) of 1997 introduced reductions in Medicare payments to the major teaching hospitals calculated at $5.6 billion over the first 5 years after implementation. The BBA also brought other changes directly affecting GME. Financial changes in health care over the past decade have increased the pressure on academic institutions, which must preserve or improve the quality of training and the quality of care and manage an increased workload with fewer funds available and a narrow margin for errors. Yet the use of new technology promises to help simplify processes, decreasing workloads for residents and faculty members and increasing overall productivity, and new sources of funding have been suggested. By reviewing the financial challenges of radiologic training in today's academic centers, the authors reach the conclusion that there is still space for improving academic quality and the quality of care within current financial boundaries. But more reliable data about the specific benefits and drawbacks of having a residency program in a clinical radiology department are required.