A Portrait of Breast Imaging Specialists and of the Interpretation of Mammography in the United States

A pre-post study of stressors and burnout affecting breast radiologists before and during the COVID-19 pandemic

Rationale and objective

To compare burnout and stressors of breast radiologists prior to and during the COVID-19 pandemic.

Materials and methods

Members of the Society of Breast Imaging were emailed an IRB-approved survey in January 2021 during the COVID-19 pandemic. Survey included questions from the Maslach Burnout Inventory and specific stressors including work pace, work-life balance, care of dependents, and financial strain. Data were compared to previous surveys prior to the pandemic.

Results

The response rate was 25% (261/1061) for those who opened the email. Of the respondents, 74% (194/261) were female, 82% (214/261) were white, 73% (191/261) were full time, 71% (185/261) were fellowship trained, 41% (106/261) had more than 20 years of experience, and 30% (79/261) were in academic practice.Respondents in 2021 reported frequent levels of depersonalization (2.2) and emotional exhaustion (3.4) while reporting frequent levels of personal accomplishment (5.3), a protective factor. These values were nearly identical before the pandemic in 2020: (2.2, 3.5, 5.3, respectively, p = .9). Respondents rated practicing faster than they would like as the highest stressor; however, 5 of the 6 stressors improved after the pandemic onset (p < .05). Conversely, participants perceived these stresses had gotten slightly worse since the pandemic (p < .01). Almost 50% of respondents reported they were considering leaving their practice; the most common reason was work/life balance.

Conclusion

Burnout in breast radiologists remains frequent but unchanged during the COVID-19 pandemic. While participants perceived that some stressors were worse during the pandemic, there was slight improvement in most stressors between the pre-pandemic and pandemic cohorts.

Patient and radiologist demographics influence perceptions of screening mammogram reports

OBJECTIVE

To test whether patient and radiologist demographics influence perceptions of screening mammogram reports and the interpreting radiologist.

METHODS

Patients presenting for breast imaging were surveyed. Demographics were collected and each participant was shown five mock screening mammogram reports with BI-RADS 2 findings, each with a recommendation for one year screening. Each report included a picture of the interpreting radiologist who was Black or white and male or female. Participants were asked seven Likert questions about understanding, satisfaction, and trust in the report and radiologist. Generalized estimating equation ordinal logistic regression compared responses based on participant and radiologist demographics.

RESULTS

There were 178 women who participated with a mean age of 55.1 ± 10.2 years. Most participants self-identified as white (71%) or Black (20%) and non-Hispanic (98%) with broad educational representation (28% Bachelor's and 28% Master's degree). After controlling for demographics, Black participants reported greater agreement regarding trust in the report's finding (p=0.037) if the radiologist was also Black. Black participants were less likely to be satisfied in the report quality (p=0.043). Additionally, participants without any college education reported lower agreement that they were satisfied with the report quality (p=0.020) and felt the radiologist cares about his/her patients (p=0.037). There were no significant associations for radiologist gender or participant age.

DISCUSSION

Participant perceptions of screening mammograms and the interpreting radiologist can be influenced by participant and provider race as well as participant education. These findings could have implications for mammography adherence, breast radiologist recruitment, and developing patient centric reports.

Breast Imaging and Social Media: A Model Specialty for Increasing Interest and Awareness of Radiology in Pre-Medical Students

OBJECTIVE

To assess how a virtual shadowing (VS) session on breast imaging (BI), shared through social media, can increase interest and awareness of radiology in pre-medical students.

METHODS

This study was IRB exempt. A VS slide presentation on BI mentorship, didactic lecture, and deidentified image-rich, case-based learning was created. This session was advertised and presented live through an Instagram page (Pre-Health Virtual Shadowing, @virtualshadowing) geared toward pre-health students. Students were asked to complete a two-question self-assessment using a 5-point Likert scale on which 1 was "least" and 5 was "most." Question 1 read: "Please rate your overall knowledge about radiology and what a radiologist does," and question 2 read: "Please rate your interest in possibly looking into radiology as a potential career."

RESULTS

A total of 420 participants logged into the VS session; 82% (345/420) answered the pre-session survey and 48% (202/420) answered the post-session survey. Of post-survey respondents, 84% (170/202) were female and 70% (143/202) were 22 years old or younger. There was a significant difference in mean pre-session survey responses to question 1 when compared to mean post-session survey responses (2.67 vs 3.55, P < 0.001). There was also a significant difference in mean pre-session survey responses to question 2 when compared to mean post-session survey responses (3.16 vs 3.58, P < 0.001). Our VS session remains on YouTube and has 6157 views to date.

CONCLUSION

When shared through VS on social media, breast imaging can increase interest and awareness of radiology in pre-medical students.

Peer learning in breast imaging

With the increasing focus on quality and safety in medicine, radiology practices are increasingly transitioning from traditional score-based peer review to peer learning. Participation in a peer learning program can increase learning, practice improvement, and cultivation of interpersonal relationships in a non-punitive environment. As breast imaging errors are the most cited in medical malpractice cases, learning and attention to and reduction of these errors in breast imaging are especially important. We describe the strengths of a peer learning program, implementation process in a breast imaging program, challenges to overcome, and strategies to support success.

Diversity and Inclusion in Breast Imaging and Radiology at Large: What Can We Do to Improve?

Purpose of Review

A racially and ethnically diverse healthcare workforce leads to increased access to care and better health outcomes. Radiology and specifically the patient-centered subspecialty of breast imaging have a growing mismatch between the demographics of the physician workforce and the patient population served. Identifying and addressing the barriers for diversity is imperative in order to decrease disparities in breast cancer morbidity and mortality and achieve excellence in patient care.

Recent Findings

Three major barriers to promoting diversity and inclusion in the field of breast imaging and in the specialty of radiology more generally are unconscious bias, lack of mentorship for underrepresented minority (URM) students, and career development challenges facing women in radiology. We focus on these three issues and provide suggestions for addressing each of them.

Summary

Tackling unconscious bias through encouraging individual accountability and establishing implicit bias programs at the institutional level, supporting both formal and informal mentorship opportunities for URMs, and creating an environment to support women in leadership will bring us one step closer to fostering a diverse and inclusive breast imaging workforce and meeting the healthcare needs of the diverse US population.

COVID-19 and Breast Radiologist Wellness: Impact of Gender, Financial Loss, and Childcare Need

PURPOSE

The purpose of this study was to evaluate the emotional and financial impact of coronavirus disease 2019 (COVID-19) on breast radiologists to understand potential consequences on physician wellness and gender disparities in radiology.

METHODS

A 41-question survey was distributed from June to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Psychological distress and financial loss scores were calculated on the basis of survey responses and compared across gender and age subgroups. A multivariate logistic model was used to identify factors associated with psychological distress scores.

RESULTS

A total of 628 surveys were completed (18% response rate); the mean respondent age was 52 ± 10 years, and 79% were women. Anxiety was reported by 68% of respondents, followed by sadness (41%), sleep problems (36%), anger (25%), and depression (23%). A higher psychological distress score correlated with female gender (odds ratio [OR], 1.9; P = .001), younger age (OR, 0.8 per SD; P = .005), and a higher financial loss score (OR, 1.4; P < .0001). Participants whose practices had not initiated wellness efforts specific to COVID-19 (54%) had higher psychological distress scores (OR, 1.4; P = .03). Of those with children at home, 38% reported increased childcare needs, higher in women than men (40% versus 29%, P < .001). Thirty-seven percent reported that childcare needs had adversely affected their jobs, which correlated with higher psychological distress scores (OR, 2.2-3.3; P < .05).

CONCLUSIONS

Psychological distress was highest among younger and female respondents and those with greater pandemic-specific childcare needs and financial loss. Practice-initiated COVID-19-specific wellness efforts were associated with decreased psychological distress. Policies are needed to mitigate pandemic-specific burnout and worsening gender disparities.

Improving radiologist's ability in identifying particular abnormal lesions on mammograms through training test set with immediate feedback

It has been shown that there are differences in diagnostic accuracy of cancer detection on mammograms, from below 50% in developing countries to over 80% in developed world. One previous study reported that radiologists from a population in Asia displayed a low mammographic cancer detection of 48% compared with over 80% in developed countries, and more importantly, that most lesions missed by these radiologists were spiculated masses or stellate lesions. The aim of this study was to explore the performance of radiologists after undertaking a training test set which had been designed to improve the capability in detecting a specific type of cancers on mammograms. Twenty-five radiologists read two sets of 60 mammograms in a standardized mammogram reading room. The first test set focused on stellate or spiculated masses. When radiologists completed the first set, the system displayed immediate feedback to the readers comparing their performances in each case with the truth of cancer cases and cancer types so that the readers could identify individual-based errors. Later radiologists were asked to read the second set of mammograms which contained different types of cancers including stellate/spiculated masses, asymmetric density, calcification, discrete mass and architectural distortion. Case sensitivity, lesion sensitivity, specificity, receiver operating characteristics (ROC) and Jackknife alternative free-response receiver operating characteristics (JAFROC) were calculated for each participant and their diagnostic accuracy was compared between two sessions. Results showed significant improvement among radiologists in case sensitivity (+ 11.4%; P < 0.05), lesion sensitivity (+ 18.7%; P < 0.01) and JAFROC (+ 11%; P < 0.01) in the second set compared with the first set. The increase in diagnostic accuracy was also recorded in the detection of stellate/spiculated mass (+ 20.6%; P < 0.05). This indicated that the performance of radiologists in detecting malignant lesions on mammograms can be improved if an appropriate training intervention is applied after the readers' weakness and strength are identified.

Perceptions of Adequacy of Breast Imaging Training in the United States among Breast Radiologists

OBJECTIVE

To evaluate the perceptions of breast imaging training in the United States among practicing breast radiologists.

METHODS

An anonymous electronic survey was sent to physician members of the Society of Breast Imaging. Study participants were queried about why they practice breast imaging, what percentage of their clinical practice consists of breast imaging, details about their breast imaging training, and how well their training prepared them for their breast imaging practice. Results were stratified by whether respondents completed a breast imaging fellowship and length of time practicing breast imaging. Results were compared using the Chi-squared test or Fisher's exact test.

RESULTS

We received 271 completed survey responses. Of the survey respondents, 52.4% (141/269) were employed in private practice, 24.2% (65/269) in academic practice, and 23.4% (63/269) in a mixed/hybrid practice. Overall, 46.6% (125/268) of respondents reported practicing a greater proportion of breast imaging than anticipated during training and 18.7% (50/268) had not anticipated that their future practice would include breast imaging at all. The 62.3% (167/268) of survey respondents who had completed a breast or women's imaging fellowship were significantly more likely to report sufficient training in screening mammography, diagnostic mammography, breast procedures, and MRI interpretation.

CONCLUSION

Our study highlights perceived areas of insufficiency in breast imaging training. These were most notable among those who did not complete a breast imaging fellowship. These insufficiencies may be considered when updating the next version of the residency training curriculum.

Perfecting detection through education

Introduction

Radiologists’ image reading skills vary, such variations in image interpretations can influence the effectiveness of the early treatment of disease and may have important clinical and economic implications. In screening mammography, clinical audits are used to assess radiologists’ performance annually, however, the nature of these audits prevent robust data analysis due to the low prevalence of breast cancer and the long waiting periods for the audit results. Research-based evidence revealed a need for changes in the methods utilised to optimise the assessment of the efficacy of radiologists’ interpretations.

Methods

A cloud-based platform was developed to assess and enhance radiologists’ performance help reduce variability in medical image interpretations in a research environment; however, to address a number of limitations, the platform was commercialised to make it available worldwide.

Results

DetectED-X’s team have been able to make their cloud-based platform available worldwide, tailored to the needs of radiologists and accredited for continuing medical/professional education; thus, changing the continuous professional development practice globally.

Conclusion

DetectED-X’s Rivelato, was developed to address a need for effective, available and affordable educational solutions for clinicians and health care workers wherever they are located. A true fusion of industry, academia, clinics and consumer to adapt to the growing needs of clinicians’ around the world, the latest being COVID-19 global pandemic. DetectED-X repurposed its platform to educate physicians around the world on the appearances of COVID-19 on Lung Computed Tomography scans, introducing CovED to clinicians worldwide free of charge as a multi-national consortium of collaboration to help fight COVID-19, showing how research-based evidence can create effective and scalable change globally.

Telemammography: Technical Advances Improve Patient Access in Breast Care

Screening mammography's efficacy in reducing breast cancer deaths depends on patient compliance with screening recommendations and the radiologist's interpretative skills. Reasons for suboptimal screening compliance may be multifactorial, including possible limitations in access. Additionally, while studies show experienced breast radiologists are more accurate in their mammographic interpretation, only a minority of the nation's mammograms are interpreted by breast imaging specialists. To simultaneously optimize the benefit of early breast cancer detection while minimizing the harms associated with a false positive interpretation, delivery models that help improve access to breast expertise should be considered. Telemammography is one such delivery model that may be underutilized in current practice. While radiologists and other stakeholders of healthcare have accepted teleradiology interpretation of non-mammography studies as routine, telemammography use and acceptance is less well known. In this article, we review the operational components of a telemammography practice in today's information- and technology-dependent society. Current use of telemammography and remaining potential challenges are discussed. Telemammography can improve healthcare delivery and access by bringing together patients and breast expertise. If accepted, use of telemammography can help meet Centers for Disease Control's Healthy People 2020 goals related to breast cancer.

The roles of clinical audit and test sets in promoting the quality of breast screening: a scoping review

Breast screening programmes enhance the probability of early breast cancer detection in many countries worldwide; however, the success of these efforts is highly dependent on the ability of breast screen readers to detect abnormalities in the screened population, which has low prevalence. Therefore, this task can be challenging. Clinical audit is a key quality assurance measure that aims to keep the screen reading performance within acceptable standards. Auditing, nonetheless, is a lengthy process, and its accuracy is dependent on available clinical data, which often can be limited. Mammographic standardised test sets are a different screen reading evaluation approach that provides participants with instant feedback based on a simulated environment. Although a test set provides unique evaluative qualities, its ability to represent clinical performance is debated. This article describes the distinctive roles of clinical audit and test sets in measuring and improving the quality of breast screening and highlights the relationship between test sets and clinical performance.

Improvement of Cancer Detection on Mammograms via BREAST Test Sets

BACKGROUND

Breast Screen Reader Assessment Strategy (BREAST) is an innovative training and research program for radiologists in Australia and New Zealand. The aim of this study is to evaluate the efficacy of BREAST test sets in improving readers' performance in detecting cancers on mammograms.

MATERIALS AND METHODS

Between 2011 and 2018, 50 radiologists (40 fellows, 10 registrars) completed three BREAST test sets and 17 radiologists completed four test sets. Each test set contained 20 biopsy-proven cancer and 40 normal cases. Immediate image-based feedback was available to readers after they completed each test set which allowed the comparison of their selections with the truth. Case specificity, case sensitivity, lesion sensitivity, the Receiver Operating Characteristic (ROC) Area Under the Curve (AUC) and Jackknife Free-Response Receiver Operating Characteristic (JAFROC) Figure of Merit (FOM) were calculated for each reader. Kruskal-Wallis test was utilized to compare scores of the radiologist and registrars across all test-sets whilst Wilcoxon signed rank test was to compare the scores between pairs of test sets.

RESULTS

Significant improvements in lesion sensitivity ranging from 21% to 31% were found in radiologists completing later test sets compared to first test set (p ≤ 0.01). Eighty three percent of radiologists achieved higher performance in lesion sensitivity after they completed the first read. Registrars had significantly better scores in the third test set compared to the first set with mean increases of 79% in lesion sensitivity (p = 0.005) and 37% in JAFROC (p = 0.02). Sixty percent and 100% of registrars increased their scores in lesion sensitivity in the second and third reads compared to the first read while the percentage of registrars with higher scores in JAFROC was 80%.

CONCLUSION

Introduction of BREAST into national training programs appears to have an important impact in promoting diagnostic efficacy amongst radiologists and radiology registrars undergoing mammographic readings.

Digital Breast Tomosynthesis: Radiologist Learning Curve

Background There is growing evidence that digital breast tomosynthesis (DBT) results in lower recall rates and higher cancer detection rates when compared with digital mammography. However, whether DBT interpretative performance changes with experience (learning curve effect) is unknown. Purpose To evaluate screening DBT performance by cumulative DBT volume within 2 years after adoption relative to digital mammography (DM) performance 1 year before DBT adoption. Materials and Methods This prospective study included 106 126 DBT and 221 248 DM examinations in 271 362 women (mean age, 57.5 years) from 2010 to 2017 that were interpreted by 104 radiologists from 53 facilities in the Breast Cancer Surveillance Consortium. Conditional logistic regression was used to estimate within-radiologist effects of increasing cumulative DBT volume on recall and cancer detection rates relative to DM and was adjusted for examination-level characteristics. Changes were also evaluated by subspecialty and breast density. Results Before DBT adoption, DM recall rate was 10.4% (95% confidence interval [CI]: 9.5%, 11.4%) and cancer detection rate was 4.0 per 1000 screenings (95% CI: 3.6 per 1000 screenings, 4.5 per 1000 screenings); after DBT adoption, DBT recall rate was lower (9.4%; 95% CI: 8.2%, 10.6%; P = .02) and cancer detection rate was similar (4.6 per 1000 screenings; 95% CI: 4.0 per 1000 screenings, 5.2 per 1000 screenings; P = .12). Relative to DM, DBT recall rate decreased for a cumulative DBT volume of fewer than 400 studies (odds ratio [OR] = 0.83; 95% CI: 0.78, 0.89) and remained lower as volume increased (400-799 studies, OR = 0.8 [95% CI: 0.75, 0.85]; 800-1199 studies, OR = 0.81 [95% CI: 0.76, 0.87]; 1200-1599 studies, OR = 0.78 [95% CI: 0.73, 0.84]; 1600-2000 studies, OR = 0.81 [95% CI: 0.75, 0.88]; P < .001). Improvements were sustained for breast imaging subspecialists (OR range, 0.67-0.85; P < .02) and readers who were not breast imaging specialists (OR range, 0.80-0.85; P < .001). Recall rates decreased more in women with nondense breasts (OR range, 0.68-0.76; P < .001) than in those with dense breasts (OR range, 0.86-0.90; P ≤ .05; P interaction < .001). Cancer detection rates for DM and DBT were similar, regardless of DBT volume (P ≥ .10). Conclusion Early performance improvements after digital breast tomosynthesis (DBT) adoption were sustained regardless of DBT volume, radiologist subspecialty, or breast density. © RSNA, 2019 See also the editorial by Hooley in this issue.

Correlation Between Screening Mammography Interpretive Performance on a Test Set and Performance in Clinical Practice

RATIONALE AND OBJECTIVES

Evidence is inconsistent about whether radiologists' interpretive performance on a screening mammography test set reflects their performance in clinical practice. This study aimed to estimate the correlation between test set and clinical performance and determine if the correlation is influenced by cancer prevalence or lesion difficulty in the test set.

MATERIALS AND METHODS

This institutional review board-approved study randomized 83 radiologists from six Breast Cancer Surveillance Consortium registries to assess one of four test sets of 109 screening mammograms each; 48 radiologists completed a fifth test set of 110 mammograms 2 years later. Test sets differed in number of cancer cases and difficulty of lesion detection. Test set sensitivity and specificity were estimated using woman-level and breast-level recall with cancer status and expert opinion as gold standards. Clinical performance was estimated using women-level recall with cancer status as the gold standard. Spearman rank correlations between test set and clinical performance with 95% confidence intervals (CI) were estimated.

RESULTS

For test sets with fewer cancers (N = 15) that were more difficult to detect, correlations were weak to moderate for sensitivity (woman level = 0.46, 95% CI = 0.16, 0.69; breast level = 0.35, 95% CI = 0.03, 0.61) and weak for specificity (0.24, 95% CI = 0.01, 0.45) relative to expert recall. Correlations for test sets with more cancers (N = 30) were close to 0 and not statistically significant.

CONCLUSIONS

Correlations between screening performance on a test set and performance in clinical practice are not strong. Test set performance more accurately reflects performance in clinical practice if cancer prevalence is low and lesions are challenging to detect.

Breast Density Legislation in New England: A Survey Study of Practicing Radiologists

RATIONALE AND OBJECTIVES

This study aimed to assess radiologists' knowledge about breast density legislation as well as perceived practice changes resulting from the enactment of breast density legislation.

MATERIALS AND METHODS

This is an institutional review board-exempt anonymous email survey of 523 members of the New England Roentgen Ray Society. In addition to radiologist demographics, survey questions addressed radiologist knowledge of breast density legislation, knowledge of breast density as a risk factor for breast cancer, recommendations for supplemental screening, and perceived practice changes resulting from density notification legislation.

RESULTS

Of the 523 members, 96 responded, yielding an 18% response rate. Seventy-three percent of respondents practiced in a state with breast density legislation. Sixty-nine percent felt that breast density notification increased patient anxiety about breast cancer, but also increased patient (74%) and provider (66%) understanding of the effect of breast density on mammographic sensitivity. Radiologist knowledge of the relative risk of breast cancer when comparing breasts of different density was variable.

CONCLUSIONS

Considerable confusion and controversy regarding breast density persists, even among practicing radiologists.

Educational interventions to improve screening mammography interpretation: a randomized controlled trial

OBJECTIVE

The objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation.

MATERIALS AND METHODS

We randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance.

RESULTS

One hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015).

CONCLUSION

In this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

Web-based mammography audit feedback

OBJECTIVE

Interpreting screening mammography accurately is challenging and requires ongoing education to maintain and improve interpretative skills. Recognizing this, many countries with organized breast screening programs have developed audit and feedback systems using national performance data to help radiologists assess and improve their skills. We developed and tested an interactive Website to provide screening and diagnostic mammography audit feedback with comparisons to national and regional benchmarks.

MATERIALS AND METHODS

Radiologists who participate in three Breast Cancer Surveillance Consortium registries in the United States were invited during 2009 and 2010 to use a Website that provides tabular and graphical displays of mammography audit reports with comparisons to national and regional performance measures. We collected data about the use and perceptions of the Website.

RESULTS

Thirty-five of 111 invited radiologists used the Website from one to five times in a year. The most popular measure was sensitivity for both screening and diagnostic mammography, whereas a table with all measures was the most visited page. Of the 13 radiologists who completed the postuse survey, all found the Website easy to use and navigate, 11 found the benchmarks useful, and nine reported that they intended to improve a specific outcome measure that year.

CONCLUSION

An interactive Website to provide customized mammography audit feedback reports to radiologists has the potential to be a powerful tool in improving interpretive performance. The conceptual framework of customized audit feedback reports can also be generalized to other imaging tests.

The future of mammography: radiology residents' experiences, attitudes, and opinions

OBJECTIVE

The objective of our study was to assess the experiences and preferences of radiology residents with respect to breast imaging.

MATERIALS AND METHODS

We surveyed radiology residents at 26 programs in New York and New Jersey. Survey topics included plans for subspecialty training, beliefs, and attitudes toward breast imaging and breast cancer screening and the likelihood of interpreting mammography in the future.

RESULTS

Three hundred forty-four residents completed the survey (response rate, 62%). The length of time spent training in breast imaging varied from no dedicated time (37%) to 1-8 weeks (40%) to more than 9 weeks (23%). Most respondents (97%) agreed that mammography is important to women's health. More than 85% of residents believed that mammography should be interpreted by breast imaging specialists. Respondents shared negative views about mammography, agreeing with statements that the field was associated with a high risk of malpractice (99%), stress (94%), and low reimbursement (68%). Respondents endorsed several positive attributes of mammography, including job availability (97%), flexible work schedules (94%), and few calls or emergencies (93%). Most radiology residents (93%) said that they were likely to pursue subspecialty training, and 7% expressed interest in breast imaging fellowships.

CONCLUSION

Radiology residents' negative and positive views about mammography seem to be independent of time spent training in mammography and of future plans to pursue fellowship training in breast imaging. Systematic assessment of the plans and preferences of radiology residents can facilitate the development of strategies to attract trainees to careers in breast imaging.

Identifying minimally acceptable interpretive performance criteria for screening mammography

PURPOSE

To develop criteria to identify thresholds for minimally acceptable physician performance in interpreting screening mammography studies and to profile the impact that implementing these criteria may have on the practice of radiology in the United States.

MATERIALS AND METHODS

In an institutional review board-approved, HIPAA-compliant study, an Angoff approach was used in two phases to set criteria for identifying minimally acceptable interpretive performance at screening mammography as measured by sensitivity, specificity, recall rate, positive predictive value (PPV) of recall (PPV(1)) and of biopsy recommendation (PPV(2)), and cancer detection rate. Performance measures were considered separately. In phase I, a group of 10 expert radiologists considered a hypothetical pool of 100 interpreting physicians and conveyed their cut points of minimally acceptable performance. The experts were informed that a physician's performance falling outside the cut points would result in a recommendation to consider additional training. During each round of scoring, all expert radiologists' cut points were summarized into a mean, median, mode, and range; these were presented back to the group. In phase II, normative data on performance were shown to illustrate the potential impact cut points would have on radiology practice. Rescoring was done until consensus among experts was achieved. Simulation methods were used to estimate the potential impact of performance that improved to acceptable levels if effective additional training was provided.

RESULTS

Final cut points to identify low performance were as follows: sensitivity less than 75%, specificity less than 88% or greater than 95%, recall rate less than 5% or greater than 12%, PPV(1) less than 3% or greater than 8%, PPV(2) less than 20% or greater than 40%, and cancer detection rate less than 2.5 per 1000 interpretations. The selected cut points for performance measures would likely result in 18%-28% of interpreting physicians being considered for additional training on the basis of sensitivity and cancer detection rate, while the cut points for specificity, recall, and PPV(1) and PPV(2) would likely affect 34%-49% of practicing interpreters. If underperforming physicians moved into the acceptable range, detection of an additional 14 cancers per 100000 women screened and a reduction in the number of false-positive examinations by 880 per 100000 women screened would be expected.

CONCLUSION

This study identified minimally acceptable performance levels for interpreters of screening mammography studies. Interpreting physicians whose performance falls outside the identified cut points should be reviewed in the context of their specific practice settings and be considered for additional training.

Individualized computer-aided education in mammography based on user modeling: concept and preliminary experiments

PURPOSE

The authors propose the framework for an individualized adaptive computer-aided educational system in mammography that is based on user modeling. The underlying hypothesis is that user models can be developed to capture the individual error making patterns of radiologists-in-training. In this pilot study, the authors test the above hypothesis for the task of breast cancer diagnosis in mammograms.

METHODS

The concept of a user model was formalized as the function that relates image features to the likelihood/extent of the diagnostic error made by a radiologist-in-training and therefore to the level of difficulty that a case will pose to the radiologist-in-training (or "user"). Then, machine learning algorithms were implemented to build such user models. Specifically, the authors explored k-nearest neighbor, artificial neural networks, and multiple regression for the task of building the model using observer data collected from ten Radiology residents at Duke University Medical Center for the problem of breast mass diagnosis in mammograms. For each resident, a user-specific model was constructed that predicts the user's expected level of difficulty for each presented case based on two BI-RADS image features. In the experiments, leave-one-out data handling scheme was applied to assign each case to a low-predicted-difficulty or a high-predicted-difficulty group for each resident based on each of the three user models. To evaluate whether the user model is useful in predicting difficulty, the authors performed statistical tests using the generalized estimating equations approach to determine whether the mean actual error is the same or not between the low-predicted-difficulty group and the high-predicted-difficulty group.

RESULTS

When the results for all observers were pulled together, the actual errors made by residents were statistically significantly higher for cases in the high-predicted-difficulty group than for cases in the low-predicted-difficulty group for all modeling algorithms (p < or = 0.002 for all methods). This indicates that the user models were able to accurately predict difficulty level of the analyzed cases. Furthermore, the authors determined that among the two BI-RADS features that were used in this study, mass margin was the most useful in predicting individual user errors.

CONCLUSIONS

The pilot study shows promise for developing individual user models that can accurately predict the level of difficulty that each case will pose to the radiologist-in-training. These models could allow for constructing adaptive computer-aided educational systems in mammography.

When radiologists perform best: the learning curve in screening mammogram interpretation

PURPOSE

To examine changes in screening mammogram interpretation as radiologists with and radiologists without fellowship training in breast imaging gain clinical experience.

MATERIALS AND METHODS

In an institutional review board-approved HIPAA-compliant study, the performance of 231 radiologists who interpreted screen-film screening mammograms from 1996 to 2005 at 280 facilities that contribute data to the Breast Cancer Surveillance Consortium was examined. Radiologists' demographic data and clinical experience levels were collected by means of a mailed survey. Mammograms were grouped on the basis of how many years the interpreting radiologist had been practicing mammography, and the influence of increasing experience on performance was examined separately for radiologists with and those without fellowship training in breast imaging, taking into account case-mix and radiologist-level differences.

RESULTS

A total of 1 599 610 mammograms were interpreted during the study period. Performance for radiologists without fellowship training improved most during their 1st 3 years of clinical practice, when the odds of a false-positive reading dropped 11%-15% per year (P < .015) with no associated decrease in sensitivity (P > .89). The number of women recalled per breast cancer detected decreased from 33 for radiologists in their 1st year of practice to 24 for radiologists with 3 years of experience to 19 for radiologists with 20 years of experience. Radiologists with fellowship training in breast imaging experienced no learning curve and reached desirable goals during their 1st year of practice.

CONCLUSION

Radiologists' interpretations of screening mammograms improve during their first few years of practice and continue to improve throughout much of their careers. Additional residency training and targeted continuing medical education may help reduce the number of work-ups of benign lesions while maintaining high cancer detection rates.

Best ways to provide feedback to radiologists on mammography performance

OBJECTIVE

The Mammography Quality Standards Act of 1992 required a minimum performance audit of radiologists performing mammography. Since then, no studies have evaluated radiologists' perceptions of their audit reports, such as which performance measures are the most or least useful, or what the best formats are to present performance data.

MATERIALS AND METHODS

We conducted a qualitative study with focus groups and interviews of 25 radiologists currently practicing mammography. All radiologists practiced at one of three sites in the Breast Cancer Surveillance Consortium (BCSC). The discussion guide included open-ended questions to elicit opinions on the following subjects: the most useful performance outcome measures, examples of reports and formats that are easiest to understand (e.g., graphs or tables), thoughts about comparisons between individual-level and aggregate data, and ideas about additional performance measures they would find useful. All discussions were tape-recorded and transcribed. We developed a set of themes and used ethnographic software to qualitatively analyze and extract quotes from transcripts.

RESULTS

Radiologists thought that almost all performance measures were useful. They particularly liked seeing individual data presented in graphic form with a national benchmark or guideline for each performance measure clearly marked on the graph. They appreciated comparisons between their individual data and their peers' data (within their facility or state) and requested comparisons with national data (such as the BCSC). Many thought customizable, Web-based reports would be useful.

CONCLUSION

Radiologists think that most audit statistics are useful; however, presenting performance data graphically with clear benchmarks may make them easier to understand.

Analysis of malpractice claims in mammography: a complex issue

PURPOSE

The aim of this study was to analyse malpractice claims in mammography, estimate the specific risk of future claims and assess their impact on radiologists and society.

MATERIALS AND METHODS

The study considered insurance claims filed by radiologists of the Italian Society of Medical Radiology (SIRM) over a 12.5-year period between 1 January 1993 and 30 June 2005. We isolated claims related to presumed diagnostic errors in mammography. We then estimated the number of claims arising from events in the study period that are expected to be filed over the next few years, before the expiration of the prescriptive period of 10 years.

RESULTS

The total number of claims was 1,088. Of these, 302 were caused by alleged diagnostic errors in cases of cancer; 189 (62%) concerned breast cancers and mammographic technique. Assuming a constant frequency of claims filed by radiologists, we expect a further 637 claims relating to the study period, for a total of 1,725 claims, with 178 claims being related to breast imaging. The predicted rate therefore increases to 10.5 per thousand, equal to a risk of one litigation per radiologist per 10 years of work.

CONCLUSIONS

The analysis uncovered a complex problem: although radiologists save many lives through the radiographic diagnosis of breast cancer and consequently contribute to the welfare of society, in practice, they can face real or alleged errors, with serious judicial consequences. Awareness of professional risk in current society may represent a valuable reference for choosing and planning to work in radiology.

Radiologists' performance and their enjoyment of interpreting screening mammograms

OBJECTIVE

One might speculate that radiologists who enjoy mammography may exhibit better performance than radiologists who do not.

MATERIALS AND METHODS

One hundred thirty-one radiologists at three Breast Cancer Surveillance Consortium (BCSC) registries completed a survey about their characteristics, clinical practices, and attitudes related to screening mammography. Survey results were linked with BCSC performance data for 662,084 screening and 33,977 diagnostic mammograms. Using logistic regression, we modeled the odds of an abnormal interpretation, cancer detection, sensitivity, and specificity among radiologists who reported they enjoy interpreting screening mammograms compared with those who do not.

RESULTS

Overall, 44.3% of radiologists reported not enjoying interpreting screening mammograms. Radiologists who reported enjoying interpreting screening mammograms were more likely to be women, spend at least 20% of their time in breast imaging, have a primary academic affiliation, read more than 2,000 mammograms per year, and be salaried. Enjoyment was not associated with screening mammography performance. Among diagnostic mammograms, there was a significant increase in sensitivity among radiologists who reported enjoyment (85.2%) compared with those who did not (78.2%). In models adjusting for radiologist characteristics, similar trends were found; however, no statistically significant associations remained.

CONCLUSION

Almost one half of radiologists actively interpreting mammograms do not enjoy that part of their job. Once we adjusted for radiologist and patient characteristics, we found that reported enjoyment was not related to performance in our study, although suggestive trends were noted.

Predictors of radiologists' perceived risk of malpractice lawsuits in breast imaging

OBJECTIVE

The shortage of radiologists in breast imaging may be related to heightened malpractice lawsuit concerns. Our objective was to examine radiologists' reported experiences and perceptions of future lawsuit risk and explore personal and professional factors that may be associated with elevated perceptions of risk.

MATERIALS AND METHODS

Radiologists who routinely interpret mammography examinations in diverse regions of the United States (Washington, Colorado, and New Hampshire) completed a mailed survey in 2002 and 2006, including questions on demographics, practice characteristics, and medicolegal experience and perceptions as well as a validated scale measuring reactions to uncertainty in clinical situations. A survey assessing the radiologists' work facilities was also completed in 2002.

RESULTS

Participation by eligible radiologists was 77% (139 of 181) in 2002 and 71% (84 of 118) in 2006. The percentage of radiologists reporting malpractice claims related to mammography in the previous 5 years was 8% on the 2002 survey and 10% on the 2006 survey. Radiologists' mean estimate of the probability of being sued for malpractice in the next 5 years (41% in 2002 and 35% in 2006) was markedly higher than the actual reported risk. Radiologists' age, sex, clinical experience, and workload were not associated with a higher perceived risk of being sued. Radiologists who reported higher perceived risk of lawsuits were more likely to have experienced a prior malpractice claim, to report knowing colleagues with prior lawsuits, and to score higher on a scale measuring anxiety caused by uncertainty in clinical situations. Radiologists working at facilities that did not use double reading reported higher perceived risk, but the difference was not statistically significant.

CONCLUSION

Radiologists working in breast imaging substantially overestimate their risk of a future malpractice lawsuit. Radiologists with higher risk perceptions show more negative reactions to uncertainty in a clinical setting. Understanding that their actual risk of malpractice lawsuits may be substantially lower than anticipated may help reduce radiologists' fears and alleviate the manpower shortage in mammography. Programs to address the shortage of breast imagers could be targeted toward radiologists with heightened malpractice lawsuit concerns.

Breast imaging fellowships in the United States: who, what, and where?

OBJECTIVE

The purpose of this study was to determine the characteristics of fellowship programs offering breast imaging training and their success in filling positions.

CONCLUSION

A comprehensive list of fellowship training opportunities in breast imaging may help potential applicants identify relevant programs.

Radiologists' clinical practice of neuroimaging

PURPOSE

Because of the importance of neuroimaging as a radiology subspecialty, the aim of this study was to provide a detailed portrait of the demographics, clinical activities, and practices of radiologists heavily involved in neuroimaging.

METHODS

The authors analyzed data from the ACR's 2003 Survey of Radiologists, a large, stratified random-sample survey in which respondents were guaranteed confidentiality. The survey achieved a 63% response rate, and responses were weighted to make them representative of all radiologists in the United States.

RESULTS

Three-fourths of US radiologists reported doing neuroradiology; 9% reported that neuroradiology was their main subspecialty, and 9% reported spending more than 50% of their clinical work time doing neuroradiology. Of these latter two categories, more than about 75% had certificates of added qualification (CAQs) in neuroradiology, and more than 80% had done neuroradiology fellowships. However, of those spending more than 50% of their clinical work time doing neuroradiology, 7% neither had CAQs nor had done fellowships in the field. One-fourth of radiologists with CAQs or who had done neuroradiology fellowships spent less than 30% of their clinical work time doing neuroradiology. One-third to one-half of neuroimaging was performed by radiologists not heavily involved in the field. Only 6% to 8% of radiologists heavily involved in the field were women, compared with 22% in other subspecialties.

CONCLUSIONS

Neuroimaging has the great strength of being a relatively well-integrated subspecialty in that a very large majority of those heavily involved in its practice have CAQs and did fellowships in the field. Among possible concerns are the relatively few women in the field and the apparent waste of expertise resulting from one-fourth of those with neuroradiology subspecialty training or certification being relatively little immersed in its practice.

Communication in the diagnostic mammography suite: implications for practice and training

RATIONALE AND OBJECTIVES

The diagnostic mammography suite is a microcosm of challenging physician-patient communication in radiology. Little has been written about communication practices in the diagnostic mammography suite, the effect of this communication on both physicians and patients, and implications for radiology training programs. We surveyed radiology residents and staff about communication training, practices, and experiences communicating directly with patients in the diagnostic mammography suite.

MATERIALS AND METHODS

We asked the membership of the Association of Program Directors in Radiology to disseminate surveys to radiology residents and staff radiologists in their institutions. We analyzed response frequencies and correlations.

RESULTS

We received responses from 142 residents and 120 staff radiologists. More than half of staff respondents spoke personally with every patient who had an abnormal diagnostic mammogram; 37% felt they had inadequate time to do so. Most residents and staff highly rated their own communication skills and confidence in ability to explain results and respond to patients' emotions, but experienced stress doing so. A majority of respondents reported no formal communication skills education after medical school. Twenty-nine percent of staff respondents regularly observed residents' communication with patients and 39% of residents reported receiving feedback about their communication. Residents' opportunities to observe staff communicate with a patient and to receive feedback on their own patient interactions were correlated with self-rated communication skill and confidence in ability to respond to patients' emotions (P < .05).

CONCLUSIONS

Radiologists engage in challenging and stressful patient communication interactions. There is a paucity of educational curricula on interpersonal and communication skills in radiology. This has implications for both patient and physician satisfaction and patient outcomes.

Physician workload in mammography

OBJECTIVE

United States Food and Drug Administration (FDA) guidelines for certification require that radiologists interpret > or = 960 mammography examinations within each 2-year period (approximately 480 annually). The purpose of our study was to estimate per-physician annual volumes of mammography interpretation.

SUBJECTS AND METHODS

Our study includes 4.2 million mammography examinations performed at 196 facilities between 1998 and 2004. We calculated the annual interpretive volumes per physician, the proportion of mammography examinations interpreted by radiologists in specified volume categories, and the impact on mammography capacity if annual interpretive volume requirements increased.

RESULTS

The mean annual mammographic interpretive volume was 1,777. Approximately 31% of radiologists interpreted < 1,000 mammography examinations annually, yet these low-volume radiologists interpreted only 10% of all mammograms. The 10% of radiologists who interpreted > or = 3,000 mammography examinations annually interpreted 32% of all examinations. Rural radiologists interpreted fewer examinations annually compared with urban radiologists. If the minimum annual volume requirement were increased to 1,000 mammograms per year, only 10% of the overall U.S. mammography capacity would be affected. If the requirement were increased to 2,000 mammograms annually, 47% of capacity would be eliminated, and a major rearrangement of workload would be required because most radiologists would no longer interpret enough examinations to meet the revised standards.

CONCLUSION

Doubling physician annual volume requirements would result in a small impact on overall mammography capacity. Increasing volume requirements to 2,000 mammography examinations annually would require a dramatic increase in the number of mammography examinations interpreted by the higher volume radiologists. Unless previously low-volume radiologists increased their volumes, raising requirements to 2,000 examinations could curtail access to mammography, particularly in rural areas.

Radiologist characteristics associated with interpretive performance of diagnostic mammography

BACKGROUND

Extensive variability has been noted in the interpretive performance of screening mammography; however, less is known about variability in diagnostic mammography performance.

METHODS

We examined the performance of 123 radiologists who interpreted 35895 diagnostic mammography examinations that were obtained to evaluate a breast problem from January 1, 1996, through December 31, 2003, at 72 facilities that contribute data to the Breast Cancer Surveillance Consortium. We modeled the influence of radiologist characteristics on the sensitivity and false-positive rate of diagnostic mammography, adjusting for patient characteristics by use of a Bayesian hierarchical logistic regression model.

RESULTS

The median sensitivity was 79% (range = 27%-100%) and the median false-positive rate was 4.3% (range = 0%-16%). Radiologists in academic medical centers, compared with other radiologists, had higher sensitivity (88%, 95% confidence interval [CI] = 77% to 94%, versus 76%, 95% CI = 72% to 79%; odds ratio [OR] = 5.41, 95% Bayesian posterior credible interval [BPCI] = 1.55 to 21.51) with a smaller increase in their false-positive rates (7.8%, 95% CI = 4.8% to 12.7%, versus 4.2%, 95% CI = 3.8% to 4.7%; OR = 1.73, 95% BPCI = 1.05 to 2.67) and a borderline statistically significant improvement in accuracy (OR = 3.01, 95% BPCI = 0.97 to 12.15). Radiologists spending 20% or more of their time on breast imaging had statistically significantly higher sensitivity than those spending less time on breast imaging (80%, 95% CI = 76% to 83%, versus 70%, 95% CI = 64% to 75%; OR = 1.60, 95% BPCI = 1.05 to 2.44) with non-statistically significant increased false-positive rates (4.6%, 95% CI = 4.0% to 5.3%, versus 3.9%, 95% CI = 3.3% to 4.6%; OR = 1.17, 95% BPCI = 0.92 to 1.51). More recent training in mammography and more experience performing breast biopsy examinations were associated with a decreased threshold for recalling patients, resulting in similar statistically significant increases in both sensitivity and false-positive rates.

CONCLUSIONS

We found considerable variation in the interpretive performance of diagnostic mammography across radiologists that was not explained by the characteristics of the patients whose mammograms were interpreted. This variability is concerning and likely affects many women with and without breast cancer.