Author: Logan Young

  • Epilepsy and Dementia—A New Utility

    Epilepsy and Dementia—A New Utility

    Published January 21, 2022

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    Allison M. Grayev

    Associate Professor of Radiology, Neuroradiology Section Director, Spine Imaging
    Associate Residency Program Director
    University of Wisconsin School of Medicine and Public Health

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      Chadwick L. Wright

      Assistant Professor, Department of Radiology
      Division of Molecular Imaging and Nuclear Medicine
      Wright Center of Innovation in Biomedical Imaging
      The Ohio State University Wexner Medical Center

        Although these two populations—epilepsy patients and dementia patients—may seem very different at first glance, they share a number of important characteristics. Their clinical presentation is often myriad and varied, and early diagnosis leads to better long-term outcomes and more efficient health care utilization. Radiology is often critical for the proper diagnosis and management of these patients. To best utilize imaging resources and interpret studies, we will explore anatomic and functional considerations in these disease processes during our Sunday Featured Session, “Multimodality Approach to Epilepsy and Dementia,” at the 2022 ARRS Annual Meeting in New Orleans, LA.

        In 2020, the estimated health care costs for Alzheimer treatment alone was estimated at $305 billion, not including other causes of dementia. It is even more difficult to quantify the monetary cost of epilepsy treatment, much less the cost of quality of life issues. Often times a combined approach with multiple imaging modalities is needed to accurately diagnosis these conditions—but where do we start, and how do we integrate the information?

        Higher-resolution anatomic imaging, including diffusion tensor imaging, holds promise in both conditions, but it often serves as an entry point into the diagnostic algorithm. Artificial intelligence has gained traction in automatic segmentation of brain parenchyma, theoretically allowing a more precise localization of volume loss, which can be seen in selective areas in both conditions. This may allow stratification of patients in a community setting, before potential referral to a tertiary center for further evaluation.

        Having a working understanding of available molecular imaging agents is also critical for optimizing patient evaluation. Although fluorine-18 fluorodeoxyglucose (18FDG) is in common use for oncologic PET, there is applicability in neurodegenerative imaging, potentially allowing the identification of relatively hypometabolic areas prior to the development of anatomic changes. Additional neurodegenerative PET imaging agents target amyloid and tau protein deposition. Brain perfusion nuclear medicine imaging, as well as 18FDG-PET, can also be helpful in the assessment and localization of epileptogenic foci.

        https://arrs.org/ARRSLIVE/Education/OnlineCourses/OC_MAED22.aspx

        The goal of our “Multimodality Approach to Epilepsy and Dementia” session is to explore a different utility of anatomic and molecular imaging in the evaluation of patients with these challenging neurological disorders, allowing radiologists to better understand potential imaging algorithms and advanced diagnostic tests.

      • Thriving in a Multigenerational Workforce

        Thriving in a Multigenerational Workforce

        Published January 5, 2022

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        Jonathan Kruskal

        2021-22 ARRS President

          Unlike any prior time period in our history, the contemporary workplace will soon encompass five different generations, distinguished variously, but typically defined and labeled by year of birth. Here, I’m referring to Baby Boomers (1946–1964), Generation X (1965–1980), Generation Y or Millennials (1981–1995), Generation Z (1996–2010), and the forthcoming Generation Alpha (2011–2025). Largely driven by the advertising world, hoping to better target their marketing campaigns, efforts have been made to easily distinguish these groups based on social influences, generational values, behaviors, and preferences.  

          I suspect that these labels may have complicated matters even further. For example, the COVID-19 pandemic-induced shift to the virtual workplace may well have exacerbated intergenerational tensions in areas where groups are supposed to differ. Think social interactions, communication preferences, work-life integration and wellness strategies, perceptions of technology usage, and willingness to change. These differences must surely have led to breakdowns in communications, team function, and clinical performance, among many others.

          On one hand, these age-based delineations can be a helpful reference point, particularly when leading multigenerational teams. There are some proposed defining factors, such as cultural movements, historical milestones, technological advancements, learning preferences, and lifestyle traits for each period that can be interesting to delve into and see whether they resonate with yourself and your teams. These features can be lively conversation starters and help you glean insight into how best to manage morale and burnout, as well as create more inquiry, respect, and open-mindedness among such a diverse population. However, surely additional factors beyond age should be equally impactful; consider background experience and training, levels of maturity, tenure within an organization, and lineage in a role.

          Is it possible that the COVID pandemic has influenced societal perceptions of generations, and might the pandemic influence the formation of generational identities for those still in formative years?

          It seems to me that this is a very opportune time to work to address and dispel age-associated or generational stereotypes.

          Dispel the Myths

          That said, it’s so important that we inquire, appropriately and respectfully, about the stories of others to expand upon—and maybe even rebut—marketing matrices.

          Upon reflection, I don’t think that people neatly fit into their age-based silo. As I look across the multigenerational tables as a Baby Boomer by age, I certainly have “silo creep” and span several different buckets. You might think World War II, for example, was a defining life event for me, but that wouldn’t be true. Rather, I grew up as a relatively privileged individual during the segregated South African apartheid era, which left an indelible impact on my values, philosophies, and priorities.

          I know I’m not alone here. When speaking with a millennial colleague, it became clear that these categories are not cut and dried:

          “I think some of these characteristics are pretty broad generalizations. I am part of the millennial category, but it has never quite resonated with me. Millennials are often painted in an unfavorable light, such as when it comes to work ethic, world views, and materialism, just as Baby Boomers can be criticized for not being tech-savvy, and seniors can be stereotyped as dependent and frail.”

          “My father, a Baby Boomer, studied computer science as an undergraduate, before it became an official degree program at Boston University. My grandfather, a member of the Silent Generation, ran his final Boston Marathon in 4 hours and 30 minutes at age 72 and continued to participate in road races into his 80s. To me, labels can be tough because they don’t allow for nuance and individuality; they don’t tell the whole story.”

          It’s easy to jump on the bandwagon and affirm negative generalizations, but this can be damaging when it comes to building an inclusive team. We must ensure these categories, simply based on a number, don’t serve as a detrimental springboard for misunderstandings about behaviors and preferences.

          Seek Data and Understanding

          It’s our responsibility as leaders to build diverse teams and foster respectful environments for every member of our workplace and beyond. We can strive to enact change at the national level, such as by communicating the importance of accommodating different learning styles for different generations at major conferences and advocating for educational material that best suits the learner (e.g., didactic talks vs. handouts vs. podcasts, etc.).

          Locally, we can commit to better understanding our colleagues on a one-on-one basis. If one generation prefers frequent, regular, unvarnished feedback, provide that. If possible, be willing to adapt traditional annual reviews to meet worker preferences. Support departmental social media initiatives but be respectful of those who might not wish to expand their digital presence at this time. You’ll find that some cohorts might thrive on multitasking, while others prefer to focus on tasks linearly. Take all of these factors into consideration. 

          Ask, listen, collect data, and repeat. Run a short quarterly communication survey asking how employees prefer to receive information within the department, or whether digital Grand Rounds lectures are meeting their academic needs. Sometimes, simply listening and giving people a choice can make all the difference when it comes to feeling a true sense of appreciation and belonging at work.

          Not fully understanding the complexities of our multigenerational workforce has been described as a contributor to workplace stress and burnout. Challenges managing, building, and leading multigenerational teams have been recognized, yet solutions have not. We must first hear from our colleagues directly. For example, you might ask a more seasoned colleague what it was like when they first started out in radiology. How have things changed over time? In their perspective, has it generally been for the better, or have there been obstacles along the way? How has patient care evolved? Older generations might consider asking younger generations about what their highly digital academic training experiences are like today. When an opportunity presents itself, respectfully inquire and listen to build connections and understanding.

          Celebrate Our Diversity of Ages 

          One good aspect of the multigenerational descriptors is that they remind us of the remarkable diversity of values, preferences, and skills that we are so fortunate to have in our workforce. Understanding, embracing, welcoming, including, and being respectfully inquisitive about these differences will serve us far better. Acknowledging that differences exist and committing to learning about them is a lifelong journey.

          Starting today, instead of trying to transform one generation to adjust to another, let’s:

          • celebrate the diversity of ages in our workforce
          • embrace all skills, expertise, and experiences
          • focus on intentional inclusion activities
          • shift the focus away from this single cultural descriptor (age) and build teams that are as diverse as possible
          • avoid alienating labels and siloes and stereotypes

          Never before have four different generations worked together in Beth Israel Deaconess Medical Center radiology, bringing different values, preferences, communication styles, strategies for work-life integration, and wellness approaches into the milieu. The list of differences is extensive and complex. What a terrific and timely opportunity to embrace! A field such as imaging is so dependent on the structure and function of high-performing teams. Therefore, it behooves us to better understand the different generations and explore how best to take advantage of these opportunities.

          I would love to hear about how you are tackling this intricate topic at your own institutions. If this subject resonates with you and/or you are inclined to share, please feel free to email me directly: jkruskal@bidmc.harvard.edu.

        • Letters to a Young Radiologist

          Letters to a Young Radiologist

          Paul M. Bunch

          Assistant Professor of Radiology
          Wake Forest School of Medicine

          Erik H. Middlebrooks

          Professor of Radiology
          Program Director, Neuroradiology
          Mayo Clinic College of Medicine and Science

          The transition from trainee to independent radiologist represents a pivotal time full of opportunities and challenges. In our experience, navigating this transition is often simultaneously exciting and intimidating. Although many of the associated opportunities and challenges are common to both private and academic practice, others may be unique to one’s specific practice environment.

          For example, after training, it is important that all radiologists be able to perform high-quality clinical work autonomously and efficiently. Additionally, building trust and earning the respect of referring physicians is advantageous for all radiologists desiring to become a “go-to” imager for challenging cases and difficult clinical problems. However, newly minted academic radiologists are often also interested in developing educational content and research programs, whereas new private practice radiologists may choose to focus on honing their business acumen.  

          In our experience, most residents and fellows receive outstanding clinical radiology education; however, their non-clinical professional education is commonly more variable. As such, many trainees and junior attending radiologists stand to benefit from educational programming dedicated to the development of important non-clinical professional skills and from the opportunity to interact with and ask questions of knowledgeable experts that may not otherwise be easily accessible. Fortunately, radiology is replete with experts who are more than willing to share their knowledge and experience to help others, particularly for the benefit of young professionals.

          For these reasons, we presented “Early Career Advice: What I Wish I Knew Earlier” as a Sunday Featured Session at the ARRS Annual Meeting.

          This course featured a diverse group of highly successful radiologists representing perspectives from the private and academic practice settings. These radiologists shared practical knowledge and lived experience related to professional challenges frequently encountered by young radiologists that are less frequently covered by traditional residency and fellowship didactic curricula. The selected topics are particularly relevant for young professional radiologists (e.g., residents, fellows, junior academic faculty, and junior private practice associates) preparing for or currently navigating the transition from trainee to independent radiologist, regardless of private or academic practice setting. Faculty emphasized practical pearls they wish they had learned earlier.

          More specifically, didactic presentations covered:

          1. the benefits of active participation in radiology societies, like ARRS, for early career success,
          2. critical aspects of personal and practice-related finances,
          3. the importance of and successful strategies for building advantageous professional relationships,
          4. the value of branding for individual and practice success, as well as practical tips for effectively developing and professionally promoting one’s individual and group practice brands
        • Metrology and Standards for Quantitative MRI

          Metrology and Standards for Quantitative MRI

          Published January 21, 2022

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          Stephen E. Russek

          Project Leader, Imaging Physics; Applied Physics Division
          Codirector, MRI Biomarker Measurement Service
          National Institute of Standards and Technology, US Department of Commerce

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            Karl F. Stupic

            Director, MRI Biomarker Measurement Service
            National Institute of Standards and Technology, US Department of Commerce

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              Kathryn E. Keenan

              Project Leader, Quantitative MRI; Applied Physics Division
              National Institute of Standards and Technology, US Department of Commerce

                Medical imaging is rapidly advancing and includes many modalities: ultrasound (US), MRI, radiography, CT, PET, SPECT, and optical coherence tomography. New modalities, such as digital breast tomography and low-field MRI, are being integrated into the clinical workflow. Multimodal imaging, such as PET/CT and PET/MRI, and combined imaging therapy, such as MR linear accelerator, are rapidly expanding. Additionally, the amount of data extracted by radiologists by eye, via complex analysis tools, and using AI-based systems is dramatically increasing. Radiologists require that data are accurate and reproducible. To ensure this, calibrations and standards are needed. Phantoms—imaging calibration structures—are used to ensure scanner accuracy, stability, and comparability. Phantoms need to be readily available, easy to use, and have accurate and traceable components. In addition, imaging and analysis protocols must be rigorously validated, and the fundamental measurands, image-based biomarkers, must be carefully and precisely defined.

                Many organizations have programs to assist in making image-based data more precise and reliable, including the Radiological Society of North America Quantitive Image Biomarker Alliance, National Cancer Institute Quantitative Imaging Network, American College of Radiology (ACR), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Equipment Manufacturers Association, American Association of Physicists in Medicine, International Society for Magnetic Resonance in Medicine (ISMRM), National Physical Laboratory (United Kingdom), Physikalisch-Technische Bundesanstalt (Germany), and the National Institute of Standards and Technology (NIST). NIST, the US national metrology institute, has been assisting clinical, research, and medical device organizations in the development and dissemination of medical standards for over 100 years. An early example from around 1905 (Fig. 1) depicts calibration equipment and commercial medical mercury thermometers.

                Fig. 1—Medical mercury thermometers and NIST calibration apparatus, circa 1905. (Courtesy of NIST)

                In the early 1900s, getting a universally accepted temperature scale was a critical issue. The need for medical metrology and standards has grown since then, and it is a critical part of our health care infrastructure. Below, we look at some recent NIST activities in standards for quantitative MRI.

                Scanner Performance

                Understanding and monitoring scanner performance is essential. Critical parameters include geometric distortion, resolution, signal-to-noise ratio, and image uniformity. An example of MRI geometric distortion and image uniformity measurements are shown in Figure 2; the measurements were made using an MRI system phantom developed by NIST and ISMRM. The geometric distortion is due to nonuniform gradients, and it is important to understand both the intrinsic distortion and the efficacy of the distortion corrections, often applied after imaging. A 3D gradient-echo scan can give the accuracy of the gradient calibrations, accuracy of distance and local volume measurements, and presence and efficacy of post-scan corrections.

                Fig. 2—Photo and images of MRI system phantom. (A) shows image uniformity map take on 3T scanner using head coil thorough 200 mm spherical volume. (B), (C), (D), and (E) show geometric situation—difference between apparent position of each fiducial sphere and real position (modified from Magn Reson Med with permission from ISMRM).

                Figure 3 shows an image of an ACR-type resolution inset, along with a synthetic image: an ideal image for the pulse sequence used. Then, the synthetic image can be modified, by including blurring, to match the observed image. Protocol dependent resolution, scanner resolution, and other nonidealities can be quantified.

                Fig. 3—(A) MRI of ACR-type resolution inset, (B) synthetic image (ideal image, given pulse sequence), (C) synthetic image modified to include finite scanner resolution to make synthetic image match observed image, (D) minimization of difference between image and synthetic image (modified from Magn Reson Med with permission from ISMRM).

                Intersite Comparisons

                Intersite comparisons are critical to determine how accurately image-based biomarkers can be measured. Proton spin relaxation times, T1 and T2, are useful biomarkers to distinguish tissue types and healthy from unhealthy tissue. A recent multisite study comparing MRI T1 measurements shows considerable variation using common protocols, including an inversion recovery protocol, which, albeit too time-consuming for clinical use, is considered a gold standard. Figure 4 shows the deviation in measured T1 from NIST reference measurements, which have a well-defined uncertainty. The uncertainty defines an interval about the measured value within which there is a 97% probability that the real value will lie. One can see that there is considerably more uncertainty in the scanner measurements, and there is a vendor-dependent bias. Being able to define uncertainty intervals in image-based biomarker measurements, with traceability to the international system of units, is an important challenge for our community.

                Fig. 4—Results from T1 multisite study showing deviation of measured T1 times using an inversion-recovery protocol from NIST reference values for different scanner vendors. Gray box shows uncertainty interval for reference values (modified from PLoS ONE with permission from Public Library of Science).

                Validating Complex Biomarkers

                There are many complex MRI-based biomarkers, including proton spin relaxation times, proton density, fat fraction, water diffusion coefficient, diffusion kurtosis, anisotropic diffusion parameters, tissue elasticity, local concentration of metabolites and neurotransmitters, blood flow, and perfusion parameters. Diffusion-based biomarkers are a good example of the challenges encountered getting precise and useful in vivo measurements. There is a hierarchy of parameters that can be measured with increasingly complex models. The more complex models (e.g., diffusion spectral imaging [DSI]) can provide more information about underlying tissue, but validation, standardization, and implementation are more difficult. Simple models, such as extracting the apparent diffusion coefficient (ADC), can be very informative and useful, but limitations of the model must be addressed in the accuracy and uncertainty analysis. The phantom below (Fig. 5) contains both isotropic and anisotropic and diffusion elements to test the accuracy of many different types of diffusion-based measurements, including ADC and DSI parameters.

                Fig. 5—Comprehensive phantom with anisotropic and isotropic diffusion components developed for Department of Veterans Affairs to monitor MRI system parameters relevant to brain health. (Courtesy of NIST)

                Phantom Lending Library

                To assist clinical sites, research centers, scanner manufacturers, and phantom venders, NIST and NIBIB have established a medical phantom lending library containing calibrated traceable phantoms available for short-term loan. MRI system phantoms, diffusion phantoms, breast, and cardiac phantoms are available for loan with associated calibration documents, databases, and analysis software. Incorporation of phantoms into the lending library allows clinical and research sites easy access to phantoms, new imaging and measurement protocols to be validated on a common set of calibration structures, and phantoms to be curated with long-term stability established. Convenient access to standard calibration structures should facilitate the development and validation of improved measurement protocols and establish a framework to provide uncertainty intervals on image-based measurements.

                Medical imaging scanners are sophisticated and powerful tools that can be extended to metrology systems, capable of making precise in vivo measurements of many different structural and functional tissue parameters. The work by the many institutions listed here is making this transition possible. Medical imaging metrology and standards are important components of this transition and the US medical/health care infrastructure. They often run in the background, but neither should be overlooked.

              • ARRS Partners With Pelvic Floor Disorders Consortium on MRI Defecography Guidelines

                ARRS Partners With Pelvic Floor Disorders Consortium on MRI Defecography Guidelines

                Published on December 21, 2021

                The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of radiologists, colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, physiotherapists, and other advanced care practitioners—formed to bridge gaps and enable collaboration between these specialties. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but given the differences in their respective training, they approach, evaluate, and treat such patients with their own unique perspectives.

                In a multisociety-endorsed article in the October edition of AJR (published concurrently with Diseases of the Colon & Rectum, International Urogynecological Journal, and Female Pelvic Medicine and Reconstructive Surgery Journal), the 24 members of the PFDC Working Group on MRI reached consensus regarding many clinically relevant considerations for performing, interpreting, and reporting MR defecography (MRD). Based upon the PFDC Working Group’s consensus guidelines, corresponding synoptic interpretation templates were suggested for this unique patient population.

                Contrast Medium Considerations

                On the basis of the literature and their collective expertise, the PFDC Working Group advised that MRD should be performed with rectal distention, using rectal contrast medium, and with image acquisition during defecation. Rectal distention and defecation are both crucial components of MRD that distinguish the examination from simple dynamic pelvic floor MRI performed with the Valsalva maneuver. Moreover, compared with Valsalva images, prior AJR research has shown larger, more recurrent prolapse on MRD examinations with rectal distention and on defecation images. [4] (Fig. 1).

                Fig. 1—59-year-old woman with history of rectal bulge and sensation of incomplete defecation. B = bladder, R = rectum, V = vagina. A–C, Sagittal steady-state images at rest (A), Valsalva (B), and defecation (C) show bladder, vaginal apex (asterisk), and anorectal junction (dashed arrow) at or above pubococcygeal line (PCL) (line) at rest (A). During Valsalva (B), bladder extends below PCL and there is small cystocele (solid arrow), vaginal apex is lower than at rest (asterisk) but remains above PCL, and there is descent of anorectal junction (dashed arrow). During defecation (C), there is significantly larger descent of bladder below PCL and enlargement of cystocele (solid straight arrow), vaginal apex now prolapses below PCL (asterisk), and there is significant descent of anorectal junction below PCL (dashed arrow). There are also anterior (left curved arrow) and posterior (right curved arrow) rectoceles.

                Technique and Reporting/Grading of Relevant Pathology

                Apropos of so many differing clinical backgrounds, the PFDC Working Group debated which of two grading scales to utilize for internal rectal intussusception: descriptive reporting or the Oxford Grading Scale [5]. After much deliberation, the panel agreed that a uniform description of rectal intussusception as intrarectal, intraanal, or complete external (extraanal) would provide adequate clinical details to be deemed the minimum reporting standard.

                Ultimately, these consensus definitions and interpretation templates can be augmented with additional radiologic maneuvers and report elements—specific patient indications, health care provider preferences, local practice patterns, etc.—”but the suggested verbiage and steps should be advocated as the minimum requirements when performing and interpreting MRD in patients with evacuation disorders of the pelvic floor,” the 15 coauthors of this AJR article concluded.

              • Cardiac Events in Athletes

                Cardiac Events in Athletes

                Published December 21, 2021

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                Lewis D. Hahn

                Department of Radiology, Division of Cardiothoracic Imaging
                University of California San Diego

                  In the US, approximately 100–150 athletes each year die from sudden cardiac death (SCD) during competitive events. Though moderate exercise has been shown to be cardioprotective, vigorous exertion during sports can lead to abrupt hemodynamic changes, triggering ventricular tachycardia or fibrillation in the setting of an underlying cardiac abnormality. As a result, SCD is approximately twice as likely in athletes, compared with the general population. In most cases, the underlying cause can be diagnosed by imaging. Radiologists play a pivotal role in helping clear potential athletes before they begin playing sports and in the workup of athletes after a sudden cardiac arrest.

                  Causes of Cardiac Events and Patient Demographics

                  The most common causes of SCD in the US are hypertrophic cardiomyopathy (HCM) and anomalous coronary arteries. According to the US National Registry of Sudden Death in Athletes, from 1980 to 2011, HCM constituted 36% of SCD cases and anomalous coronary arteries constituted 19%. A variety of less common causes are responsible for the remainder of cardiac events and include arrhythmogenic cardiomyopathy (AC), noncompaction cardiomyopathy, myocarditis, valvular disease, and coronary artery disease. Additional causes that can be diagnosed without imaging findings include channelopathies, Wolff- Parkinson-White syndrome, and commotio cordis. Similar statistics have been found in series examining sudden cardiac arrest, in addition to SCD. The frequency of cause differs by age. For instance, coronary artery anomalies are more common in middle school athletes. In patients over 35 years old, coronary artery disease is the most common cause.

                  The vast majority of SCDs occur in male athletes. The reasons for this are not entirely clear, but it has been hypothesized that greater intensity of physical training, more frequent participation in contact sports, such as football and boxing, and undocumented protective metabolic mechanisms in female athletes may contribute [4]. More than half of patients with SCD are football and basketball players. African-American athletes are at higher risk for cardiovascular death than patients of other ethnicities, potentially related to a greater rate of participation in sports and a higher incidence of cardiomyopathy.

                  Imaging Two Common Causes of Sudden Cardiac Death

                  Hypertrophic Cardiomyopathy

                  HCM is the most common cause of death in athletes younger than 35 years old. The underlying cause is usually an inherited abnormality of the sarcomeres. Though HCM can be diagnosed on echocardiography, it is definitively evaluated on cardiac MRI (CMR), allowing complete anatomic and tissue characterization. CMR is also more sensitive for detection of apical aneurysm and thrombus, compared with echocardiography. The main diagnostic criterion for HCM is an end-diastolic wall thickness greater than or equal to 15 mm without left ventricular dilation or evidence of systemic disease to explain the degree of hypertrophy. The location of thickening can vary among patients, most often involving the septum (asymmetric septal hypertrophy) (Fig. 1A). Other types of hypertrophy include concentric (Fig. 1B), midcavity, apical (also known as spade-like) (Fig. 1C), and mass-like.

                  Fig. 1—Patients with hypertrophic cardiomyopathy. A–C, SSFP images show asymmetric basal septal hypertrophy (A), concentric hypertrophy (B), and apical variant (C) with small apical aneurysm (arrow, C) in three different patients. D, SSFP left ventricular three-chamber view in another patient shows left ventricular outflow tract obstruction secondary to systolic anterior motion of mitral valve (gray arrow) and marked hypertrophy of anteroseptum (white arrow). Dephasing jet resulting from flow acceleration is also seen. E, Late gadolinium-enhanced MR image in another patient shows extensive myocardial delayed enhancement in nonvascular distribution (arrows).

                  Left ventricular outflow obstruction in HCM can result in syncope, exercise limitation, or chest pain. MRI typically shows a thickened basal anteroseptum with a dephasing jet secondary to flow acceleration. The mitral valve is pulled into the left ventricular outflow tract as a result of flow acceleration, resulting in further obstruction (Fig. 1D). This systolic anterior motion of the mitral valve is best visualized on the three-chamber view of the left ventricle. Commonly, an associated mitral regurgitation is directed posteriorly because of incomplete coaptation of the mitral valve leaflets. Both 2D phase-contrast and 4D flow imaging techniques have been applied to assess the pressure gradient caused by obstruction, but this is generally better assessed with echocardiography because of improved temporal resolution for observing peak velocity. The criterion for obstruction is a gradient greater than or equal to 30 mm Hg.

                  Radiologists also have a role in identifying predictors of SCD. Implantable cardioverter-defibrillator (ICD) placement is dictated on the basis of individual risk. Myocardial thickening greater than 30 mm measured at end diastole constitutes massive hypertrophy, and its presence raises consideration for ICD placement. An apical aneurysm (Fig. 1C) also raises the risk for thromboembolism and SCD. LGE is typically hazy and observed in a midmyocardial distribution (Fig. 1E). The presence of LGE greater than or equal to 15% of the myocardial mass doubles the risk of a cardiac event, though current guidelines from the American College of Cardiology Foundation and American Heart Association (AHA) have yet to incorporate LGE. The presence of myocardial delayed enhancement also helps distinguish HCM from athlete’s heart.

                  Many patients with HCM have abnormal papillary muscles, which may be important to identify for presurgical planning. The identification of a hypertrophied anterolateral papillary muscle inserting directly into the anterior mitral leaflet can lead to greater obstruction. A long anterior mitral leaflet may necessitate mitral valve repair and has been defined as an anterior leaflet length greater than 30 mm. Additional abnormalities include accessory anterolateral papillary muscles and accessory left ventricular muscle bundles that can contribute to outflow obstruction. In such cases, the surgeon will need to adjust the surgical approach, including reduction of the papillary muscles.

                  Anomalous Coronary Arteries

                  Anomalous coronary arteries are the second-most common cause of SCD. Normally, the left main coronary artery arises from the left coronary sinus of the aortic root, and the right coronary artery arises from the right coronary sinus. Coronary anomalies consist of deviations of this usual anatomy.

                  Anomalous coronary arteries are often initially evaluated by echocardiography, followed by coronary CTA for patients with persistent concern for an anomalous coronary artery. In some patients, MRI is performed—such sequences can be performed without contrast material but can be difficult to perform in young patients without anesthesia. In addition, smaller vessels are more difficult to analyze because of lower spatial resolution.

                  When assessing the coronary arteries, a radiologist should evaluate the origin and course of the left main coronary artery, right coronary artery, left anterior descending artery, and left circumflex artery. Most coronary anomalies are asymptomatic. Examples include a retroaortic course of the left circumflex artery, separate origins of the left anterior descending and left circumflex arteries from the aortic root, and a prepulmonic course of the left anterior descending artery.

                  The most frequent types of potentially hemodynamic significant coronary artery anomalies are those with an interarterial course. An anomalous origin of the right coronary artery with an interarterial course between the aorta and the main pulmonary artery is the most common in young athletes; if symptomatic, repair is indicated. In the absence of symptoms, institutional policy may vary, but patients generally undergo a stress test to evaluate for inducible ischemia. An anomalous left coronary artery from the right coronary sinus (Fig. 2) has a higher risk of ischemia, and patients with this anomaly are recommended to undergo surgical repair regardless of symptoms. For any interarterial course, a slit-like origin suggests an intramural course with greater risk of SCD.

                  Fig. 2—Anomalous left anterior descending coronary artery in 25-year-old army recruit experiencing chest pain at boot camp. A and B, Axial CT image (A) and 3D reformation (B) show interarterial course of left main coronary artery (arrow). Slit-like origin suggests intramural course. C and D, Late gadolinium-enhanced left ventricular three-chamber (C) and four-chamber (D) MR images show subendocardial delayed enhancement (arrows) of mid to apical septum and basal to mid lateral wall, compatible with left main coronary artery distribution infarction.

                  An important distinction from an interarterial course of the left main coronary artery is a transseptal course in which the anomalous coronary arteries pass through the septum, rather than between the aorta and main pulmonary artery. Unlike an interarterial course, a transseptal course is thought to be benign and rarely requires surgical correction, though an exercise stress test is still required.

                  An additional benign differential consideration is a highrising coronary artery, which arises 1 cm or more above the level of the sinotubular junction in the ascending aorta. The origin may be slightly rotated clockwise with respect to the right coronary sinus, but this is a benign entity without hemodynamic consequence.

                  Finally, anomalous left or right coronary arteries arising from the pulmonary arteries generally require surgical treatment in athletes. Because of the lower pressure of the pulmonary arteries, blood flow is actually reversed—this represents a steal phenomenon in which coronary artery blood flow shunts to the pulmonary arteries via collateral vessels.

                  The author thanks Seth Kligerman for review of this article and assistance with figures.

                • Pass or Fail? How a USMLE Update Could Change Radiology Residency

                  Pass or Fail? How a USMLE Update Could Change Radiology Residency

                  Rebecca V. Zhang

                  Incoming Radiology Resident (July 2022)
                  Hospital of the University of Pennsylvania
                  Philadelphia, Pennsylvania

                  By the time you read this, results from the United States Medical Licensing Examination (USMLE) Step 1 exam will have changed from a numeric score to pass or fail. As students, medical schools, and residency programs anticipate this upcoming change, many are left wondering if and how this update will affect applicant selection for radiology residencies. Our study used an anonymous and voluntary 14-question online survey to assess program directors’ views on the scoring change of Step 1 from numeric to pass or fail, while assessing if other metrics, such as Step 2 Clinical Knowledge (CK) scores, may become more important during application review. Eighty-eight of 308 (29%) members of the Association of Program Directors in Radiology (APDR) completed the survey.

                  Our study found that more than two-thirds of survey respondents indicated their programs currently use a Step 1 screen before sending interview invitations. Specific to radiology, previous studies have demonstrated a correlation between Step 1 performance and both the number of interpretive errors made as a radiology resident and future success on the American Board of Radiology Core Exam. Our study also found that more than 90% of survey respondents anticipate their programs may or definitively will require Step 2 CK scores before application review, once Step 1 becomes pass or fail; in contrast, many radiology programs presently do not require Step 2 CK scores before reviewing applications. In addition, our study found that regardless of the current use of a Step 1 screen, survey respondents did not significantly differ in their anticipation of requiring Step 2 CK scores (p=0.71) or extending later interviews to accommodate Step 2 CK scores (p=0.64). This finding may reflect hesitancy from programs to place significant weight on Step 2 CK before more research is done. There may be increased utility of using Step 2 CK scores over Step 1 scores as a marker of clinical knowledge, as the material covered in Step 2 CK has greater clinical relevance than that of Step 1. Through faculty, peer, and patient-level evaluations, previous studies from internal medicine have shown that Step 2 CK scores correlate better to clinical performance both during and after residency than Step 1 scores. It could be informative to examine whether this correlation exists with Step 2 CK scores and performance in radiology residency, as more residency applicants may include Step 2 CK scores with their initial application in upcoming years.

                  Although making Step 1 pass or fail may help mitigate the significant distress surrounding the examination, there are valid concerns that the stress surrounding Step 1 will simply be transferred to Step 2 CK, when Step 2 CK becomes the only remaining standardized metric among applications. In an ideal world, all applications would receive a thorough and holistic review with consideration of both qualitative and quantitative characteristics. However, many selection committees do not have enough resources to do so, given the growing number of applications each program receives for the same number of residency spots. Some specialties have implemented preference signaling and supplemental applications to highlight an applicant’s top programs of interest and specific program characteristics (location, patient population, research, etc.) a particular applicant is seeking. Some studies have suggested more drastic measures, such as application caps, to reduce the usage of standardized test scores as a filter during application review and allow for more holistic application reviews. While changing Step 1 to pass or fail does not resolve all the challenges associated with the residency selection process, it does pave the way for additional meaningful changes to the system in the future.

                • Acute Ischemic Stroke: Treatment and Imaging Updates

                  Acute Ischemic Stroke: Treatment and Imaging Updates

                  Published January 4, 2022

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                  Jeremy J. Heit

                  Assistant Professor Departments of Radiology and Neurosurgery
                  Center for Academic Medicine Stanford University

                    Acute ischemic stroke (AIS) results from occlusion of a cervical or cerebral artery, and it is the leading cause of disability in the US. The most severe forms of AIS result from thrombo- or thromboembolic occlusion of the internal carotid artery or proximal (M1 segment) of the middle cerebral artery, and these occlusions are termed large vessel occlusions (LVOs). LVOs are amenable to thrombectomy, which is a minimally invasive endovascular surgery that removes the thrombus from the affected artery (Fig. 1).

                    Fig. 1—59-year-old male with atrial fibrillation developed sudden onset of left facial droop, left hemiplegia, dysarthria, and right-sided gaze preference (National Institutes of Health Stroke Scale score: 16). Emergent brain imaging was performed that demonstrated hypodensity in right lentiform nucleus (A, arrow) on non-contrast head CT, large vessel occlusion of M1 segment of right middle cerebral artery on CTA (B, arrow), small ischemic core on CT perfusion imaging (C, pink region indicated by arrow), and salvageable penumbra on CT perfusion imaging (D, dashed outline). Patient was transferred to neuroendovascular suite, and digital subtraction cerebral angiogram confirmed right M1 occlusion (E, arrow). Thrombectomy was performed, which resulted in complete revascularization of right middle cerebral artery (F, arrow). After remarkable recovery, patient had no residual symptoms three months posttreatment.

                    Thrombectomy treatment of AIS due to LVO has exploded, following the publication of multiple randomized trials that demonstrated superior outcomes with thrombectomy treatment in patients presenting in both early (0–6 hours from last known well) and late (6–24 hours from last known well) time windows. These studies not only found thrombectomy to be superior to medical treatment, but they also fundamentally changed the evaluation and treatment triage of AIS-LVO patients.

                    Previously, the best medical therapy for AIS was intravenous thrombolysis with tissue plasminogen activator (tPA), but tPA treatment was limited to patients who present within 3–4.5 hours from symptom onset. The time-sensitive nature of tPA treatment was a significant barrier, and it limited the number of patients eligible for treatment. The success of the thrombectomy trials has shattered the stopwatch that governs tPA treatment in LVO patients, and we have now entered an era in which imaging guides stroke treatment, rather than the time from symptom onset.

                    The imaging evaluation of AIS patients has moved beyond the non-contrast head CT (NCCT) that has guided intravenous thrombolysis treatment decisions since 1995. Thrombectomy has the greatest impact when it is performed in a patient with minimal ischemic brain injury and an LVO, and these patients are identified at a minimum with an NCCT and a CT angiogram (CTA). Most of the index randomized thrombectomy trials also used CT perfusion (CTP) to characterize brain tissue that was likely permanently injured (the ischemic core) and the presence of underperfused, but salvageable, brain tissue (the penumbra). Due to the success of these trials, there has been a marked increase in CTP utilization for the evaluation of AIS patients with LVO. The increased use of CTA and CTP is making a meaningful impact on stroke treatment, but this usage has the potential to significantly strain radiology practice resources, given that AIS LVO patients should be screened for thrombectomy candidacy up to 24 hours after they were last known to be well.

                    The need for timely evaluation of AIS patients and the increased utilization of CTA and CTP is being aided by the integration of automated image processing and artificial intelligence (AI) techniques that identify thrombectomy treatment candidates. The emergence and implementation of these disruptive software platforms has integrated into clinical practice at a pace seldom seen in medicine, demonstrating the potential value of AI to the practice of radiology.

                    The success of thrombectomy and the increased use of CTA and advanced brain imaging, such as CTP, requires that radiologists are well aware of AIS patient evaluation and treatment workflows. Apropos, A RRS is offering an exciting and timely Sunday Featured Session with leading stroke experts during the 2022 Annual Meeting in New Orleans, LA. Join us for “Code Stroke: What Every Radiologist Should Know Early.”

                  • Finding Our Proverbial Sunrooms

                    Finding Our Proverbial Sunrooms

                    Published on December 21, 2021

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                    Jonathan Kruskal

                    2021–2022 ARRS President

                      Feeling stuck, joyless, or “meh?” You, like many others, might be languishing. In fact, it might be the dominant emotion of 2021.

                      Sociologist Corey Keyes describes mental health as a continuum: ranging from flourishing, that state of wellbeing we all seek to achieve, to languishing, the absence of wellbeing, and a lower state of mental health. Languishing is distinct from depression, yet individuals who are languishing are at a higher risk of future mental illness (such as depression and anxiety disorders), as shown by Keyes et al..

                      Simply put, languishing is a series of emotions, rather than a mental illness. Adam Grant, writing in the New York Times, refers to languishing as “the neglected middle child of mental health” and “the void between depression and flourishing.” Given the negative impacts on productivity, morale, innovation, team building, retention, and engagement, nonprofit organizations and corporations alike must take this widespread state seriously.

                      The pandemic has impacted almost every structural framework of our lives, such as socializing, working, vacationing, traveling, and exercising—and, in turn, compromised our sources of joy. With no clear path as to when and how our “future state” will present itself, we continue to exist in an ongoing and indefinite interim state. As uncertainties persist and routines remain in flux, many people are being shuffled into a state of languishing.

                      You Might Be Languishing if You Are:

                      • overwhelmed or emotionally numb
                      • distracted and unfocused
                      • depleted, empty, and/or disinterested
                      • unmotivated or procrastinating
                      • not functioning at your full capacity
                      • unable to feel excited about upcoming events
                      • cynical about your colleagues and leaders

                      How Can We Shift From Languishing to Flourishing?

                      Below, I share a compilation of suggestions from the experiences of many. If the symptoms of languishing seem familiar to you, perhaps one or more of these strategies might help. If even one person finds solace in these ideas, it would bring me joy.

                      • Prioritize your health: Do your best to eat healthily, drink plenty of water, sleep well, and incorporate movement into your life. Schedule and keep your annual health appointments. Consider alternative medicine modalities, such as acupuncture and chiropractic medicine. Find moments to sit in silence and simply breathe. Use your personal time and plan vacations, including memorable “staycations.” Disconnect from work and social media during your time off. Set boundaries and learn how to respectfully say “no,” when needed. Take your first small step toward doing something you’ve always wanted to do for your health today.
                      • Protect your time: Manage your time intentionally and purposefully. Detach, disconnect, and learn how to engage your personal reset button. You might try scheduling uninterrupted time for yourself to recharge your batteries, even if this means “doing nothing.” Limit social media scrolling and email checking. Consider recapturing your prepandemic experiences; for example, create a virtual “commute” that includes a home spin class, podcast episodes, reading, music, or another element that helps you transition from the waking to working hours.
                      • Make positive connections: Reengage or recreate your personal and professional network. Recall who once might have lifted you up. Walk and chat, gather and eat, find and embrace, and explore commonalities with positive people. When possible, spend less time with those who drain your energy and spirits. Seek a peer support buddy with whom you can share your experiences and feelings. Look for authentic and uplifting connections to replenish yourself emotionally.
                      • Reflect on the current situation: Acknowledge the loss and anxiety and frustrations and grief. What have you lost? What have others lost? What has everybody lost? Recognize that you’re not alone here.
                      • And then, practice gratitude: Recognize what you do have, rather than focusing on what you don’t. Appreciate what is working, rather than focusing on what isn’t. Try keeping a daily gratitude journal or using a meditation app, like Calm or Headspace, for guided gratitude practices.
                      • Find flow and motivation: What’s on your music playlist, and when did you last update the content? Step out of your comfort zone by trying a new recipe, exercise, podcast, app, or online class. Get better at something, whether it’s dance, yoga, art, reading, writing, meditation, music, composting, or gardening. Explore mindful crafting, photography, collecting, and other hobbies. Reconnect with and walk barefoot in nature for additional grounding.
                      • Celebrate small successes: Rethink what constitutes success, however small. It may be someone else’s success or happiness that you contributed to. When overwhelmed, rethink your goal-setting strategy. Set simpler goals that are achievable, and enjoy the successes that you are contributing to. It’s OK to start small. Perhaps also schedule achievable self-care activities each day.
                      • Rethink your possessions: What would you like to keep or surround yourself with? These items might include things that bring you joy, inspiration, hope, confidence, or calm. Consider decluttering a room or maybe even your entire living space over a period of time. According to a recent Psychology Today article, decluttering can be very beneficial.
                      • Change your scenery: Breaking from a stagnant routine is challenging. I encourage all of us to find ways to get out of our emotional basement and head up to our proverbial sunroom. Take a stroll through your memory banks to recall what may have once ignited your passions. Learn the art of introspection—what does your perfect day look like?—and consciously do something new or different to refresh your spirits. Check out your local museum, gallery, or library with a friend. Sign up for an online class or enjoy a virtual comedy show. You never know what you may discover.
                      • Find joy in giving: When did you last wrap a small gift? Who can you help today? What causes would you like to reengage with? Have you discussed and explored different options with your friends and family? Try to get back to your talents and gifts. Learn to be a peer supporter. Research volunteer opportunities in your community. Contemplate your purpose and remember what truly drives you. Helping others can bring a tremendous sense of inner fulfillment.
                      • Activate your personal coping strategies: For some, the average workday may seem filled with one stressful encounter after another. Meetings may not go as planned. Your workflow may be interrupted. The dominant sentiment might be that this is just another tough day. Is it possible that you are being too hard on yourself and in your judgments? For example, while you may feel that a meeting, interaction, or event didn’t quite go as planned, perhaps that is from your perspective. Maybe others had a different perspective and felt more positive about the encounter. Activate your personal coping strategies to decompress, relax, boost your energy, stay focused, gain perspective, and reflect on the bigger picture.
                      • Explore therapy. It’s a strength to recognize when we need professional help. According to a recent Value Penguin survey of more than 1,300 US adults, “nearly 30% of Americans have seen a therapist during the coronavirus pandemic, and 86% say it’s helped them cope.” Psychiatrists, psychologists, social workers, therapists, and other licensed practitioners are trained to help patients construct a personal repertoire of coping strategies. There are many forms of therapy to consider, including psychodynamic, cognitive behavioral, dialectical behavioral, mindfulness-based, and art. One or more of these modalities could help you address and manage stressful life events.

                      The journey from languishing to flourishing is of indeterminate length, and some of the “travel aids” listed above may be more effective than others. What we need is a means of sharing best practices—what worked well and what didn’t—multigenerational preferences and impacts, as well as other solutions that have been identified along the path. I can only wish each of you who may be experiencing a state of languishing a very safe, healthy, memorable, and rewarding trip back!

                    • COVID-19 in Colombia: A New Trigger for Health Care Disparities

                      COVID-19 in Colombia: A New Trigger for Health Care Disparities

                      Published on October 28, 2020

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                      Paula Andrea Forero

                      Radiology Research Assistant
                      Fundación Santa Fe de Bogotá

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                        Ángela Moreno

                        Radiologist, Department of Cardiothoracic Imaging
                        Fundación Santa Fe de Bogotá

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                          Bibiana Pinzón

                          Radiologist, Department of Cardiothoracic Imaging
                          Fundación Santa Fe de Bogotá

                            In March 2020, Colombia first faced what would become the cause of a new kind of chaos in this country: the coronavirus disease (COVID-19) pandemic. Nobody knew for sure what it was about, but one certainty was that we had to be prepared for the fight. However, it wasn’t as simple as it sounded, especially in a country were the health care system teeters every day on that fine line between sustainability and collapse.

                            In an undeveloped region, Colombia experiences barriers to health constantly. Despite having a policy that, ideally, aims to guarantee access and equity, the reality reveals the opposite. In this case, the COVID-19 outbreak tipped the balance further in favor of disparity: across the country, hospital infrastructure and capacities were not sufficient. Medicines—sedatives, anesthetics agents, even oxygen—and supplies, such as ventilators, were also in short supply. In addition, the availability of personal protective equipment (PPE) varied according to the prestige of the institutions; therefore, it was not uncommon to see health care workers in rural areas exposed to the virus without any protective measures. Not to mention that social indiscipline contributed to poor epidemiological control. With the arrival of the COVID-19 vaccine, things didn’t change much. Compared to countries on continents like North America and Europe, Colombia in northern South America has a very low rate of vaccination. Only 16.5% of Colombians are vaccinated. Vaccine prioritization is determined by the government, depending upon age and the availability of boosters, which are scare at times. 

                            As our lives changed, so did our work in medicine. Undoubtedly, medical imaging and diagnostic radiologists became even more important resources in this battle. The demand for our specialty increased enormously, bringing new challenges to overcome. Radiologists had to learn a new language—the language of COVID-19—which included new imaging classifications, findings, and approaches (Fig. 1).

                            Fig. 1—80-year-old man with COVID-19. Conventional axial chest CT image (left) shows barely noticeable peripheral ground-glass opacities (within red box) in left upper lobe. Electron density image (right) obtained at same time as conventional image shows clearly visible ground-glass opacities (within red box).

                            The radiological diagnosis of a new, lethal entity was in our hands. Regarding personnel, technicians, nurses, and radiologists remain on the front lines, due to their contact with ill or potentially infected patients; and as for statistics, the number of chest radiographs and CT scans increased exponentially throughout this period. They are still our most requested studies.

                            However, these numbers have been very fluctuant. At the beginning of the pandemic, in March and April of 2020, when both quarantine and curfew were established, the number of imaging studies related to COVID-19 at our institution in Bogotá were 77 and 160, respectively. Come August, our total COVID-19-related images numbered 1,617, coinciding with the country’s epidemiological peak. This year, January, May, and June have been the months with the most imaging evaluations made (1,953, 2,823, and 3,124, respectively), surpassing what we interpreted in many months of 2020. These data show that as the virus evolved and infection control and prevention became more lax, Colombians forgot about self-care and contagion increased significantly, producing an evident strain on medical staff and the entire health care system.

                            This situation is not over yet. Although many advances have been made, there is still a lot of uncertainty—still a long way to go. Hopefully, better days are coming for Colombia and for all of us. COVID-19, beyond doubt, represents a lesson to countries around the world in reassuring the public health care system as a fundamental pillar of society.

                          • The First Victim of Errors in Heath Care: Looking Beyond Physical Harm

                            The First Victim of Errors in Heath Care: Looking Beyond Physical Harm

                            Published October 22, 2021

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                            Bettina Siewert

                            Vice Chair for Quality and Safety
                            Beth Israel Deaconess Medical Center

                            2013 ARRS Leonard Berlin Scholar in Medical Professionalism

                              In my colleague Jonathan Kruskal’s article, we learned about health care professionals as “second” victims of medical errors and how we can support them. Here, we will focus on the “first” victim, or the patient who has experienced such an error. Historically, quality efforts in health care have focused on the reduction of errors causing physical harm to patients. Only recently has the scope widened to include non-physical or emotional harm.

                              Patients are known to frequently experience emotional harm when interacting with the health care system through violations to their dignity. Emotional harm from disrespect to a patient’s dignity can, in turn, lead to a loss of trust. Patients may therefore cease to fully engage with health care providers. This interferes with future care and with our efforts to fully integrate patients as members of the health care team.

                              As informed team members who are actively involved in their care, patients are known to make critical contributions to their safety and play a vital role in team success. Like clinical staff, patients will only feel comfortable to participate, ask questions, and speak up about concerns in a psychologically safe environment based on a culture of respect and trust. The need to address emotional harm in patients is therefore twofold: to avoid non-physical harm to patients and to avoid its consequences, including a loss of trust, so that patients continue to be fully engaged in their care.

                              How Common Is Emotional Harm? 

                              Evidence in the literature raises the concern that patients may suffer emotional harm more frequently than physical harm and that its incidence is currently underreported. Underreporting may be due to clinical staffs’ lack of awareness about the concept of non-physical or emotional harm and its reportability. A study from 2004, for example, details how a group of providers aimed to develop patient-centered typologies of medical errors. During this work, providers discovered that 70% of patient-reported harmful events in the primary care setting related to emotional harm. If this estimate is correct and non-physical harm events were reported in the future, this would more than double the number of departmental quality assurance-related incident reports.

                              What Are the Causes of Emotional Harm?

                              Emotional harm is mainly caused by failing to be patient-centered, which can include disregarding patients’ expressed wishes, delaying care, and communicating ineffectively, either due to insufficient interpreter resources for non-English-speaking patients or other factors. The Joint Commission views patient-centered care as an important element of safe, quality care. Patient-centered care encourages “the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.” Patients and their care suffer when previously made decisions are not honored. A delay in care (such as postponing a non-urgent interventional radiology procedure for an emergency add-on case) is understandable to clinical staff, and to some degree, to most patients. However, repeated cancellations or rescheduled procedures will make patients feel insignificant and that they are not receiving the care they need in a timely fashion. Ineffective or infrequent communication with the patient, such as not updating them on changes in diagnostic or treatment plans, or NPO status, causes additional harm.

                              Other drivers of emotional harm include disrespectful communication/treatment, minimizing patients’ concerns, violating patients’ privacy, failing to care for personal possessions, and prejudice or discrimination. Disrespectful communication among staff is a frequent occurrence in health care. A recent survey by the Institute for Safe Medication Practices showed that disrespectful behaviors were observed by 70% of staff multiple times a year. Patients are exposed to this behavior indirectly when observing staff or can be an active participant in a disrespectful encounter.

                              What Are the Manifestations of Emotional Harm?

                              Emotional harm can be conceptualized as harm to a patient’s ‘dignity,’ which can be caused by failing to demonstrate adequate ‘respect’ for the patient as a person (dignity being defined as the intrinsic, unconditional value of an individual, and respect being defined as the actions that honor and acknowledge dignity). Patients can experience insults to their dignity as frustration, anger, belittlement, sadness, disrespect, violation, anxiety, worry, and a loss of trust in the clinician and the patient-provider relationship. The severity of emotional harm can range from mild to severe. Severe cases represent up to a quarter of total cases and may require patients to undergo therapy to deal with the trauma from the event.

                              What Is the Impact of Emotional Harm on Patients?

                              Emotional harm impacts patients on multiple levels. The effect of emotional harm on the individual patient can be serious; sometimes, it’s described as worse than physical injury. Emotional harm can lead to a loss of trust in health care providers, and patients may choose to transfer their care to another institution. Alternatively, it may lead to a loss of trust in health care in general, with the patient foregoing needed health care in the future. In a 2018 survey by the Betsy Lehman Center for Patient Safety, 66% of patients reported losing trust in the health care system after a medical error. Patients reported foregoing future care, with 34–67% avoiding the physician, facility, or health care overall, even six years after the event. This can lead to delays in diagnoses and treatments and result in adverse patient outcomes.

                              Emotional harm, whether of a patient or team member, comes at a great cost to health care teams. In staff members, disrespectful treatment has been shown to lead to a decrease in the ability to function, affecting procedural performance, as well as diagnostic abilities. Teamwork is also influenced by disrespected individuals being less willing to utilize team functions, such as information sharing and help-seeking. The latter also applies to patients being treated disrespectfully. Patients may be unwilling to share important health information with the team or voice observations that could lead to the prevention of medical errors.    

                              How Can We Prevent Emotional Harm?

                              To prevent emotional harm in health care and to harvest the full potential of patients as team members, several improvement efforts are needed. Patient and staff education about the nature and importance of emotional harm must be mandatory to encourage the reporting of these events, so that effective countermeasures can be introduced and tested for efficacy.

                              Staff communication training and individual feedback are also important countermeasures. Staff communication training needs to focus on active listening, or making the patient feel heard, by rephrasing/summarizing the patient’s statements and reflecting them to the patient to ensure an accurate understanding. Additional measures include explicitly asking for and following the patient’s stated preferences or explaining when and why this is not possible and offering alternatives. Closed-loop communication is vital to keep the patient updated on developments in their care and continuously engaged in shared decision-making, should new information become available.

                              Lastly, individual feedback to staff who were involved in an emotionally harmful event will be key and likely successful in preventing future instances. Towbin et al., in an effort to improve disrespectful communication, were able to demonstrate an increase in positive interactions from 48% to 90% after providing feedback to staff. Feedback was shared with individuals about the events they were involved with and anonymized among the group to maximize learning.

                              In conclusion, by increasing awareness of emotional harm as a frequently occurring, preventable medical error, and providing staff with communication training and individual feedback, this newly recognized concept will hopefully soon be eliminated.

                            • When Errors Occur: Recognizing and Supporting the Second Victim in Health Care

                              When Errors Occur: Recognizing and Supporting the Second Victim in Health Care

                              Published October 25, 2021

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                              Jonathan Kruskal

                              2021–2022 ARRS President

                                “My section chief called and asked me to review an oncology staging CT scan that I had read last year. It didn’t take me long to recognize that I had missed an enhancing lesion in the pancreatic head that since metastasized all over the peritoneal cavity and into the lungs. How could I have possibly missed the original mass? Did I read this case carefully? What should I do now? Should I call and talk with the referring provider? She’ll lose all confidence in my clinical skills. Should I contact the patient? What will my radiology colleagues and trainees think of me? What about my family? What about the patient’s family? Should I apologize? Do I call risk management? Will I be sued? Will the local newspapers write about this? I feel absolutely awful. What can I possibly do to help now? Is this the end of my career as a radiologist?”

                                This scenario is not uncommon—a medical provider, such as a radiologist, can make an unintended error that becomes very consequential for the patient. Chances are, that radiologist won’t have the tools to manage the situation or know who to ask for help, which can lead them down a lonely, emotional, and difficult path. Even seemingly small errors can have a butterfly effect, magnifying and negatively impacting the patient and their loved ones at a later date, as well as the provider, their institution, and their future patients.

                                While we must always focus on providing the safest, most effective care to each patient, in this issue of InPractice, I want to stand up for our many so-called “second victims” [1], who were without guidance or resources when they needed them most. As we continue our theme of building and sustaining high-performing teams, there may be times when medical professionals fall victim to the many consequences of an adverse event and experience second-victim syndrome.

                                The term “victim” is in no way intended to protect, minimize, or excuse the event; rather, it aims to highlight that, in addition to supporting the patient and their loved ones, we need to provide and activate additional resources for our own team after an adverse event. This speaks to a desirable culture of support and learning, rather than one of blame and punishment.

                                What and Who Is a Second Victim?

                                The second victim is the health care professional who commits an unintentional error or is involved in a serious adverse event and is traumatized by the event. Let’s think beyond a radiologist who accidentally left a guidewire in during a minimally invasive procedure. Consider the technologist after a patient suffers a serious adverse contrast reaction. Or the nurse when a patient becomes aggressive, or the sonographer who has detected a fetal demise. Consider the resident who participated in a study interpretation with a missed finding that becomes untreatable. An individual or team in our profession, no matter their professional level, can be susceptible to this concept.

                                What Are Some of the Manifestations of Being a Second Victim?

                                The immediate impact can parallel an acute stress disorder or a preexisting psychological condition and may require urgent care. The impact may last weeks to months, or even longer, and include symptoms of post-traumatic stress disorder. The clinical and emotional manifestations—such as feelings of inadequacy, shame, guilt, anxiety, grief, and clinical depression—can be broad, varied, and extremely serious. Additionally, an individual’s physical health, sleep, work performance, and relationships can suffer greatly during this period. For health care workers, clinical confidence may be affected, as well as self-esteem and cognitive function, thus interfering with their ability to provide safe care to other patients.

                                Why Is This Phenomenon Increasingly Recognizable?

                                It is now widely acknowledged that health care workers can be significantly impacted by adverse patient events. The rate of adverse outcomes, errors, or complications is not actually increasing, though; our willingness to report and speak up safely about errors is. This, coupled with greater regulatory oversight (such as auditing for compliance with national patient safety goals), creates a natural and rather awkward tension between the desire to collectively learn and improve from errors, and the desire to protect individuals and teams and avoid the medical, legal, and institutional consequences of an adverse event. Growing peer learning practices, along with the expansion of disclose, apology, and offer programs, are likely contributing to this tension, too.

                                How Can We Support Second Victims?

                                The focus on stress, burnout, and wellness may have contributed to the growing awareness of second victims. This is a chicken and egg phenomenon—somebody who experiences stress or burnout in the workplace is more likely to make an error. When errors occur, these contribute to stress and perhaps even to burnout. In both circumstances, recognizing that a problem exists, providing appropriate support to the individuals involved, and offering training programs [2] to deliver such support is critical.

                                To create change, we must begin at the local level and educate our leaders and peers about how to anticipate and recognize the signs and symptoms of anxiety and other psychological conditions—both within ourselves and others. When things go wrong, as they will, all practices must have a dedicated team or process in place that first takes care of the patient, then oversees peer support for additional victims, while managing risk, regulatory, and compliance components.

                                I cannot advocate strongly enough for effective peer support programs, though not all victims will access available support services for fear of consequences, or for fear of being considered weak or vulnerable. These services must be confidential and readily available. Peer support programs can address both the emotional and informational aspects:

                                • How is the patient doing?
                                • What is happening?
                                • What will happen?
                                • What might happen?

                                Peer support may expand to counseling, including providing time and space and ongoing support for healing. Chances are, your institution or practice has an employee assistance program that includes several of these resources. It’s up to us to share them and encourage our teams and colleagues to seek the support that they need [3].

                                As physicians, we must remember that we are both human and fallible. Where we can improve is by learning from our errors and near-misses and sharing these lessons widely with the participation and support of our leaders within a culture of no blame.

                                Notes

                                • There are growing calls to abandon the term “second victim.” Instead, patient advocates are asking that health care professionals and institutions break down barriers and take more responsibility by engaging with patients, families, and advocacy organizations to understand more broadly how everyone is affected by medical harm.
                                • Caring for the caregiver: the RISE program. Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine website.
                                • If you or someone you know is experiencing a psychological crisis, you are not alone. Call 911 or go to the nearest emergency room. You can also call the National Suicide Prevention Lifeline at 800-273-TALK (8255) to speak with a trained crisis counselor 24/7 or text NAMI to 741-741 to connect with a trained crisis counselor to receive crisis support via text message 24/7.