Author: Logan Young

First question: should radiologists really be performing inpatient fludeoxyglucose (FDG) PET/CT? Our recent nuclear medicine editorial in the American Journal of Roentgenology (AJR), “Inpatient FDG PET/CT: Counterpoint—A Costly Yet Subpar Evaluation That Prolongs Hospital Length of Stay,” highlights key problems with this diagnostic pathway [1], as well as why it may be preferably to defer inpatient PET examinations in most clinical scenarios.

No doubt, the volume of imaging studies is increasing nationwide. According to ARRS’ own estimates [2], U.S. radiologists perform some 80 million CTs each year—probably more. Those are just the examinations we are able to track via billing data. 

PET/CT is no exception to rising volumes. In fact, one Journal of Nuclear Medicine single-center study reported a greater than five times increase in inpatient PET/CT examinations over a 10-year period at the authors’ institution [3]. Despite the increasing utilization of inpatient PET/CT, the procedure, itself, can be limited by both questionable clinical rationale and poor study quality. Moreover, due to distinct differences in reimbursement between inpatient and outpatient PET procedures, your health care system will likely get paid less for performing inpatient studies. 

Quite often, the quality of PET/CT is limited in inpatient settings. Contributing factors to this suboptimal image quality include higher mean blood glucose levels. Patient motion remains a factor, too. As noted in Annals of Nuclear Medicine, acute processes (e.g., infection) also continue to confound our interpretations [4].

So, another question: what do all three of these FDG PET/CT studies here (Fig. 1) have in common that could be contributing to their poor image quality? 

Fig. 1—First patient could not tolerate examination. Second patient suffering from respiratory distress. Third patient receiving course of high-dose steroids, resulting in altered biodistribution of fludeoxyglucose F¹⁸.

PET/CT is often ordered on an inpatient basis for initial oncologic staging. However, if there is no plan to initiate treatment while admitted to the hospital, an inpatient PET may only result in a substandard examination, while not changing patient management.

Given that PET/CT examinations are regularly booked weeks in advance, scheduling an inpatient study is challenging, frequently requiring a cancellation in the outpatient setting. This disruption can lead to prolonged patient stays, which increase overall costs and the risk of health care-associated adverse events.

Speaking of cost, inpatient PET/CT is costly to the health care system. Private insurance may not cover an inpatient PET, since the examination is typically viewed as an outpatient study. It is also worth noting that the Centers for Medicare & Medicaid Services bundle inpatient costs—with hospitals possibly receiving reduced or even no payment for high-cost items (i.e., PET/CT).

To reiterate our points, PET/CT in the inpatient setting is a pricey, subpar test that can potentially provide misleading diagnostic information to referring clinicians and patients. With rare exceptions, radiologists should counsel referring providers to skip the inpatient PET…and order an outpatient study instead.

Not everyone agrees with us, of course. For the opposing perspective, we urge you to cross-reference the original AJR Point, “A Strategic Path to Patient-Centered Yet Cost-Effective Care,” by two diagnostic radiologists from Oregon Health & Science University in Portland: Laszlo Szidonya, MD, PhD, and Nadine Mallak, MD [5]. 

References

1. Dietsche E, Scaringi J. Inpatient FDG PET/CT: Counterpoint—A Costly Yet Subpar Evaluation That Prolongs Hospital Length of Stay. AJR 2024. Jul; 223:e2330655. doi: 10.2214/AJR.23.30655
2. Munden RF. Disruptors of the Radiology Workforce—The Next Generation. ARRS InPractice website. www.radfyi.org/2024-arrs-in-training-issue. Published August 12, 2024. Accessed August 16, 2024.
3. Crandall J, Gajwani P, Wahl R. Trends in Utilization of FDG PET/CT in an Inpatient Population. J Nucl Med 2016. May; 57(suppl 2):1771
4. Yan X, Kang J, Zhou Y, et al. Imaging Quality of F-18-FDG PET/CT in the Inpatient Versus Outpatient Setting. Ann Nucl Med 2013. Jul; 27:508-14. doi: 10.1007/s12149-013-0714-8
5. Szidonya L, Mallak N. Inpatient FDG PET/CT: Point-A Strategic Path to Patient-Centered Yet Cost-Effective Care. AJR 2024 Jul; 223:e2330585. doi: 10.2214/AJR.23.30585

The American Roentgen Ray Society (ARRS) is proud to announce that the Society of Radiologists in Ultrasound (SRU) will present “A Sound Investment: SRU Consensus Statements, 2022–2024” on Sunday, April 27, during the 2025 ARRS Annual Meeting at Marriott Marquis Marina in San Diego, CA. 

Part of a new SRU initiative, known as “SRU Presents,” this ARRS Featured Session will host the lead author of each of SRU’s four consensus statements [1–4] published over the past two-and-a-half years (Fig. 1), including routine pelvic ultrasound for endometriosis; ultrasonography of superficial soft-tissue masses; management of incidentally detected gallbladder polyps; and a lexicon for first-trimester ultrasound.

Fig. 1—Pathologically proven adenoma with high-grade dysplasia (courtesy of SRU)

Delivered as a quartet of didactic summaries, alongside practical cases from each corresponding publication (Fig. 2), “A Sound Investment: SRU Consensus Statements, 2022–2024” will detail the recent high-quality recommendations from these consensus panels, all of which included practicing radiologists and clinical experts in relevant fields. 

Fig. 2—Transverse view of lower uterus with adhesions of deep endometriosis (arrows) to both ovaries, resulting in “kissing ovaries” typical of deep endometriosis (courtesy of SRU)

The expert moderators and lecturers for this ARRS Featured Session—all SRU fellows, as well as several past presidents of the society—will reinforce the modality’s most up-to-date nomenclature and guidelines (Fig. 3). 

Fig. 3—Palpable “mass” (arrows) in right groin of patient with catheterization for cardiac ablation one month ago, corresponds to ill-defined, avascular region of increased echogenicity in subcutaneous fat, typical of fat necrosis (courtesy of SRU)

Specific “SRU Presents” lectures will focus on determining which gallbladder polyps do not require further imaging; how to describe and manage superficial soft-tissue masses; methods for augmenting routine pelvic ultrasound to detect endometriosis; and developing preferred terms and synonyms, as well as words to avoid, during first-trimester ultrasound.

All 2025 ARRS Annual Meeting registrants, in-person attendees and virtual participants, will be shown illustrative examples and have the opportunity to ask questions of the lead authors of these SRU Consensus Statements (Fig. 4), expediting their incorporation into routine dictation templates. 

Fig. 4—Example of definite early pregnancy loss (EPL) with intrauterine gestational sac with mean sac diameter of 27 mm and no visible embryo (courtesy of SRU)

AJR Finds Interreader Agreement on SRU Incidental Gallbladder Polyp Recommendations

Earlier this year in ARRS’ own American Journal of Roentgenology (AJR), 10 abdominal radiologists showed substantial agreement for gallbladder polyp risk categorizations and surgical consultation recommendations, although areas of reader variability were identified [5].

“The findings support overall reproducibility of the Society of Radiologists in Ultrasound (SRU) recommendations,” wrote Mark A. Anderson, MD, from the department of radiology at Massachusetts General Hospital in Boston. “Nonetheless, efforts should seek to further improve the consistency of polyp risk categorization by radiologists.”

Anderson et al.’s AJR accepted manuscript included 105 patients (median age, 52 years; 75 women, 27 men) with a gallbladder polyp on ultrasound—without features highly suspicious for invasive or malignant tumor—who underwent cholecystectomy (January 1, 2003–January 1, 2021). Ten abdominal radiologists independently reviewed ultrasound examinations and, using SRU recommendations, assessed one polyp per patient for risk category (extremely low, low, indeterminate) and possible recommendation for surgical consultation. Interreader agreement was evaluated between five radiologists with less than 5 years of experience and five more experienced (≥ 5 years) radiologists. Polyps were classified pathologically, either neoplastic or nonneoplastic. 

Ultimately, among 10 abdominal radiologists applying the SRU’s recommendations from 2022, interreader agreement for risk category assignments was substantial among all readers (k = 0.710), less-experienced readers (k = 0.705), and more-experienced readers (k = 0.692). Interreader agreement for surgical consultation recommendations was substantial among all readers (k = 0.795) and more-experienced readers (k = 0.740), and almost perfect among less-experienced readers (k = 0.811).

References

1. Young SW, Jha P, Chamié L, et al. Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis. Radiol 2024 Apr; 311:e232191. doi: 10.1148/radiol.232191
2. Jacobson JA, Middleton WD, Allison SJ, et al. Ultrasonography of Superficial Soft-Tissue Masses: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiol 2022 Jul; 304:18–30. doi: 10.1148/radiol.211101
3. Kamaya A, Fung C, Szpakowski JL, et al. Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations. Radiol 2022 Nov; 305:277–289. doi: 10.1148/radiol.213079
4. Doubilet PM, Benson CB, Bourne T, et al. Diagnostic Criteria for Nonviable Pregnancy Early in the First Trimester. Ultrasound Q 2014 Mar; 30:3–9. doi: 10.1097/RUQ.0000000000000060 
5. Anderson MA, Mercaldo S, Cao J, et al. Society of Radiologists in Ultrasound Consensus Conference Recommendations for Incidental Gallbladder Polyp Management: Interreader Agreement Among 10 Radiologists. AJR 2024 May; 222:e2330720. doi: 10.2214/AJR.23.30720

In radiology, the new so often begets the novel. For imaging lung cancer, specifically, as innovative therapeutic options become more readily available, updated quantitative biomarkers are required to better buttress treatment selection, patient surveillance, and pharmaceutical development. 

To be fair, Florian J. Fintelmann, MD, was already hard at work developing and validating imaging’s next generation of lung cancer biomarkers before becoming the 2019 ARRS Scholar. He just needed more time. Time to hone his understanding of critical oncological concepts in cohorts receiving mutation-specific therapies or immunotherapy. Time to investigate the relationship between CT body composition metrics, frailty, and cardiopulmonary function, while establishing reference values to support sarcopenia diagnosis. Time to define a leading role for chest CT beyond lesion detection, tumor staging, and surgical planning to patient-level prognostication.

Armed with a two-year, $90,000 grant from The Roentgen Fund®, as the assistant professor of radiology at Harvard Medical School and Massachusetts General Hospital staff radiologist explains, he got exactly what he wanted when he needed it the most.

InPractice: How has receiving The Roentgen Fund’s ARRS Scholarship informed your current research? 

Florian J. Fintelmann, MD: My work as an ARRS Scholar has allowed me to dive deep into methodological questions, taking the time required to lay a solid foundation for many of the questions my Thoracic Imaging Percutaneous Thermal Ablation Team at Massachusetts General Hospital is addressing these days. The time afforded by this scholarship has allowed me to build up a multidisciplinary team, as well as apply for additional grant funding. The initial project that formed the basis for my ARRS Scholarship, “Advancing Lung Cancer Care With Imaging Biomarkers,” has morphed into multiple other projects. In addition, the Roentgen Fund’s provisioning of resources has since allowed me to develop a wide portfolio with three successful lines of research. 

IP: And how has becoming an ARRS Scholar supported you, personally?

FJF: The Roentgen Fund’s support was instrumental in two distinct ways. Firstly, it enabled me to take classes at the Harvard School of Public Health. They have a wonderful summer course on clinical effectiveness, which allowed me to brush up on a lot of skills, learn several new ones, and connect with a very motivated community of budding researchers. Again, the other big aspect was protected time. Starting in 2019, I opted for the two-year model, meaning I had 50% of my time devoted to research during the duration of the scholarship. Of course, this ran right into the COVID-19 pandemic. So, while the world was being turned upside down, after initial trials and errors, I was able to claw back some of that protected time. Being an ARRS Scholar was a truly wonderful experience that allowed me to make significant inroads in terms of my own expertise and the team-building I do now with colleagues.

IP: Any advice for emerging researchers interested in applying for a Roentgen Fund fellowship?

FJF: My advice is simple: apply early. And if you’re not successful, apply again. In fact, I received my ARRS Scholarship on a second attempt. If you are at all interested in applying for any of the six Roentgen Fun scholarship programs, I strongly encourage you to do so because receiving one is a life-changing opportunity. It can take some practice, though. No one knows how to apply for a research or career award just by virtue of being a radiologist. Applying, and especially winning, are additional skills that you will need to learn to be successful. From writing up a plan to connecting with the right people, don’t be afraid to ask for help either.

IP: To whom did you look for help with your application, Dr. Fintelmann?

FJF: Particularly, I would like to shout out Dr. Anthony Samier, who was instrumental in helping me with the ARRS Scholarship application. Of course, my chair, Dr. Jim Brink, my division chief, Dr. Jo-Anne Shepard—the list goes on and on. There are a number of people who have made themselves available to help me move this forward. I appreciate everyone who supported me along the journey, and I want to say thank you to all those who believed I could do it.  

IP: Since 1992, some 50 radiologists have been named ARRS Scholars. What’s it like knowing you, too, are on this list? 

FJF: Becoming part of this legacy has been a critically important aspect of my research career. Looking back at so many prior scholars, and the community that’s been shaped by this shared experience, is really quite humbling. There are incredibly accomplished people on that list, some of whom I’ve had the pleasure of meeting or working with. Also, I think about those ARRS Scholars who will come after me. We’re all one big, happy family!

Over the past two decades, the practice of radiology has changed, with radiologists having become more isolated. With the digital revolution precipitating widespread implementation of both EHR and PAC systems, radiologists have increasingly worked from workstations with less patient contact and decreasing personal interactions with referring clinicians. 

The COVID-19 pandemic further isolated radiologists. The initial social distancing requirements, use of PPE, promotion of remote work environments, and reduced meaningful social interactions during this era have amplified the loneliness of radiologists.

As humans, radiologists have a fundamental need to socially connect. And for good reasons: social isolation and loneliness, markers of poor social health [1], have been associated with multiple adverse psychological outcomes, especially sleep fragmentation [2], as well as anxiety and depressive symptoms. Studies suggest loneliness is a risk factor for stroke, as well as for hypertension, cognitive decline, and progression of Alzheimer’s dementia [3]. Restoring a sense of community—at work and beyond—can help radiologists overcome isolation, improve their overall wellness, and mitigate significant health issues.   

How does a radiologist do so? 

Radiology is a team sport, in which radiologists interact daily with patients, non-clinical staff, technologists, and other radiologists. In the workplace, these interactions can be leveraged to create a sense of community. A positive attitude among teammates can help create a bond of positive energy. Social gatherings organized by the clinical team, both within and outside of the department, can help further create camaraderie between members of the team. 

Radiologists also have opportunities to develop connections with referring clinicians. Multidisciplinary tumor boards offer a unique opportunity for radiologists to interface directly or virtually with referring clinicians and become engaged in the care of complex patients. This collaborative atmosphere promotes personal job satisfaction. 

Organizations can be instrumental in supporting a culture of community at work. Physician lounges provide a safe space for radiologists to interface with physicians from other specialties. Organization-led social events, such as fundraisers and family outings, may further promote a sense of collegiality. 

Beyond the organization, another way for radiologists to connect with colleagues is to attend regional and national society meetings. A great example is the ARRS Annual Meeting, to be held next year from April 27 through May 1 in the beautiful backdrop of California’s San Diego marina. A wonderful medium to cross-fertilize ideas, this meeting offers opportunities to not only learn educational content from leading experts, but also to socialize and collaborate with other radiologists from around the globe. 

2025 ARRS Wellness Symposium: Building a Radiology Community of Positivity

Helping us move forward in the wellbeing space during the ARRS Annual Meeting, our 2025 Radiology Wellness Symposium in San Diego will lay out a lot of the hard work done by many imaging centers to shift the narrative in our working environments. The widespread shortage of radiologists, combined with higher volumes and the prevalence of burnout, has been challenging radiology practices of all types. 

Focused on hard-won practical solutions for workforce belonging and overall positivity, multi-generational leaders in radiology education, operations, and informatics will tackle the differing approaches for schedule optimization, multiple strategies to help those trainees who are unwell, better incorporation of international medical graduates, and the many benefits of proper coaching and mentoring. 

As with all ARRS Annual Meeting sessions, live and virtual audience interaction remains welcome, especially during our question-and-answer portions, so I hope to see you in San Diego or online for the “2025 ARRS Wellness Symposium: Building a Radiology Community of Positivity!” 

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References

1. Campagne D. Stress and Perceived Social Isolation (Loneliness). Arch Gerontol Geriatr 2019. May–Jun; 82:192–199. doi: 10.1016/j.archger.2019.02.007
2. Griffin SC, Williams AB, Ravyts SC, et al. Loneliness and Sleep: A Systematic Review and Meta-analysis. Health Psychol Open 2020. Jan–Jun; 7:2055102920913235. doi: 10.1177/2055102920913235
3. Byrne C, Saville CWN, Coetzer R, et al. Stroke Survivors Experience Elevated Levels of Loneliness: A Multi-Year Analysis of the National Survey for Wales. Arch Clin Neuropsychol 2022 Feb 23; 37:390-407. doi: 10.1093/arclin/acab046

The mission of the American Roentgen Ray Society’s (ARRS) Global Partner Society (GPS) program is to build long-standing relationships with key leaders and organizations in the worldwide imaging community—increasing awareness of our society’s services in specific nations, while raising the stature of Global Partner Societies among ARRS members.

At the request of the Singapore Radiological Society (SRS), ARRS sent two breast imaging specialists, Drs. Jay R. Parikh and Donna M. Plecha, to present during the first-ever Singapore Breast Imaging Conference (SBIC) in May.

On day one, Dr. Parikh highlighted opportunities and concerns alike for the clinical embrace of AI in breast imaging. Leading lively discussions on burnout at large, he also moderated a panel and question-and-answer session on the challenges of locoregional staging and surveillance of breast cancer in Asian practices, specifically. (Please turn back to page 12 of this issue of InPractice to read more insights from Dr. Parikh, chair of ARRS’ new Quality and Practice Subcommittee.) 

During the second day of SRS’ “Breast Imaging: Today and Tomorrow, Shaping Breast Care in Asia” conference at the Centre for Healthcare Innovation, Dr. Plecha discussed best practices for personalized breast screening, including critical updates to known, biopsy-proven malignancies in the sixth category of the American College of Radiology’s Breast Imaging Reporting and Data System (BI-RADS).

“The SRS wishes to express our sincere gratitude for ARRS’ support of our inaugural SBIC. Your support was truly invaluable,” said organizing chair Dr. Niketa Chotai. 

She continued: “Both Jay and Donna were exceptionally knowledgeable, engaging, and approachable, and all attendees greatly appreciated their contributions, which significantly enhanced our collective knowledge. We truly believe their insights will positively impact breast care practices and patient outcomes in the region.”

Also presenting during SBIC was our SRS Global Ambassador Dr. Wei Yang, who received SRS’ Glass Award on behalf of ARRS. Dr. Yang presented “Updates In Axillary Node Management: What The Radiologist Should Know” during Dr. Parikh’s panel, with additional lectures on the imaging of augmented breasts and how to develop social intelligence and international leadership for radiologists to survive and thrive. 

The previous month, the entire ARRS membership proudly welcomed delegates from the Philippine College of Radiology (PCR), our newest GPS member, to the 2024 ARRS Annual Meeting at the John B. Hynes Veterans Memorial Convention Center in Boston, MA. 

Founded in 1948, the PCR focuses on education and training for more than 2,500 radiologists, including some 1,000 in-training members. With chapters located throughout the country, as well as several dedicated subspecialty groups, PCR serves more than 50 accredited institutions. Each PCR chapter holds its own annual convention in their respective regions, while PCR subspecialty societies meet routinely for mid-year events and scientific meetings. While in Boston, current ARRS International Outreach Committee chair Dr. Carol Wu and Dr. Glenn Gaviola, ARRS Global Ambassador for PCR, held a global partner meeting with PCR treasurer Dr. Rodney Fernan.

Also this May, Stephen F. Keevil, PhD, president of the British Institute of Radiology (BIR)—the oldest medical imaging society in the world—was recognized with honorary membership via the ARRS Annual Meeting Global Exchange. Our Annual Meeting Global Exchange incorporates one partner society annually into the educational and social fabric of our meeting, with ARRS reciprocating at said partner society’s own meeting. Professor Keevil served on the faculty for the 2024 ARRS Annual Meeting Global Exchange, “Screening Patient Pathways Across the Pond: Highlights and Challenges for Radiology in the UK and USA.” Reviewing current practice standards for screening lung and female breast cancer in both nations, this two-hour Featured Session addressed common techniques and comparative difficulties of maintaining an effective screening program. 

An international organization with members in imaging, radiation oncology, and underlying sciences, since 1897, the BIR has worked to improve medicine, health, and patient care through the science and practice of radiology.

The 2025 ARRS Annual Meeting Global Exchange will host the Mexican Society of Radiology and Imaging (SMRI) in San Diego, CA. ARRS Global Exchange course director Dr. Daniel Vargas is working with SMRI and ARRS faculty to present a comprehensive course on advances in cardiac imaging.

In April, then ARRS president-elect Dr. Angelisa M. Paladin traveled to Yokohama to represent our society at the 83rd congress of the Japan Radiological Society (JRS). During a lively session on human resources in radiology, led by JRS faculty Drs. Seun Eun Jung and Kei Yamada, the Dr. Paladin detailed current initiatives for nurturing success and happiness during radiology residency training (Read Dr. Paladin’s column regarding living and working happier on this second page of this edition of InPractice). Additional speakers for this JRS session devoted to developing the next generation of radiologists included Drs. Masashi Tamura, Yoshiyuki Watanabe, Stefan O. Schönberg, and Thomas M. Grist. 

Established in 1950, the 7,500-member JRS remains Japan’s leading society in the field of radiological sciences.

Free-Access GPS Resources: Southern African Chest Lectures, Argentine Head and Neck Tips  

This summer, ARRS launched a brand-new Global Education course with the Radiological Society of South Africa (RSSA). Collaboratively assembled by Dr. Abraham (Fourie) Bezuidenhout, ARRS Global Ambassador for RSSA, the four lectures of the “Southern Africa Thoracic Radiology Lecture Series: RSSA-ARRS Education Initiative” were presented live on a monthly basis all last year. The result—now free and open-access through our GPS education program—has quickly become a popular online series of important topics in thoracic radiology:

• Acute Aortic Syndrome | Diana Litmanovich, MD
• A Chest Fellowship in 45 Minutes: Useful Information for the Resident | Fourie Bezuidenhout, MD
• Cystic (and Smoking) Related Lung Disease | Brent P. Little, MD
• Lung Biopsy Complications and How to Minimize Them | Olga R. Brook, MD

Established in 1974 as the Professional Association of Radiologists in South Africa, RSSA has since expanded to include Botswana, Namibia, and Zimbabwe. With a membership base of almost 1,000 individuals and nearly 100 practices, RSSA’s South African Journal of Radiology (SAJR) publishes research articles, editorial letters, and personal opinions on radiological practice, as well as South African health-related news, obituaries, and general correspondence. Razaan Davis of Stellenbosch University is the Editor in Chief of SAJR.

Meanwhile, “Tips and Tricks on Head and Neck” was developed as an ARRS Global Education course by Dr. Carlos Previgliano, ARRS Global Ambassador, alongside the Argentina Society of Radiology or Sociedad Argentina de Radiología (SAR). This course presents five high-impact lectures reviewing fundamental neuroimaging topics: 

• Suprahyoid Neck: What the Clinician Wants to Know | Christine M. Glastonbury, MD 
• Infrahyoid Neck: What the Clinician Wants to Know | Justin Brucker, MD 
• Do Not Miss Head & Neck Lesions | Aaron Michael Betts, MD 
• Tips and Tricks for Evaluating Perineural Spread | Jennifer Gillespie, MBBS 
• Rapid-Fire Case Review: Head and Neck | Xin (Cynthia) Wu, MD

SAR has maintained prolific activity since its founding in 1917. Convening annually in September for the premier event in the country for the specialty, SAR congresses have hosted distinguished radiologists and physicians from across Argentina and around the globe. Having developed instructional resources of differing scope and complexities, SAR’s course on diagnostic imaging has been offered for over a quarter-century—presently through the University of Buenos Aires. A council of the society also designed and maintains a nationwide professional certification and recertification program. Additionally, SAR helps promote the research pursuits of young and emerging professionals, permanently instituting scholarships and prizes for exceptional scientific work. 

Going forward, I want to use my InPractice column to share more of the major principles of being and working happier with the full membership of the American Roentgen Ray Society (ARRS). Perhaps the biggest hurdle to happiness is how we think about it. Many physicians do tend to feel like happiness is this destination. ‘I just have to get happier,’ or so we tell ourselves. 

But as Dr. Arthur C. Brooks, endowed professor at Harvard’s Kennedy and Business Schools, has reminded me, true happiness is directional—a direction and the steps you take. Teaching one of the most requested classes at Harvard, Dr. Brooks heads up the Leadership and Happiness Laboratory as well, and I’ve had the pleasure of speaking to him. He’s a wonderful person who has contributed to increasing my understanding of the science of happiness.  

If we take a look at our environment in the social media age, the consumer economy focuses our attention on money, power, pleasure, and prestige. There are several traps in defining happiness these ways. Dr. Brooks likes to talk about how one of the chief components of happiness is enjoyment. But what’s the difference between enjoyment and pleasure? Pleasure is something that is kind of hedonistic. It hits our limbic system, making us want more. Think of that French fry! You have one French fry; you want the next French fry (at least I do). 

Enjoyment is different. Science has shown that enjoyment hits a different part of the body. Chemically, enjoyment on functional MRI is not in the limbic system, but instead within the prefrontal cortex. And researchers have found that enjoyment comes from being with others and creating memories. Indeed, enjoyment is very different. 

Another big one, satisfaction, is defined as what you have, divided by what you need. At many points in our lives, we can’t help but to think about consumerism: I need to have more. I have to have more money, a longer vacation, etc. This feeling rises, peaks, and then in our mid-40s, people start to recognize that what they need and what they have can be decreased. They start simplifying. Based in gratitude, genuine satisfaction is looking at what you have, then being satisfied. 

The last component of happiness is interesting: meaning. With meaning, it’s often struggle, strife, and pain. Naturally, a lot of people have questions, asking ‘Why is this happening to me, versus in life, and what can I learn from this experience to grow?’

The residency program in Portugal is achieved through the National Access Competition for Specialized Training. The process begins with candidates completing a medical degree, including a master’s degree in medicine from a recognized university. After obtaining this degree, candidates must take the National Access Exam, which evaluates the knowledge acquired during their medical training. The score obtained in this exam is crucial for the selection of both the specialty and the training location.

Based on National Access Exam scores, candidates choose their medical specialty and the hospital or oncological institution where they will train. The selection is made according to ranking, with higher-scoring candidates having priority in their choices. Once selected, the candidates begin their residency in their chosen medical specialty.

Radiology is a vital and dynamic medical specialty in Portugal, playing an essential role in both diagnosis and treatment. The radiology residency program in Portugal spans 60 months and offers comprehensive training designed to equip residents with the necessary skills and knowledge to excel in this field. Approximately 30 hospitals or oncological institutions across Portugal provide training for radiology residents. These institutions are located in the north, central, south, and islands of Portugal, ensuring a wide geographical distribution of training opportunities. Each offers unique learning experiences and exposure to diverse patient populations and medical conditions, such as specialized oncological centers.

The first 48 months of radiology residency involve mandatory training in conventional imaging, covering bone densitometry, ultrasound, MRI, CT, and interventional radiology techniques. Residents rotate through these different modalities, gaining hands-on experience and developing their diagnostic and technical skills.

During these rotations, residents are exposed to a broad range of anatomical areas, such as musculoskeletal, nervous, cardiovascular, genitourinary, and digestive systems, as well as head and neck, chest, breast, and pediatric radiology. This diverse exposure ensures that residents become well-rounded radiologists capable of addressing a wide variety of clinical scenarios.

The final 12 months of the program are dedicated to specialization. Residents typically choose up to two areas of focus, each lasting six months, allowing them to delve deeper into specific fields of interest and further refine their expertise.

Throughout their training, residents also complete a 12-hour emergency shift each week, working as part of a team that includes both residents and specialists.

Radiology residents in Portugal are encouraged to actively participate in academic and research activities. They should aim to present posters at national and international conferences and publish relevant articles in indexed scientific journals.

In 2016, a survey conducted among Portuguese medical residents assessed their satisfaction with their medical residency in Portugal [1]. Regarding radiology, 94% of surveyed doctors responded that they would choose radiology as their specialty again, demonstrating high satisfaction with their residency in this specialty.   The radiology residency program in Portugal is a rigorous and comprehensive training pathway that prepares residents to become skilled and knowledgeable radiologists. Through a combination of clinical rotations, academic learning, research activities, and emergency duties, residents gain the expertise required to excel in this rapidly evolving field. The emphasis on research and academic participation further enriches the training experience, ensuring that graduates are well-equipped to contribute to the advancement of radiology.

Reference

Martins MJ, Laíns I, Brochado B, Oliveira-Santos M, Teixeira PP, Brandão M. Satisfação com a Especialidade entre os Internos da Formação Específica em Portugal. Acta Med. Port. 2015 Mar-Abr;28(2):209-221

First, I want to thank Dr. Erik Paulson for an incredible year of leadership. It has been such a joy to work with Erik over these many years, and I am honored to have him pass me the ARRS gavel. 

Also, I am extremely proud to announce that ARRS is doubling-down on its commitment to providing the best education to members by launching a second journal! Designed to complement AJR, this brand-new journal is going to be image-rich. It’s going to be published bi-monthly, starting in 2025, and it’s going to be called the Roentgen Ray Review, or R3. And I am happy to say that R3’s inaugural Editor in Chief is Dr. John Leyendecker. John welcomes any thoughts on what our members would like to see in this new journal from ARRS.

I’m most excited to discuss the science of happiness, a topic dear to my heart, here in the pages of InPractice. Why is happiness important? Why, or how, do we link happiness with the workplace? It’s something that we should consider often. 

Right now, if I ask you to recall a happy memory, many of us will think of things outside of work. Work doesn’t immediately come to mind. I find this incredibly interesting: where is the word “work” derived from? Let’s start there. It’s Latin from “trepaliare,” which means to inflict suffering. I kid you not. You can’t make this up, right? Okay, how we link this to medical care, in particular, is that data show our happiness—our job satisfaction—is the most important factor determining quality of care. We need to care about our team, and we need to take care of ourselves. We have to be grounded, knowing that wellness is critically important in health care. Data have also shown that for people who are happy and satisfied at their jobs, their production is better, and they don’t call in sick. For all of us involved in leadership, we know the cost of staff turnover.  

So, how are we doing? Let’s talk about our baseline. There was a U.S. survey that went out to all physicians, and the response was huge because people really do care about this topic. 25% of all physicians reported being happy at work. 

Drilling down, how happy are radiologists? In 2022, we ranked 20th of 29 specialties. A whopping 60% of radiologists reported feeling burnt out. The two largest factors contributing to that burnout were long hours and, interestingly, a feeling of lack of respect for their specialty. Another survey went out, and again, 63% of radiologists reported at least one burnout measure. When imaging leaders were polled, 80% recognized this as a significant problem, but only 20% of those same leaders felt that they had adequate mechanisms at their disposal. There’s a trickle-down effect here, too. Everyone working with colleagues, residents, and trainees: if you are not doing well, they will feel it. And if mama ain’t happy, the house isn’t happy.

We can couple these surveys with data from the Association of American Medical Colleges that just came out predicting we’re going to have a shortage of 10,000–35,000 radiologists by 2034. As we all know, COVID intensified this issue, as many radiologists cut back their hours or took early retirement. Then, we have an aging population. In the next decade, 2 out of 5 active physicians will turn 65 years old. If you think about these personnel shortages, this personal dissatisfaction, we need to be talking about wellness initiatives aimed at our happiness. 

So, let us talk about it. Personally, when I think about happiness, it conjures up many fun feelings of my family, my dog. About five years ago, though, I was not happy. I was struggling at work and with the meaning of my work. In fact, I reached out to many of you reading this message now. I was going through a transition, and my closest girlfriend at home happened to be a good friend of Arthur C. Brooks, an endowed professor at Harvard’s Kennedy and Business Schools. (Actually, Dr. Brooks teaches the most requested class at Harvard, leading a happiness lab as well, and both are hard to get in to!) My friend said, “I’m going to give you his book. I want you to read it, and then, we have to talk about it.” And it really was life-affirming and life-changing. Moving forward here in InPractice, I will share some of the major principles of being and working happier. One of the biggest is that a lot of us tend to feel like happiness is this destination. ‘I just have to get happier,’ we tell ourselves. But as Dr. Brooks points out, true happiness is a direction—a direction and the steps you take. We may not always be able to find happiness, especially at work, but we can be happier. Stay tuned!

Volunteers have been foundational to the American Roentgen Ray Society (ARRS), allowing North America’s very first radiological society to ensure its strategic initiatives remain achieved. And to carry out the organizational needs and directives of this society, ARRS members and associate members alike are invited to serve on standing or ad hoc committees furthering our overall mission: improving health through a community committed to advancing the profession of medical imaging and its allied sciences. 

Presently, there are ARRS committees expertly focused on professional and practice improvement, scientific innovation, education, membership, and international outreach. The ARRS Professional and Practice Improvement Committee has been charged with overseeing our professional development programs, cultivating leadership opportunities, as well as initiating several practice quality improvements.  

Chief among these improvements has been establishing a brand-new ARRS Quality and Practice Improvement Subcommittee–a working group with an overarching charter of promoting both workplace wellness and personal wellbeing to ARRS members of each practice type, private or academic, at every stage of their career, from residency to fellowship to active practice and beyond.   

For “Words of Wellness” here in InPractice, members of the ARRS Quality and Practice Improvement Subcommittee discuss what “wellness” and “wellbeing” mean in their own clinical practices, research focuses, and everyday lives.

“I am a breast radiologist and professor of radiology in the division of diagnostic imaging at UT MD Anderson Cancer Center. Most physicians go into medicine and endure medical school and radiology residency for the betterment of patients. Along the course of training and further into our careers, data show a high prevalence of burnout in radiology. Additionally, physician burnout has been associated with negative outcomes for organizations, physicians, and patients.  

Since burnout is a workplace-related phenomenon, radiology practice leaders need to stop redesigning the radiologist. Instead, they should focus on redesigning processes. Physician leadership is inversely related to burnout. Therefore, practice leaders need to be held accountable for radiologist burnout in their workplaces. Radiologists work very hard to become credentialed and take care of patients, so they should not be marginalized into feeling like cogs in a wheel. The road to overcoming the complex issue of radiologist burnout to wellness requires leaders to listen to their radiologists, co-create solutions, and build trust across their teams.”

“My journey towards wellness has its roots in yoga. My yoga practice started in college, and during graduate school, I became a certified yoga instructor. During medical school, I taught yoga classes for my fellow medical students, weaving concepts of presence and self-awareness into my classes. 

As a trainee, I find that training and wellness are often difficult to reconcile; not just for myself, but also for my colleagues. The aspect of wellness that I struggle with the most is self-care. In medicine, we are trained with the expectation to place the hospital’s needs always before our own. Our training culture has classically praised the individual who finds more of themselves to give, without reprieve or compensation. The internalization of this culture manifests as a loss of self-worth. To balance this, I have found that the pillars of self-care can be derived from both the physical principles of yoga—flexibility and strength—in addition to the yogic principle of community. 

Flexibility, strength, and community are the mental and social foundations on which I build my self-care and self-acceptance.”

“Wellness at work starts with processes that improve your life, not impede it. Making your job something you look forward to, not dread. The first step is identifying what at work is leading to stress and unhappiness. 

These can be big things, such as we need more staff to cover calls, or small items, such as moving the cutoff time to read cases from 5:00 to 4:30 pm. The hard part is that these changes are extremely practice-specific. What has helped in my practice is likely to be irrelevant to someone else’s. Therefore, it is critical that leadership listen to radiologists and be willing to make changes. There is no one-size-fits-all, and no one outside your practice can tell you what to do. So, it all starts with identifying pain points, and then getting leadership to listen and be willing to change.”

I am an abdominal radiologist and professor of radiology and urology at the University of North Carolina at Chapel Hill. In my current role of executive vice chair, I have worked on several initiatives to improve work-life balance across all members of the team: faculty, residents, and staff.

In my view, small tweaks can lead to great improvement. Optimization of worklists to equalize efforts and/or allow for flexibility or remote interpretation has been key to finding that balance of teaching, clinical acuity, and clinical load for our team. These tweaks allow faculty to have autonomy and flexibility in their work and daily lives.

Efforts to help physicians practice at their level are equally important. Automation of protocols, software to propagate measurements from ultrasound examinations straight to reports, and motivated staff to help relay and close the loop on incidental findings are all examples of such efforts. It’s a constant work-in-progress that requires a unified team with open and honest communication between all team members.

I am an abdominal radiologist in the abdominal and ultrasound divisions at Mayo Clinic Rochester. Being a radiologist, I have found much of my source of unwellness and burnout tend to be psychological, rather than physical. There is a lot of mental burden, and it is no surprise that radiology is the most mentally demanding physician specialty with increasing workload contributing to burnout.

Music is something I have always enjoyed, and I’ve curated a “Wellness Playlist”—songs for those mentally tougher days in the reading room. Music has been found to improve mood and decrease anxiety and cortisol levels, even improving depression. Physiologically, music can decrease blood pressure, heart rate, and respiratory rate. In particular, listening to peaceful and low tempo music has been found to decrease heart rate.

There are times in the reading room where I find it useful to have relaxing music to help decrease anxiety and irritation, as well as calm down. However, there are days where I want and need to get pumped up to help tackle a rougher day, just like getting pumped up at the gym for a workout. In fact, motivational music has been shown to combat cognitive and physical performance decline caused by exercise fatigue in sports. Another factor shown to combat cognitive and physical decline is a 30-minute nap. This also showcases the importance and power of sleep, which we are all very aware of in mitigating burnout and unwellness. Since we are on the topic of sleep, listening to relaxing music has been found to be as effective as diazepam in reducing anxiety, and thus beneficial for aiding sleep. Music can lower our blood pressure, heart rate, and respiratory rate to help us fall asleep and achieve quality sleep, further boosting our wellness.

The health care sector—and especially medical imaging—greatly contributes to global greenhouse gas emissions. Recent research has highlighted the colossal energy appetite of CT and MRI scanners, spotlighting substantial nonproductive energy waste during idle periods (1–3). 

But do interventional radiology and interventional cardiology face similar energy consumption challenges? 

To find the answer, my University Hospital Basel colleagues from the departments of radiology, cardiology, urology, and building management equipped interventional imaging devices with power sensors and calculated their energy demand, carbon emissions, and annual costs (4). 

The idle power consumption of CT scanners and basic fluoroscopy devices (e.g., used for peripherally inserted central catheter line insertions) is around 3 kilowatt-hours (kWh). Biplanar angiography devices used in interventional radiology and catherization labs have around 2–2.5 times higher power requirements, ranging between 5–7.5 kWh (Fig. 1)

Simply powering down these devices when not in use decreased power consumption and increased energy efficiency by 22–93%. System shutdowns could be safely practiced without causing damages, affecting the systems’ lifespan, or voiding service warranties.  

Vendors have started to encourage customers to consistently power down systems overnight and during idle periods longer than an hour in their best practice guidelines. If you do not already shut down your imaging devices, our AJR Original Research article includes projected annual savings for doing so. 

On a device level, consistently powering down idle-running devices overnight and on weekends may save up to 39,000 kWh in energy consumption, 5 metric tons in greenhouse gas emissions, and $10,000 in electricity costs.

For multiple devices, savings add up!

Based on their institutional setting, we estimated combined annual savings of 144,640 kWh in energy consumption, 18.6 metric tons in greenhouse gas emissions, and $37,896 in electricity costs. The included cost and carbon emission sensitivity analyses allow radiology, cardiology, and urology departments to estimate their potential cost savings and sustainability benefits, depending on local electricity prices and carbon intensities accordingly.

Savings vary with usage patterns and may be lower for practices offering around-the-clock emergency procedures. However, switching off can still pay off without sacrificing readiness and prompt care, given short start-up and shutdown times of modern devices (ca. 2–5 minutes).

But even when consistently powering down idle-running systems (Fig. 2), most of the devices’ energy consumption still occurred inactively without a patient being in the room for a procedure (overall: ~60%, range for individual devices: ~41-96%.)

Given how the energy consumption of the devices is distributed, we concluded that there is much room left to further improve sustainability in interventional radiology. However, these would require technical innovations and more eco-friendly designs from the systems’ manufacturers. 

In summary, interventional imaging systems are energy intensive in their operation. The annual energy demand of each device is as high as that of 1 to 5 4-person households. Nonproductive energy consumption outside procedures is disproportionately high. Powering down idle-running devices can decrease costs and increase sustainability. Meanwhile, system shutdowns and start-ups can be safely and quickly performed. However, technical innovations are needed to further improve sustainability in interventional radiology writ large.

For more reasons why now is the perfect time to ramp up your sustainable imaging efforts, “the yellow journal” has since published multiple Editorial Comments for our full-length manuscript—authored by individuals who served as the article’s peer reviewers before acceptance (i.e., those most familiar with its content). AJR Editorial Comments by Nadja Kadom [5] and by Katherine Frederick-Dyer [6] offer insights from different perspectives regarding the energy consumption of interventional imaging equipment. It’s worth noting, too, that the AJR Global team has published Chinese and Spanish translations, both PDF and audio files, for our article’s abstract.

References

1. Brown M, Schoen JH, Gross J, Omary RA, Hanneman K. Climate change and radiology: impetus for change and a toolkit for action. Radiol 2023 May; 307:e230229
2. Picano E, Mangia C, D’Andrea A. Climate change, carbon dioxide emissions, and medical imaging contribution. J Clin Med 2022 Dec 27; 12:215
3. Brown M, Snelling E, De Alba M, Ebrahimi G, Forster BB. Quantitative assessment of CT energy use and cost savings through overnight and weekend power down in a radiology department. Canadian Association of Radiologists Journal 2023; 74:298–304
4. Vosshenrich J, Mangold D, Aberle C, et al. Interventional imaging systems in radiology, cardiology, and urology: energy consumption, carbon emissions, and electricity costs. AJR 2024 Mar 20 [published online]. Accepted manuscript. doi:10.2214/AJR.24.30988
5. Kadom N. Editorial comment: The time to start is now. AJR 2024 Mar 27 [published online]. Accepted manuscript. doi:10.2214/AJR.24.31188
6. Frederick-Dyer K. Editorial comment: Let’s not be idle about idle power consumption. AJR 2024 Apr 3 [published online]. Accepted manuscript. doi:10.2214/AJR.24.31222

Living more sustainably has been on my mind recently, and I think other radiologists may be similarly interested. As radiologists, we play a crucial role in diagnosing and treating patients, and I strongly believe that we can do even more.

Radiology, being an essential component of modern health care, has an environmental impact, particularly in terms of energy consumption and waste generation. However, I also believe that there are opportunities for positive change. By adopting sustainable practices in our radiology departments, we can reduce our ecological footprint and contribute to a healthier planet.

As Dr. Julia H. Schoen noted in her own InPractice primer, “greener” imaging begins at home [1], so I would love to discuss potential initiatives that radiologists could undertake together, starting with our use of iodinated contrast media (ICM). Accumulating as residual waste in the vials and tubing of patients who receive them, ICM can be released into the sewage system. Although ICMs are of low toxicity, they may transform into other chemicals when undergoing wastewater treatment and/or water purification [2]. These byproducts pose risks for aquatic environments, as well as our drinking water. 

Following the shortages of iodinated contrast agents during the COVID pandemic, many radiology practices had to adopt new best practices for decreasing use and waste of iodinated IV contrast [3]. So, with supply chain disruptions resolving and inventory returning, why not adjust contrast volume for each patient based on body weight, lean body mass, or body surface? Certain imaging techniques can allow reduced IV contrast volumes, currently mostly used for patients with renal disease: low-kV techniques, dual-energy scanning with reconstruction of low-keV images, and contrast boost technique for CT angiography. 

Using multi-patient injection systems for bottle sizes up to 500 milliliters can make IV contrast administration even more efficient by individualizing the amount of contrast material injected without increasing contrast waste. True, this may require some planning ahead of the imaging day to do so efficiently. 

Changing habits is difficult, but do you switch the lights off when you leave a room in your home? How about at work? It’s tough to remember every time, I know. We often feel like a big, concerted effort is necessary to change one single bad habit, and it remains unclear whether such a small contribution can really make a difference. 

Hang in there! The 1% rule of marginal gains is the simple idea that big goals can be achieved through incremental steps. No need for making big changes overnight. Instead, let’s aim for small daily improvements. 

The three “r”s of sustainability—reduce, reuse, recycle—definitely do translate to our specialty, and there are a few low-hanging fruits worth our consideration. Remember, adopting environmentally friendly practices can also save money, and rethinking how we administer ICM is a feasible first step. 

References

1. Schoen JL, Thiel CL, Gross JS. ARRS InPractice website. www.radfyi.org/climate-change-radiology-primer. Accessed May 16, 2024
2. Dekker HM, Stroomberg GJ, Prokop M. Tackling the increasing contamination of the water supply by iodinated contrast media. Insights Imaging 2022 Feb 24; 13:30. doi: 10.1186/s13244-022-01175-x
3. EHR Interventions for Contrast Media Shortage Impact CT Utilization. ARRS InPractice website. www.radfyi.org/ehr-interventions-for-contrast-media-shortage-impact-ct-utilization. Accessed May 16, 2024