In radiology, whether you work in a large or small private practice, remotely by yourself, an academic department in a medical center, or part of a mega radiology practice, there has been a palpable shortage of radiologists. This shortage is fueled by a trend toward exclusive subspecialization with declining numbers of radiologists who can handle general work, ever-increasing expectations for service to our patients, referring doctors, hospitals, and health care systems. We have been stretched thinner. There is a desire by radiologists to have more flexible work hours or, simply stated, to work less hours overall compared to years past. There is a concern about what role artificial intelligence and machine learning will play; will we be displaced? Reimbursement has been decreasing relative to inflation and compared with other specialties. As a result of these realities and others, there is clear evidence of burnout among radiologists, similar to health care workers in other specialties. On top of that, sometimes, we find that the leaders in our organizations may be distant, or too corporate, or suffer from “toxic positivity,” which may be worse than “toxic negativity.”
There has been a steady headwind for years, but it now feels like a gale force wind. And a lot of this feels out of our control. So, goodness, how do we manage all of this? Hold on, let’s take a breath. One strategy that we can embrace and control is to develop a culture of teams within our workplaces. In fact, I have titled this series “The Teamwork Imperative” because we must establish teamwork as a core value within the radiology workforce. I believe that if we foster a culture of teams, we can mitigate and shield ourselves from some of these headwinds.
Let me be clear. Here, when I say teams, I am specifically not referring to the “macro teams” that many of us find ourselves in. For example, at Duke Health, it is said that the 30,000-plus employees are my “teammates.” That very well may be true. But no, I am referring to your local and focal team. I am referring to the individuals that you rely on daily or weekly to deliver your work product. It’s the folks you huddle with. And the teams develop where you huddle. If you are in training, I am referring to your team of co-residents, your chief residents, maybe your program director or program coordinator who you lean on. If you are in a private practice, I am referring to those that you share physical space with, or perhaps switch call with, or the individuals you show difficult cases to, or the referring docs you have developed close relationships with, and who rely on you to deliver care. In an academic environment like mine, it might be the members of your subspecialty division. If done well, the division pulls together as a team to deliver care, service, teaching, and research.
Those divisions that have a culture of team are far more effective than those who are unable to act as a team. If you are lucky enough to have these local and focal teams (and these often form and evolve organically), many challenges at work open up and become more manageable and attainable. The clouds begin to lift. Specifically, your deliverables, whatever they may be, are far more easily and effectively achieved if you have your team and approach your work from the perspective of that team.
Work becomes more efficient and fulfilling and, frankly, more fun. The work becomes more manageable, with more aspects under your control. You become more engaged. And that then becomes an antidote to burnout. Teams, therefore, contribute to retention.
Coaches discuss this all the time. I’ll borrow here from Mike Krzyzewski, the legendary Duke University men’s basketball coach. “Coach K” famously talked about the five keys to an effective team, likening them to the fingers on a hand. Each finger is individual and can stand alone, but when the five fingers of communication, trust, responsibility, caring, and productivity come together into a fist, the fist proves to be much stronger than the sum of the individual fingers.
Communication
Yes, of course, communication is about sharing news back and forth, accurately and honestly, but more importantly, communication is to be able to probe, to be able to respectfully question, and to be able to expect honest answers from your teammates. Sometimes, the questions aren’t easy, and the answers may not be easy either. To foster an effective team requires the ability and the safety of pointing out the opportunities—those ones are easy. More importantly, it is to have safety in pointing out deficiencies—those are more difficult. It is critical for teammates to be able to receive and internalize the information coming from within the group, whether it is a kudo, an observation, or a deficiency or a criticism.
You have to talk to each other. Actually talk. And in a world of remote work and texting, we don’t talk enough. Maybe the talking occurs in a partner meeting, defined clinical case conference, resident meeting, or division or department meeting. Maybe it is your team taking a coffee break or going for a midday walk to achieve “step” goals. Hopefully, the team dynamics are such that one can tap a teammate on the shoulder and engage in an effective and safe conversation.
Communication needs to be practiced. That is why I think standing, regular, in-person meetings, even if the agenda is light, are very important. The opportunity to come together regularly promotes the importance and expectation of communication. And it is habit forming. You get better at it.
Trust
Trust means telling the truth, and telling it sooner rather than later; knowing that within a team, that can be hard. It can be hard because so many of us struggle with confrontation and conflict and try to avoid them. But consider it this way, from the perspective of the iconic University of Tennessee women’s basketball coach, Pat Summitt. She said, “The absolute heart of loyalty is to value those people who tell you the truth, not just those people who tell you what you want to hear. In fact, you should value them the most, because they have paid you the compliment of leveling with you, assuming you can handle it.”
Honest and fair difficult conversations almost always produce results. If you can get through the first thirty seconds of a difficult conversation, often the clouds lift and a very productive conversation follows. For me, I need to write down the key first few sentences for that opening thirty seconds and the rest flows. If difficult conversations don’t produce results, you have learned something.
Collective Responsibility
A coach might say, “We win together, we lose together, there is no “blame game.” In the workplace of radiology, the collective responsibility is the pulling together to deliver on our various missions. Everyone does not play the same role. One partner may be a fast and efficient reader, that’s great. Her partner is slower because he spends a lot more time consulting and discussing with referring docs. Both these individuals are important to the team. Or in an academic environment, one may be more focused and skilled clinically, another may be more focused on teaching. In a team where there is collective responsibility, they complement one another and each can be proud of each other’s successes. Indeed, the light of their success shines on the other teammates, on the entire team.
Caring
This is also about humanity and human connections and colleagueship. Caring in a team reflects time spent with each other and sharing aspects of ourselves, in this case the women of Duke Radiology. The caring strengthens the interconnective web between team members, in this case at our annual Fall Gathering. It makes the team softer in a positive way, and more personable, yet, at the same time stronger.
Here is where I worry about remote work. I get it. The pandemic has shown that we can do radiology effectively, even remotely. People like it and expect it. And we have learned that we can teach remotely. Sort of. But it seems far more difficult to foster a genuine, caring environment when work is dispersed in many geographic locales and individuals work essentially independently, free of meaningful, direct interactions with other teammates, other humans. To me the same applies to Zoom meetings. All the nuanced talk and greetings pre- and post-meeting are lost. The body language is lost. The sense of community is lost, or at least different. And I think the effectiveness of the meeting suffers. Indeed, on a Zoom meeting, you can’t even have real eye contact. I worry that with remote work, the culture of our teams maybe eroded. We do need to incorporate the best aspects of some remote work, but incorporate it in a fashion that fosters caring.
Pride/Productivity
Coach K says, “Everything we do has our own personal signature on it…and if we all sign off on everything we do, then we have a chance to be great.”
And your teammates all do have the chance to add their personal touch and signature. Collectively then, we have the opportunity to harness the best of what we can be, and to be great, even with all that is facing us and challenging us in our current and future work environments. “And it is going to be hard; we all wait in life for things to get easier…when we are well staffed, when I pass the Boards, when I make partner, when the kids are older, when the pandemic is over … it will never get easier. What happens is, you handle hard better.” As pointed out by Kara Lawson, Duke women’s basketball coach.
Each of these domains, communication, trust, collective responsibility, caring, and pride; the five individual fingers are important. But when the five fingers are formed into a fist, a true team, the collective strength is much greater than the sum of the individual parts. When these five areas can be applied to our teams in radiology, we can become more effective and efficient. As individuals alone, we are relatively weak. Together as a team, we are stronger. And this is something within our control.
To me, there is an imperative to create, sustain, and grow teams in our workplace.
Colleagues, I personally invite you to join us for ARRS 2024, either in Boston or online. This exceptional event brings together top radiologists from around the world to share new knowledge shaping our field.
Our Annual Meeting is renowned for its cutting-edge education, providing clinical information you can put into practice right away. We are excited to share the latest advancements in radiology, along with comprehensive review lectures to stay sharp on core topics.
Whether you attend in person and immerse yourself in the vibrant atmosphere of Boston, or choose our convenient online option, ARRS 2024 promises to be a remarkable experience. Your participation and engagement will help us connect, learn, and advance radiology together.
Assistant Professor, Department of Diagnostic and Interventional Imaging McGovern Medical School, UT Health Houston
It is my pleasure to discuss a topic that holds a very special place in my heart—the patient experience in breast imaging. What makes this topic truly captivating is that it touches upon several areas that are significant to me: patient-centered care, team leadership, and wellness. But there is an interesting twist, and I would like to share that as well, because it’s a kind of secret passion that I’ve had for years. And that is my love for spas, just the unforgettable experience you can get during one of the most memorable stays in a hotel.
Now, you might be wondering how on earth these interests come together. How can these unrelated topics merge to create a health care experience that is as luxurious and comforting as a world-class spa getaway, while also providing exceptional patient care?
We’ve all been on the other side of the examination table. We can relate to that mixture of emotions when walking into a doctor’s office. Just think about it for a moment. What stands out in your memory from those visits? Was it the mountains of paperwork you had to fill out, the warmth of the receptionist’s smile, the chill in the examination room? Maybe it was the time you spent waiting or the multiple ongoing discussions with your insurance company. Hopefully, and more importantly, perhaps it was the actual conversation you had with your doctor. Did you feel rushed, or were you heard and understood with all your questions addressed? Too often in our fast-paced working world of technicians and radiologists trying to meet numbers and targets, we may forget that the patient is the very reason we’re in this profession.
Really think about it. The news of a potential cancer is something threatening, and it is understandable that patients are stressed and anxious from the moment they walk into our office. Why not try to make the best possible experience when patients need it the most, for when they’re the most stressed and worried in their lives?
This is where my love for hotels comes in. When I was a girl, I loved a TV show about a lady who would receive the best stays and treatments at five-star hotels in incredible places around the world. She would then share her experiences with viewers. I used to think that, one day, I could do what this lady did. Of course, I didn’t end up being like her, but as a breast imager and as a patient now, I have always liked to compare the health care industry with the hospitality business. Although going to the doctor is not all leisure or pleasure, it is part of our wellbeing, and we’re all going to need it at some point.
So, how do five-star hotels approach guest satisfaction and train their staff for this amazing service? These hotels are renowned for their exceptional customer service experience, and they invest heavily in preparing their staff. Please allow me to share a few of these key elements that I think we could borrow from their playbook. Thankfully, some of them we are already incorporating as radiologists.
Let’s start with a customer-centric philosophy. Just as in five-star hotels, we should prioritize patient satisfaction above everything else. Every interaction with a patient should reflect our commitment to their wellbeing. This is exactly what the American College of Radiology’s Imaging 3.0 initiative is all about.
Then, we have role-specific training. As hotels do, health care should provide training that is tailored for specific positions, whether it’s radiologists, technicians, or administrative staff. Everyone should receive training that is aligned with their responsibilities. Those of us who are in academic institutions, for example, should model and objectively evaluate the interactions between our trainees and our patients to identify potential areas for improvement.
I want to continue with empathy and emotional intelligence. This might be a hard one, but we can train our health care professionals to empathize with patients’ needs and emotions. Recognizing and responding to patients’ moods can lead to a more compassionate and effective health care experience.
Next, we have language and communication, which is very important. In our diverse world, especially in the United States, language training is crucial for health care professionals. Being able to communicate effectively with patients from various backgrounds is going to enhance trust and understanding.
I’ll continue with problem-solving and decision-making. Similar to how hotel staff practice handling several guest scenarios, our health care professionals can benefit from training that sharpens problem-solving and decision-making skills, ensuring they can address patient concerns effectively and promptly.
Ongoing training. I think we’re good at this one. Learning in health care should not be a one-time event. Continuing education and professional development opportunities are not only going to keep our staff updated, but will also keep them committed to the patient experience.
Finally, we have guest feedback. Like hotels—now with Yelp and Google reviews—we should actively seek patient feedback. Comments, both positive or negative, are going to be valuable for improvement.
Let’s connect all of this back to breast imaging. In diverse cities (for example, Houston, TX), diversity among our medical professionals and staff becomes essential. Having tools for communication, like translators, is helpful. More notably, having health care professionals who speak a patient’s language and share their culture creates an immediate sense of connection and trust, just as in five-star hotels.
We know that trust is the foundation of an excellent patient-radiologist relationship, ensuring they return to us for essential care; however, establishing that trust is not the radiologist’s job alone. Since we are often the last ones to see a patient, our front desk and technician staff set the tone for what the patient’s visit will look like. We all need to be on the same page, so periodic meetings and reminders about our goals in terms of patient experience are necessary.
Most importantly, we must not forget about our own wellbeing as health care professionals. And this is where administrators come in. Burnout, unfortunately, is a critical concern for radiologists. It affects our ability to provide the best care possible. We must set clear and appropriate boundaries in scheduling to prevent our staff from becoming overwhelmed and exhausted.
I know there are times when we must go above and beyond, but this should not be the baseline. If we have burned out staff, we cannot deliver the exceptional patient care and experiences we are aspiring to provide. I do feel like our role as breast imagers extends beyond our technical expertise and medical knowledge. We should create an environment where our patients feel valued, heard, and cared for. Borrowing some of these insights from the world of five-star hospitality, promoting diversity, and ensuring staff wellbeing, we can sincerely elevate the patient experience. Remember, it’s not only about what we see on the screen or the images we interpret, but how we make our patients feel through their health journey. We want this experience to be what they remember from their visit.
I am the lucky father of three girls. Before the birth of my youngest daughter, my hospital emailed to let me know that I was entitled to 3 weeks of paid parental leave. I was ecstatic. However, as I looked into it further, I found out that I was actually entitled to 12 weeks off! There was one small catch: 3 weeks were paid leave, and 9 weeks were unpaid leave. Not only was it unpaid time off, but I would have to pay the hospital for continuing some of my benefits during that time. My initial instinct was that I should just take the 3 weeks.
As the date of my daughter’s birth approached, I started to rethink my priorities. For me, time with my family was more important at my early- to mid-career stage than the 9 weeks of salary. Also, my wife and I had saved an emergency fund of 6 months of expenses that we could easily access. What better way to spend that money than to have bonding time with my new daughter and help my older daughters make the transition to being older sisters to our new arrival.
Understanding the benefits and laws surrounding paternity leave in the United States, particularly the Family and Medical Leave Act (FMLA), is crucial. Moreover, having financial literacy and an emergency fund can make this transformative experience not just feasible, but enriching for families. In this blog post, I will explore the advantages of paternity leave, delve into the FMLA laws, and discuss how financial literacy plays a vital role in embracing this invaluable time off.
Paternity leave allowed me to establish a strong emotional bond with my newborn daughter. Those initial months were invaluable for building connections that will last a lifetime. For my family with multiple children, the initial weeks involved a large change in family dynamics. Since my wonderful wife was very occupied with our newborn, I played a large role in helping my older daughters adjust to having a new member in the family, helping them embrace their new roles as older siblings, teachers, and helpers.
Support for Partners
My wife had some physical and emotional challenges after childbirth. During my paternity leave, I was able to support her and share many of the responsibilities that she was accustomed to doing. This allowed her to concentrate on our youngest daughter, helping the wellbeing of both my wife and my youngest daughter.
Time with Family
In our practice, it is very difficult to get a long period of contiguous time off. However, paternity leave offers this. During my leave, we were able to rent an Airbnb in Canada for 6 weeks. This allowed us to be very close to my dad and sister, which allowed for so much bonding time between my family and my daughters. It was the best part of the leave time. As members of a sandwich generation, my wife and I are caring for our children and our parents at the same time. It was great to be able to bring them together and spend an extended period of time together. A fantastic blog post titled “The Tail End” by Tim Urban and the Wait but Why team does a great job of explaining why such time is so precious! I highly recommend reading it.
The FMLA, enacted in 1993, enables eligible employees to take up to 12 weeks of unpaid, job-protected leave for specified family and medical reasons, including the birth or adoption of a child. Understanding these laws is crucial for fathers planning to take paternity leave.
Eligibility
FMLA applies to public agencies, public and private hospitals, and companies with 50 or more employees. To be eligible, an employee must have worked for the employer for at least 12 months and have completed at least 1,250 hours of service during the 12-month period preceding the leave.
Job Protection
One of the significant benefits of FMLA is the job protection it offers. Employees are entitled to return to their original or equivalent positions after the leave period, ensuring job security.
Health Insurance Continuation
During FMLA leave, employers must maintain the employee’s health benefits as if they were still working. During my leave, my hospital paid the employer contribution to the health plan premiums, and I was responsible for paying the employee portion of those premiums, as well as deductible and out-of-pocket costs.
Financial Independence and Emergency Fund
While the FMLA provides job protection, it is unpaid leave, which can pose financial challenges for unprepared families. Having an emergency fund can bridge this gap.
Peace of Mind
An emergency fund provides peace of mind, knowing that there’s a financial cushion to support the family during the paternity leave period.
Focus on Family
Financial stability allows fathers to focus entirely on their families—without the stress of immediate financial obligations. It empowers them to be present, both physically and emotionally, during this crucial time.
Future Planning
Financial independence encourages families to plan for the future. It ensures that the leave period doesn’t impact long-term financial goals, providing a sense of security for the entire family.
I am very lucky to work with amazing, supportive colleagues. When I proposed taking paternity leave, even though no one had done it before, I was met with support from my department, hospital, and colleagues. Another unique benefit to my leave? I was able to take it intermittently during the first year of my daughter’s life. This flexibility allowed me to work when we had visiting family in town, who could help, then take leave when it was just my wife and me. However, the present FMLA law does not require such accommodation, so this is likely employer-dependent. Now, I talk to all fathers who are expecting new babies about establishing an emergency fund, pointing out the benefits of more paternal leave. Anecdotally, this seems to be gaining traction among physicians. I know two recent father doctors who are taking their full allotment of paternity leave, as well as another father who is strongly considering taking some unpaid leave.
I believe that paternity leave (supported by laws like FMLA) is not just a break from work; it’s an investment in your family and the future. Understanding these laws and ensuring financial stability through an emergency fund can transform this period into a beautiful and enriching experience for fathers, mothers, and children alike. By embracing paternity leave and advocating for supportive policies, we contribute to the creation of healthier, happier families and a more balanced society.
Sherwin Chan, MD, PhD
Professor of Radiology, University of Missouri at Kansas City
Vice Chair of Research, Children’s Mercy Kansas City
Planning for retirement is daunting. Something that many of us end up putting off in place of doing something else, anything else. We tell ourselves it is 10, 20, 30, or even 40 years in the future. Why is it that many of us, myself included, will spend more time researching a new TV purchase or our next vacation destination than planning for retirement? I’m here to tell you that it is better to start planning for your retirement now. We can strive for improvement, as I firmly believe that a doctor who is financially literate also becomes a more effective health care provider. When you have a solid grasp of your finances, you gain the capacity to make more informed decisions, not only for the benefit of your practice but also for the wellbeing of our patients.
Determining Your Retirement Number
Many of us delay retirement planning because it appears to be an intimidating endeavor. However, it doesn’t have to be. One of the initial steps is to determine your financial independence target, recognizing that this number is likely to evolve over the course of your career. Your number represents the amount of investable retirement assets required to maintain your desired standard of living throughout retirement. When you search for “how much do you need to retire,” you’ll encounter a wide range of responses, some of which may be inaccurate. Is it $1 million, $5 million, or even $10 million for a doctor to retire? Should it be 70% of your pre-retirement income, or perhaps 10–12 times your pre-retirement income? Regrettably, many of these responses fail to address the fundamental factor: how much you spend each year ultimately determines the amount needed for your retirement.
Safe-Withdrawal Rate and the 4% Rule
In order to comfortably retire, you will need about 25 times your annual spending to fund a 30-year retirement. To put another way, an investor who maintains a portfolio consisting of 75% stocks and 25% bonds can safely withdraw 4% of their portfolio’s value annually, adjusted for inflation, to support a typical 30-year retirement without the risk of depleting their funds. This is known as your safe-withdrawal rate and what has been known to many as the 4% rule of thumb. Now, this 4% withdraw rate and spending allocation must encompass all expenses, including taxes, health care costs, and financial advisory fees. If you spend $120,000 per year, you will need about $3 million in invested assets. For every $40,000 a year spending, you will need another $1 million in your retirement portfolio. This is based off “the Trinity study,” where Cooley et al. looked at historic safe withdrawal ratebased on varying percentages of a stock/bond portfolio. This American Association of Individual Investors feature helped determine what percentage of money you could safely withdraw each year, indexed to inflation, and still have a reasonable chance of having money left after a 30-year retirement. In the majority of instances, individuals employing a 4% withdrawal rate during retirement will find themselves with a larger sum of money by the end of their retirement period compared to their initial retirement savings, frequently exceeding twice the amount they began with.
Informally referred to as “the Trinity study,” as all three authors were professors at Trinity University in San Antonio, TX, Cooley et al. updated their original 1998 paper in 2011 to include data from the Great Recession of 2008. The authors looked at historic, rolling 30-year periods from 1926–2009 to help determine what withdrawal rate, indexed to inflation, would sustain different retirement lengths using different portfolios that were invested in a mixture of stocks and bonds. This study challenged the long-held belief that if a stock portfolio maintained an average annual return of 9–12%, it would be safe to withdraw 7–9% annually in retirement, ensuring the portfolio’s sustainability indefinitely. The primary factor rendering this strategy unfeasible during various periods is the risk associated with the sequence of returns.
Sequence of Returns Risk
The sequence of returns risk relates to the idea that the performance of your portfolio early in retirement matters more than the performance late in retirement. The term “sequence” pertains to the adverse effects of experiencing low or negative investment returns during the early years of retirement, which can significantly influence the longevity of your retirement portfolio.
Consider, for instance, two retired investors who both achieved an average annual return of 7.75% throughout a 20-year retirement period, all while making annual withdrawals of $70,000 from their initial million-dollar portfolio (Fig. 1).
Fig. 1—Both investors initiated their retirement with a $1 million portfolio balance and achieved an average annual return of 7.75% over a 20-year period, while withdrawing $70,000 annually. Investor 1 (orange) experienced a 35% decline in their portfolio balance in the 15th year of retirement, while Investor 2 (gray) encountered the same 35% drop in the first year of their retirement. The sequence of portfolio returns during the early stages of retirement significantly impacts the probability of the portfolio lasting throughout the entire retirement period, necessitating a much lower withdrawal rate when compared to the average portfolio return.
In the case of the first individual, they consistently enjoyed returns of 10% per year, but in the 15th year, they experienced a significant negative return of -35%, resulting in an average return of 7.75% over 20 years. The second individual, on the other hand, also averaged a 7.75% annual return, but their portfolio started with a 35% drop in the first year, then averaged a 10% annual return for the subsequent years. It’s important to note that both individuals maintained an average return of 7.75% while withdrawing the same amount annually. However, the outcome differed significantly: the first individual concluded their 20-year retirement with nearly $400,000 more than their initial investment, whereas the second individual exhausted their funds in the 20th year. This highlights the critical importance of setting a withdrawal rate lower than your rate of return in retirement, as the sequence of returns can have a substantial impact on the outcome.
Accumulating 25 times your annual spending in investable assets serves as a general guideline for achieving a successful retirement. However, in practice, many retirees adapt their discretionary spending based on their portfolio’s performance. During prosperous years, they can afford to spend more than the 4% benchmark, while in challenging years, they have the flexibility to reduce discretionary expenses and withdraw less than 4%. Nevertheless, it all commences with gaining a preliminary understanding of your annual spending, as this forms the foundation for determining the retirement nest egg required.
So, I ask again, what’s your number?
Christopher M. Walker, MD
Glen and Karen Cox Endowed Professor of Radiology
University of Kansas Medical Center
The Glen and Karen Cox Endowed Professor of Radiology and a practicing cardiothoracic radiologist at the University of Kansas Medical Center, Christopher M. Walker, MD, is not a certified financial planner, accountant, or attorney. This information is presented for your entertainment only and does not constitute formal and personalized financial, accounting, or legal advice. Your personal situation may be different, so please consult your own tax attorney or fee-only financial planner for advice pertaining to your situation.
ARRS is collaborating with the Radiology Health Equity Coalition (RHEC) to curate and disseminate trusted resources and best practices for improving access and utilization of preventive and diagnostic imaging.
Gender-affirming care is a rapidly evolving, highly politicized component of health care, affecting patients of all ages. Over the last decade, transgender and gender-diverse patients have been better recognized as a gender minority, approximated to represent up to 2% of the general population.
A frequently stigmatized group, the health care needs of these populations are often ignored or even condemned, leading to high rates of adverse health outcomes. Therefore, it is critical for physicians and hospital systems alike to be educated in the medical and the psychosocial aspects of gender-affirming care, so to ensure competent and compassionate care that optimizes patient health, autonomy, and wellbeing.
Presented live as a Featured Sunday Session during the 123rd ARRS Annual Meeting, “Improving Care of Gender-Diverse Patients in Radiology Departments” featured expert lectures on basic gender literacy, as well as pertinent clinical, surgical, and imaging aspects of gender-affirming care.
Participants were presented with—and provided continuing access to—a gender diversity toolkit, care of the two course directors for “Improving Care of Gender-Diverse Patients in Radiology Departments” at the ARRS Annual Meeting:
Sarah Menashe, MD
Assistant Professor, Pediatric Radiology
University of Washington School of Medicine
Seattle Children’s Hospital
Jason Wright, MD
University of Washington School of Medicine
Seattle Children’s Hospital
Additionally, all viewers of this #FOAMrad resource from ARRS will enjoy a step-by-step guide and repository of resources enabling individuals and departments to improve their provision of gender-affirming care in both the adult and pediatric settings.
Gender-diverse patients deserve uniform access to culturally competent, affirmative care in an environment that is free from harassment, discrimination, and bias. Apropos, this Featured Sunday Session during the 2023 ARRS Annual Meeting sought to educate medical imagers who want to improve their understanding and delivery of gender-affirming care.
What Do You Say? Literacy in Sex- and Gender-Affirming Care”—Vaz Zavaletta, MD, PhD
Overview of Sex- and Gender-Affirming Surgery—Frances Grimstad, MD, MS
Perioperative Imaging of Sex- and Gender-Diverse Patients—Michelle LaRosa, MD
Tools for Success: Practical Toolkit for Providing Gender-Affirming Care—Sarah Menashe, MD, and Jason Wright, MD
Over the last few years, we in radiology have faced incredible and unprecedented challenges in our day-to-day work, and this is true regardless of our specific work environments. Why? The pandemic, which has touched everyone and has had a profound impact on the workplace in general. It has changed how we work, approach work, and shaped our opinions of work. And it is not just the pandemic. It is political polarization, social unrest, changes in home life and education, the remote work life. The pandemic and its effects led to a great resignation, and as a result, many of our sites are now understaffed. It has been reported that one in five doctors plan to leave their current practice in two years; two in five nurses plan to leave their practice in two years; one in three doctors expect to work less next year.
Health care workers have far greater demands now than in the pre-pandemic times. The delivery of health care has changed dramatically and quickly over the last few years. There is unprecedented “consumerism” in medicine now with a mandate to improve and rethink patient access, to provide more and better mental health services to our populations, and to have transparent pricing. Many health systems are facing financial challenges.
In radiology, whether you work in a large or small private practice, remotely by yourself, an academic department in a medical center, or part of a mega-radiology practice, there has been a palpable shortage of radiologists. This shortage is fueled by a trend toward exclusive subspecialization with declining numbers of radiologists who can handle general work, ever-increasing expectations for service to our patients, referring docs, hospitals and health care systems. There is a desire by radiologists to have more flexible work hours or, simply stated, to work less hours overall compared to previous years. There is a concern about what role artificial intelligence and machine learning will play. Will we be displaced? And reimbursement has been decreasing relative to inflation and compared with other specialties. As a result of these realities and others, there is clear evidence of burnout among radiologists, similar to health care workers in other specialties. In addition, sometimes we find that the leaders in our organizations may be distant, or too corporate, or suffer from “toxic positivity,” which may be worse than “toxic negativity.”
There has been a steady headwind for years, but it now feels like a gale-force wind. And a lot of this feels out of our control.
One strategy to manage the headwinds and one that we can embrace and control is to develop a culture of teams within our workplaces. Establish teams as a core value within your workplace. If we have a culture of teams, we can mitigate and shield ourselves from some of these headwinds.
When I refer to teams, I am specifically not referring to the “macro teams” that many of us find ourselves in. For example, at Duke Health, my hospital system, it is said that the 30,000-plus employees are my “teammates.” That very well may be true. But no, I am referring to your local and focal team. I am referring to the individuals that you rely on daily or weekly to deliver your work product. It’s the folks you huddle with. And the teams develop where you huddle. If you are in training, I am referring to your team of co-residents, your chief residents, maybe your program director or coordinator who you lean on. If you are in a private practice, I am referring to those that you share physical space with, or perhaps switch call with, or the individuals you show difficult cases to, or the referring docs you have developed close relationships with, and who rely on you to deliver care.In an academic environment, it might be the members of your subspecialty division. If done well, the division pulls together as a team to deliver care, service, teaching, and research. Those divisions that have a culture of team are far more effective than those who are unable to act as a team. It’s The Teamwork Imperative.
If you are lucky enough to have these local and focal teams (and these often form and evolve organically), many challenges at work open up and become more manageable and attainable. The clouds begin to lift. Specifically, your deliverables, whatever they may be, are far more easily and effectively achieved if you have your team, and approach your work from the perspective of a team. Work becomes more efficient, fulfilling, and, frankly, more fun. The work becomes more manageable—with more aspects in your control. You become more engaged. And that then becomes an antidote to burnout. Teams, therefore, contribute to retention.
Communication in the workplace is critical to developing teams. Of course, communication is about sharing news back and forth, accurately and honestly, but more importantly, communication is to be able to probe, to be able to respectfully question, and to be able to expect honest answers from your teammates. Sometimes, the questions aren’t easy, and the answers may not be easy either. To foster an effective team requires the ability and the safety of pointing out the opportunities—those ones are easy.More important, it is to have safety in pointing out deficiencies—those are more difficult. It is critical for teammates to be able to receive and internalize the information coming from within the group, whether it is a kudo or whether it is an observation, or whether it is a deficiency or a criticism.
You have to talk to each other. Actually talk. And in a world of remote work and texting, we don’t talk enough. Maybe the talking occurs in a partner meeting, in a defined clinical case conference, or in a resident, division, or department meeting. Maybe it is your team taking a coffee break or going for a midday walk to achieve “steps” goals. Hopefully, the team dynamics are such that one can tap a teammate on the shoulder and engage in an effective and safe conversation.
Communication needs to be practiced. That is why standing, regular, in-person meetings, even if the agenda is light, are very important. The opportunity to come together regularly promotes the importance and expectation of communication. It is habit forming. You get better at it.
The communication must be honest with an expectation for mutual trust. Trust means telling the truth, and telling it sooner rather than later; knowing that within a team, that can be hard.It can be hard because so many of us struggle with confrontation and conflict and try to avoid them.
Honest and fair difficult conversations almost always produce results. If you can get through the first 30 seconds of a difficult conversation, often the clouds lift and a very productive conversation follows. For me, I need to write down the key first few sentences for that opening 30 seconds and the rest flows. If difficult conversations don’t produce results, you have learned something.
Communicating in person is far more effective than in an email or text. Personal communication often fosters human connections and colleagueship. Time spent with each other, sharing aspects of ourselves, results in caring. The time may be as simple as grabbing a cup of coffee together or asking someone about their weekend. Caring strengthens the interconnective web between team members, making the team softer in a positive way, and more personable, yet, at the same time stronger.
And this is whyI worry about remote work. I understand well thatthe pandemic has shown that we can do radiology effectively, even remotely. People like it and expect it. And we have learned that we can teach remotely. But it seems far more difficult to foster a genuine, caring environment when work is dispersed in many geographic locales and individuals work essentially independently, free of meaningful, direct interactions with other teammates, other humans.To me, the same applies to Zoom meetings. All the nuanced talk and greetings pre- and post-meeting are lost. The body language is lost. The sense of community is lost, or at least different. And I think the effectiveness of the meeting suffers. Indeed, on a Zoom meeting, you can’t even have real eye contact. I worry that with remote work, the culture of our teams may be eroded.
So, work to develop teams in your workplace. Together, as a team, we are stronger. And this is something within our control. There is an imperative to create, sustain, and grow teams in our radiology workplace.
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. The other factor in this study by Bentouati et al. that showed to combat cognitive and physical decline was 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.
In “Words of Wellness” on www.radfyi.org/, members of the ARRS Wellness Subcommittee share what “wellness” and “wellbeing” mean in their own clinical practices, research focuses, and everyday lives.
Top 3 Songs from Dr. Wang’s Motivational Playlist for Wellness:
“Rise Up” by Andra Day
“I’ll rise unafraid.”
2. “Fight Song” by Rachel Platten
“This is my fight song Take back my life song Prove I’m alright song My power’s turned on Starting right now I’ll be strong I’ll play my fight song And I don’t really care if nobody else believes ‘Cause I’ve still got a lot of fight left in me”
3. “Hero” by Mariah Carey
“So when you feel like hope is gone Look inside you and be strong And you’ll finally see the truth That a hero lies in you”
HELP, I am getting old! I can look back at my time in the workplace and remember how different things used to be. And while changes in the workplace have mostly been gradual over decades, the COVID-19 pandemic appears to have had a catalytic effect.
I do, however, much prefer my new workplace environment over the past, and I am painfully aware that—for many readers—my current workplace is still a workplace of the “future.”
Here’s where I am at:
I have flexibility of my work hours in that we have shifts spanning different hours throughout the day, currently 7 am to 10 pm. While I cannot just choose on a daily basis which shift I am working, or even drop in whenever I feel like it, I much enjoy the ability to choose shifts that best accommodate my personal life. Also, I now have the flexibility of working from home. Although I cannot choose on any given day whether I work from home or not, certain shifts (day, evening, and weekend) allow me to do so, if that is my preferred way to work. On those days, my husband (who is a 100% remote worker) and I share the apartment as officemates. Fun!
Technology enables me to be more efficient; for example, manage emails anywhere and anytime from my smart devices and easily collaborate on shared files, while protecting my organization’s need for data security. Fancy applications, like video conferencing, surveying, and data visualization, are easily accessible to me through my organization. A nerd’s dream come true…
My work environment is defined by democracy, information sharing, learning, and collaboration. Our section makes decisions jointly, and each voice is heard. We transitioned from random score-based peer review to peer learning. And performance assessment is no longer based on knowledge agreement or RVUs, but focuses on engagement, such as participation in peer learning and educational feedback to technologists. We share information daily in an online chat that includes all radiologists and trainees on service at any location within our system. Each day, we collaborate: sharing interesting cases online, consulting each other for second opinions, taking turns in providing a teaching session.
Our work and our career paths are becoming more customized. I am interested in Quality and Safety, and I am being given the opportunity to pursue this as my professional career. Others can nurture interests in education, research, or information technology to become leaders in those areas.
These are amazing improvements taking place in our work environments. Since 2015 or so, we are said to be living through the Fourth Industrial Revolution, which is defined by cyber systems, machine learning and artificial intelligence, cloud technology, social media, a focus on human-machine interactions, deployment of nanoparticles, and a shift towards sustainability. Self-actualization is a big part of the Fourth Industrial Revolution, resulting in wokeness with regards to diversity, equity, and inclusion.
Technology developments are the major drivers of the previous Industrial Revolutions, hence the name “Industrial.” But isn’t technology developed by humans? And aren’t these humans driven by simply wanting to make our lives better? In some way, each Industrial Revolution has propelled society further up Maslow’s pyramid of needs. Mostly in developed countries, we have surpassed the stage where our livelihoods serve physiological needs, such as food and shelter; we have gained safety and security through advances in technology and science; we opened new pathways to filling social needs, such as a sense of belonging and social networking, and we are now able to achieve self-actualization for ourselves and others.
This is too rosy a picture for you? You are right. Each Industrial Revolution has also had negative effects, such as unsafe working conditions in early factories, unhealthy living conditions in overcrowded cities, a greater divide between the wealthy and poor, fake news, and now a threat that AI will overpower humanity.
So, why did I write all of this? I had a thought that the change we are living is an opportunity and responsibility, maybe even an obligation. We are given the tools to decrease radiologist burnout—let’s use them! We are given the opportunity to improve patient care through machine learning and AI—let’s go for that! We can practice radiology with a more sustainable footprint—let’s rise to this challenge. We can afford equity—let’s invest in that.
The third Industrial Revolution was named the “Digital” Revolution. Let’s make sure that history will give a positive name to our fourth Industrial Revolution.
Nadja Kadom, MD
Director for Quality, Department of Radiology, Children’s Healthcare of Atlanta Interim Director for Quality, Department of Radiology and Imaging Sciences, Emory Healthcare Professor, Emory University School of Medicine
ARRS and 11 other medical imaging organizations are collaborating on the Radiology Health Equity Coalition (RHEC) to curate and disseminate trusted resources and best practices for improving access and utilization of preventative and diagnostic imaging.
A decade has passed since the United States Preventive Services Task Force’s first recommendation of low-dose CT (LDCT) for lung cancer screening (LCS). And yet, national LCS rates still remain worrying low: fewer than 1 in 10 Americans eligible for LDCT actually undergo annual screening. Compared with more established screening examinations for other cancers—about 67% for mammographic screening, 69% for colorectal screening, and 74% for cervical screening—LCS’ less than 10% looks even lower.
The President’s Cancer Panel points to LCS as the single most effective strategy for reducing mortality from the disease, as well as for helping to close the healthy equity gap with improved access to care. Of course, for rural and racial/ethnic minority cohorts, access to and utilization of LCS has proven particularly tough. Not only are rural and minority populations more likely to live more than half an hour away from a designated screening center, all too often, these patients are also underinsured and suffer from lower levels of health literacy.
That said, low usage rates for LCS do present a unique opportunity for radiologists and allied medical professionals at every step of the imaging encounter to work together with patient and caregiver advocates, community health organizations, cancer centers, and insurers to enhance accessibility for lifesaving and effective LDCT.
Screening on Saturday?
Although advances in modalities and innovations of technique have leveled the field, perhaps the most persistent barrier to screening is scheduling. What is the patient’s availability? When is the appointment?
On Saturday, November 11, 2023, ARRS and partner societies of the Radiology Health Equity Coalition (RHEC) will collaborate with the American Cancer Society’s National Lung Cancer Roundtable for the second annual National Lung Cancer Screening Day. A key date during Lung Cancer Awareness Month, National LCS Day encourages facilities to keep open their doors on the second Saturday in November, specifically for LDCT lung screening. In addition to raising awareness for early detection of lung cancer at large, Saturday screening allows those individuals who have already been referred for LDCT to get scanned—without having to take a day off of work, themselves.
Curious if your practice or department is able to support this year’s National LCS Day on the 11th of November? There are some questions you will need to answer, first and foremost:
Talk to your supervisor or chairperson. Discuss among colleagues. You’ll need approval and allocation for the additional screening, including a CT technologist for each LCS unit.
Perhaps there’s only a timeframe you’re able to offer LCS: morning only, afternoon only, late morning/early afternoon?
Inform scheduling staff your facility will be opening on November 11, so they can offer patients that Saturday option
Confirm with IT that scheduling system is open for booking appointments
Marketing & Communications
Ask your marketing department to promote the event: press release, social media, etc.
Should your practice or department find all the necessary resources to scan on Saturday, here are some day-of tips to consider that will help you have a successful screening:
Again, ensure your National LCS Day event is staffed accordingly
CT Tech—double-check!
Registration
Maintenance and housekeeping
Security
Refreshments (if allowed)
Coffee and donuts for Saturday morning
Snacks and drinks for Saturday afternoon
Marketing & Communications
Invite PR representative to take pictures and interview patients on Saturday
National LCS Day is intended to serve as a catalyst for year-round screening awareness efforts, of course. Rather than waiting until the second Saturday in November to work screening into their routine, patients and clinicians alike are encouraged to make accessible LCS a year-round priority.
Finally, acknowledging that National LCS Day falls on the Veterans Day holiday, RHEC is pleased to be working alongside the U.S. Department of Veterans Affairs to increase outreach and awareness to our military population, in turn saving more lives.
Radiology education has evolved significantly over the last decade, particularly with respect to the medium in which content is delivered to learners. As a trainee nearly a decade ago, I relied heavily on printed books, peer-reviewed journal articles, and, occasionally, online resources for learning the fundamentals of diagnostic radiology and preparing for board examinations. In their own quest to learn the nuances of radiology, the current generation of radiology learners—medical students, residents, and fellows—are turning more frequently to open-access sources widely available on the internet .
Musculoskeletal Radiology Case Discussions
In an effort to engage this millennial generation of learners, I decided to deliver and publish educational videos on YouTube. While there is a plethora of expertly curated content online—ARRS’ own monthly newsletter, The Resident Roentgen File, chief among them—I wanted to provide a service specific for radiology trainees and medical students interested in diagnostic radiology.
To that end, each week, I publish brief musculoskeletal case discussions on high-yield topics that are geared to prepare junior and senior radiology residents for the American Board of Radiology (ABR) Core Exam. These videos are helpful for radiology residents and medical students alike—anyone wishing to learn more about the fundamentals of commonly encountered musculoskeletal pathologies and diagnoses seen in the reading room on a day-to-day basis.
ARRS #FOAMrad: Joints of the Lower Extremities
Meanwhile, this open-access ARRS Web Lecture series, Musculoskeletal Lower Extremity Joints, considers MR features and diagnosis relating to foot, ankle, and hindfoot pain; commonly missed injuries in lower extremity joints; and patterns of injuries seen on knee MRI.
United States Medical Licensing Examination Tutorials
Recently, for medical students, I started publishing short YouTube tutorials every week with tips for succeeding on the United States Medical Licensing Examination (USMLE) through the lens of imaging. Every year, I hear more and more medical students telling me that more imaging appears on the USMLE examination, and students often feel unprepared for interpreting complex images during the examination.
Thus, I decided to offer students free access to short tutorials regarding high-yield topics covered on the USMLE examination, focused on interpreting diagnoses and pathologies they are likely to encounter. As a secondary aim, I hope these videos will show medical students throughout the world the importance radiology plays in the delivery of optimal patient care.
ARRS #FOAMrad: ABR Exam Prep
As the landmark assessment for in-training radiologists, there are myriad materials of varying utility to prepare them for the ABR Qualifying (Core) Exam. Featuring practical tips from residents who have recently aced the test, this ARRS Roentgen University webinar is purposefully designed to help future test-takers of all learning types identify the most useful, truly indispensable study guides.
The landscape and education of radiology is changing; we must embrace this opportunity to provide our students and trainees the most relevant content in a way that is most feasible for their learning. I hope that radiology educators will continue to use the most pertinent innovative tools and methods to educate the new generation of learners. Our field depends upon it.
Department of Radiology and Biomedical Imaging University of California, San Francisco
Brett M. Elicker
Department of Radiology and Biomedical Imaging University of California, San Francisco
The diagnosis of interstitial lung disease (ILD) involves multidisciplinary collaboration among radiology, pulmonary medicine, rheumatology, and anatomic pathology disciplines. Imaging findings play a major role in the diagnosis of a variety of diffuse lung diseases, and the radiologist’s input into the ultimate diagnosis is often substantial [1]. Imaging is of critical importance in the diagnosis of ILD, although the accurate interpretation of characteristic high-resolution CT (HRCT) findings can be challenging. This InPractice article will review common pitfalls for those tasked with interpretation of CT in the diagnosis of ILD with a focus on avoiding common errors, identifying distinguishing features of specific diagnoses, and recognizing entities with which CT has limited sensitivity.
Overdiagnosis of Usual Interstitial Pneumonia Pattern
The goals of the radiologist in the evaluation of a patient with suspected pulmonary fibrosis are to determine whether a diffuse lung disease is present, determine the pattern of fibrosis, and provide an appropriate differential diagnosis. Usual interstitial pneumonia (UIP) pattern of pulmonary fibrosis is the most common ILD. UIP is most frequently idiopathic, but can also be secondary to connective tissue disease, medications, or exposure to asbestos [2]. Given the pervasiveness of this diagnosis, radiologists participating in the multidisciplinary diagnosis of patients with suspected ILD are frequently asked whether CT findings support a UIP diagnosis.Fortunately, guidelines can increase the confidence of radiologists in correctly identifying patients with UIP. The American Thoracic Society guidelines for the diagnosis of UIP pattern break down CT findings into four categories: UIP, probable UIP, indeterminate for UIP, and alternative diagnosis. The CT findings indicative of UIP pattern include subpleural and basal predominant fibrosis in addition to honeycombing, with or without traction bronchiectasis (Fig. 1).
Fig. 1—73-year-old man with idiopathic pulmonary fibrosis. HRCT scan shows usual interstitial pneumonia pattern of fibrosis characterized by subpleural and basal distribution of fibrosis with honeycombing.
This is to be distinguished from the probable UIP pattern, which is characterized by the same distribution of fibrosis including reticulation and traction bronchiectasis, but the absence of honeycombing [3].
The PPV of UIP pattern on CT for histologic UIP at surgical lung biopsy exceeds 90%, and as such, surgical lung biopsy is rarely performed when a confident diagnosis of UIP pattern can be made from imaging [3, 4]. For this reason, a diagnosis of UIP should only be made when the radiologist is confident that the imaging findings are consistent with this pattern, because often further diagnostic testing will not be pursued, potentially depriving the patient of the opportunity to receive the correct diagnosis. This distinction is not trivial; those diagnosed with UIP may be treated with antifibrotic medications and thus be subject to the side effects thereof. Not surprisingly, patients treated with antifibrotics for UIP will not be given immunosuppressive therapy, which could be a more appropriate treatment in the setting of another histologic diagnosis (e.g., nonspecific interstitial pneumonia) nor will an extensive search for exposures be pursued (e.g., as is done with patients with hypersensitivity pneumonitis).
Given the importance of correctly making a diagnosis of UIP and avoiding overdiagnosis of this entity, radiologists interpreting HRCT should be mindful of the potential pitfalls described in the following sections.
Correctly Distinguish Honeycombing From Mimics
Honeycombing can be confidently diagnosed when there is a group of round clustered air-filled cysts in a row or cluster in the subpleural lung [5]. The subpleural involvement in honeycombing is critical in distinguishing it from other abnormalities. Multiple layers of cysts increase the reader’s confidence in honeycombing but are not required for diagnosis. Honeycomb cysts usually range in size from 3 to 10 mm and have relatively thick, well-defined walls [6]. In general, there is moderate agreement among radiologists for the presence of honeycombing, with kappa values ranging from 0.4 to 0.6 in one series comparing 43 different observers. There was disagreement on the presence of honeycombing in 29% of these cases [7]. Use of the above general rules for the features of honeycombing is helpful when distinguishing from common mimics. The most frequent findings mistaken for honeycombing include traction bronchiectasis, cystic lung disease, emphysema, and subpleural reticulation [8].To distinguish traction bronchiectasis from honeycombing, the shape of the air-filled structure should be noted. Airways in traction bronchiectasis are tubular in shape, which may be best seen on multiplanar reformatted images. Additionally, air-filled structures in the central or peribronchovascular lung are not consistent with honeycombing and are very likely a result of dilated airways (Fig. 2).
Fig. 2—Patient with scleroderma and fibrotic nonspecific interstitial pneumonia. Left, HRCT scan shows traction bronchiectasis mimicking honeycombing. Right, HRCT scan shows that air-filled structures spare subpleural lung.
Destruction of airspaces in patients with emphysema can lead to the presence of air-filled structures in the subpleural lung; however, these structures can be distinguished from honeycombing by the overall size of emphysematous spaces that in general are larger than honeycombing cysts, the presence of paper-thin walls in emphysema in contrast to thicker walls of honeycombing, and the absence of other findings of fibrosis such as reticulation and traction bronchiectasis in patients with emphysema [9] (Fig. 3).
Fig. 3—HRCT scan shows patient with paraseptal emphysema with extensive involvement of subpleural lung, but without well-defined walls or other findings of fibrosis.
Cystic lung disease can be distinguished from honeycombing given that the cysts are often larger, scattered throughout the lung rather than clustered, and not subpleural in distribution. Shape can also be helpful in distinguishing cystic lung disease from honeycombing in that honeycomb cysts are round, whereas several cystic lung diseases are characterized by either oblong or elliptical cysts (Birt-Hogg-Dubé syndrome) or irregularly shaped cysts (Langerhans cell histiocytosis) [10].
Reticulation or fine lines in the subpleural lung can also be mistakenly identified as honeycombing. To avoid this pitfall, radiologists should ensure that the subpleural abnormality is air density rather than lung density (Fig. 4).
Fig. 4—HRCT scan shows thin lines in subpleural lung in patient with pulmonary fibrosis characterized by diffuse reticulation. Abnormality in subpleural lung is lung density (same as more central lung parenchyma) rather than air density (for example in trachea), which is helpful in confirming that these findings do not represent honeycombing.
Identify Whether the Distribution of Fibrosis Is Subpleural and Basal
Fig. 5—Fibrosis with honeycombing in atypical distribution. Left, Axial HRCT scan shows diffuse fibrosis in association with ground-glass opacity. Diagnosis was hypersensitivity pneumonitis. Right, Coronal HRCT scan shows upper lobe–predominant fibrosis. Diagnosis was sarcoidosis.
Fibrosis that is diffuse in the axial plane or predominately in an upper lung, central, or peribronchovascular distribution may indeed be associated with honeycombing but nonetheless be caused by other entities such as nonspecific interstitial pneumonia, sarcoidosis, or hypersensitivity pneumonitis [11, 12]. Subpleural and basal distribution of fibrosis is essential to describing a pattern of fibrosis consistent with UIP at imaging. A percentage of cases with atypical distributions of fibrosis and honeycombing may be subsequently identified as UIP after biopsy; however, these cases are exactly those that benefit from surgical lung biopsy because there is a relatively high chance (70%) that another diagnosis will be found [12, 13].
Identify Inconsistent Findings
Numerous CT findings are of a diagnosis other than UIP pattern including the presence of significant ground-glass opacity, marked mosaic attenuation, nodules, and consolidation [13]. Each of these findings points the radiologist toward a diagnosis other than UIP. Patients with nonspecific interstitial pneumonia (i.e., ground-glass opacities), hypersensitivity pneumonitis (i.e., mosaic attenuation), sarcoidosis (i.e., nodules), and organizing pneumonia (i.e., consolidation) can all be identified by the presence of these features, and the presence of honeycombing should not detract from the CT findings that indicate these alternative diagnoses.
Overdiagnosis of Cystic Lung Disease
Many of the pitfalls in correctly identifying honeycombing and distinguishing honeycombing from mimics can also be applied to the correct diagnosis of cystic lung disease. When considering a potential diagnosis of cystic lung disease, it is important to again identify mimics: honeycombing, dilated airways and bronchiectasis, and emphysema. The extent of abnormality, from mild to severe, is also important to consider in this context. A few scattered pulmonary cysts may be considered in the spectrum of normal, particularly for older patients, and are most likely postinfectious rather than indicative of a cystic lung disease [14].Whereas the primary features of bronchiectasis (i.e., tubular shape) and honey- combing (i.e., thick walls, clustered, subpleural) make distinguishing these entities from cystic lung disease more straightforward, correctly distinguishing cystic lung disease from emphysema can be challenging. This challenge is in part because both entities can have very thin or imperceptible walls and can occur on a spectrum from mild to severe. The presence of the “central dot” sign in which the centrilobular artery is seen within an emphysematous space can be helpful in correctly distinguishing centrilobular emphysema from a cystic lung disease; however, this finding is not reliably seen in all regions of emphysema [15] (Fig. 6).
Fig. 6—Axial HRCT scan shows “central dot” sign in patient with centrilobular emphysema.
In general, pulmonary cysts are fewer in number, noncentrilobular in distribution, and have thicker or more perceptible walls compared with centrilobular emphysema [16]. Paraseptal emphysema and panlobular emphysema are less frequently mistaken for cystic lung disease because of their strongly subpleural distribution and overall extent respectively.
Distinguishing cystic lung diseases from one another can also be challenging; however, several key features including cyst shape, number, distribution, and classic demographic factors and associated findings can aid the radiologist in providing an appropriate differential diagnosis. Using these features allows the radiologist to narrow the differential diagnosis for a particular case to fit the specific CT features seen rather than including a long differential diagnosis consisting of all cystic lung diseases [17]:
Female sex, renal angiomyolipoma Pneumothorax, renal mass Cysts and nodules Smoker Ground-glass opacity, connective tissue disease
The presence of associated features may also be helpful in correctly identifying the presence and cause of a cystic lung disease when the abnormalities are mild and nonspecific.
Pitfalls in the Interpretation of Mosaic Attenuation and Small Airways Disease
Small airways disease may present a significant challenge in HRCT interpretation and typically manifests on HRCT as two main categories of findings: nodules or mosaic attenuation. Nodules may correspond to any of the following histologic findings: inflammation within the lumen of the airways, alveolar disease centered on the airway, or peribronchiolar interstitial inflammation. Diseases categorized by nodules are generally detected on HRCT with high sensitivity and are typically straightforward to classify.
Small airways obstruction causes hypoxia distal to the area of obstruction, resulting in regional areas of reflex vasoconstriction. Given that approximately 50% of lung attenuation is due to blood flow, regional reductions in perfusion result in a decrease in lung attenuation. These regional areas of decreased lung attenuation are described as “mosaic attenuation” or “mosaic perfusion.” More precisely, mosaic attenuation is a more general term and describes the presence of geographic areas of different lung attenuation but does not make a determination as to which lung is abnormal, whether the opaque or lucent lung. Mosaic perfusion, on the other hand, implies specifically that the lucent lung is abnormal and is the finding that most precisely corresponds to airways obstruction with reflex vasoconstriction [18].
The differential diagnosis of mosaic perfusion is broad and encompasses a wide variety of both small airways diseases and pulmonary vascular diseases. It may be associated with other findings (e.g., nodules) or may be seen in isolation. The presence of mosaic perfusion is most helpful in formulating a differential diagnosis when seen in isolation, in which case it may be due to pulmonary vascular disease (mainly chronic thromboembolic disease), constrictive bronchiolitis, asthma, and hypersensitivity pneumonitis [19].Diseases characterized by isolated mosaic perfusion may present a significant challenge for several reasons. First, mosaic perfusion is a finding that is sometimes difficult to detect on HRCT. The subtle difference in attenuation frequently seen between the normal and more lucent lung is better observed when a narrow window is applied to the HRCT examination, accentuating the attenuation differences (Fig. 7).
Fig. 7—Mosaic perfusion and importance of windowing in high-resolution CT (HRCT). Left, Standard lung window in HRCT shows heterogeneous lung attenuation with subtle difference between opaque and lucent lung. Right, More narrow window accentuates difference between two lung attenuations and increases sensitivity for detection of mosaic perfusion.
Second, when small airways or vascular diseases are diffuse in nature they result in a global and uniform decrease in lung perfusion. A diffuse HRCT abnormality is difficult to identify because there is no normal lung with which to compare the abnormality. This is most commonly seen in severe constrictive bronchiolitis [20]. Additionally, diffuse air trapping on expiratory CT is difficult to distinguish from poor timing or an inadequate respiratory effort. In these cases the HRCT scan may appear normal despite profound dyspnea and marked obstruction on pulmonary function tests. The diffuse but subtle decrease in lung attenuation is often not detected given its homogeneous nature.Mosaic perfusion (i.e., abnormal lucent lung) should be distinguished from ground-glass opacity (i.e., abnormal opaque lung), however, this distinction also has several pitfalls. Features that favor mosaic perfusion include sharp borders between the two regions of lung, smaller vessels in the lucent lung, and air trapping on expiration in the areas that were lucent on inspiration that only present in small airways disease (Fig. 8).
Fig. 8—Features of mosaic perfusion on high-resolution CT (HRCT). First two images, Axial HRCT scans show typical features of mosaic perfusion including sharp borders between opaque and lucent lung (first), larger vessels in normal more opaque lung (second), and air trapping on dynamic expiratory images. Third and fourth image, Paired inspiratory (third) and expiratory (fourth) HRCT images show heterogeneous lung attenuation on inspiration and air trapping on expiration.
None of these features are perfect in making this distinction, however. For instance, diseases characterized by ground-glass opacity may occasionally be geographic with sharp borders (Fig. 9).
Fig. 9—Axial high-resolution CT scan shows ground-glass opacity due to SARS-CoV-2 infection. Sharp borders between areas of opaque and lucent lung usually suggest that lucent lung is abnormal and pattern is mosaic perfusion. However, sharp borders may occasionally be seen in ground-glass opacity, such as in this case. Normal lung and areas of ground-glass opacity show marked difference in attenuation.
In these cases, the absolute difference in attenuation between the two regions of lung may be helpful. Mosaic perfusion typically results in a relatively subtle difference in attenuation between the diseased lucent lung and the normal opaque lung. Ground-glass opacity, on the other hand, typically shows a more marked difference in density between the two areas [21]. That being said, when mosaic perfusion results in significant shunting of blood away from the diseased areas, a greater difference in lung attenuation may be present. These cases are not infrequently misinterpreted as ground-glass opacity. Another challenge in the distinction between mosaic perfusion and ground-glass opacity is that many cases of mosaic perfusion will not show a significant difference in vessel size between the lucent and opaque lung. Last, pulmonary vascular diseases characterized by mosaic perfusion will not show air trapping on expiratory CT. Thus, expiratory CT is not helpful in the diagnosis of diseases such as chronic pulmonary embolism [22].
Pitfalls in the Interpretation of Diffuse Nodular Lung Disease
Formulating a differential diagnosis of diffuse nodular lung disease is done by identifying the distribution of nodules in relation to the pulmonary lobular anatomy. Three distributions have been described: perilymphatic, random, and centrilobular [23–25]. The perilymphatic distribution is characterized by patchy, clustered nodules that are concentrated most frequently in the peribronchovascular and subpleural interstitium. Random nodules will also be seen in the subpleural lung; however, they are not clustered but instead show diffuse homogeneous lung involvement. Centrilobular nodules are characterized by a distinct lack of nodules involving the subpleural interstitium.
The determination of the predominant pattern of diffuse nodular lung disease has several pitfalls. The perilymphatic pattern shows significant heterogeneity in the distribution of nodules. Although peribronchovascular and subpleural nodules are most typical, nodules in the interlobular septa, which also contain lymphatics, may predominate [26]. These cases may be confused for lymphangitic spread of tumor or pulmonary edema, although the thickening of the interlobular septa in pulmonary edema should be smooth, not nodular. The centrilobular interstitium is continuous with the peribronchovascular interstitium. Rarely, lymphatic diseases may have a predominance of centrilobular nodules overlapping with the centrilobular distribution (Fig. 10).
Fig. 10—Axial high-resolution CT scan shows centrilobular nodules in perilymphatic disease. Many centrilobular nodules (arrows) are present in this patient with sarcoidosis. Subpleural nodules reflect perilymphatic distribution of disease.
Although many centrilobular nodules may be present in lymphatic diseases, nodules should also be seen in the peribronchovascular or sub- pleural interstitium. This is in distinction to the centrilobular pattern in which only centrilobular nodules are present and no subpleural nodules should be seen. Lastly, diseases typically associated with a perilymphatic distribution of nodules (such as sarcoidosis) may occasionally show a fairly homogeneous involvement of the lung, mimicking a random distribution [27] (Fig. 11).
Fig. 11—Axial high-resolution CT scan shows perilymphatic distribution mimicking random nodules. Innumerable tiny nodules are present. Although pattern resembles random distribution, heterogeneous distribution in lung shows proportionally more nodules along fissures (arrows) than would be expected for random distribution.
A greater number of nodules in the subpleural or peribronchovascular interstitium may be the only clue that the distribution is perilymphatic.
Diseases for Which HRCT Has Limited Sensitivity
Certain categories of diseases may present with significant symptoms or pulmonary function test abnormalities but only manifest with mild HRCT abnormalities. Understanding the subtle imaging clues that may be present in these diseases is important in increasing the sensitivity of imaging for diagnosis. The two main categories of disease that show this discrepancy between symptoms and pulmonary function tests and HRCT manifestations of disease include small airways diseases and pulmonary vascular diseases. As discussed above, small airways diseases that manifest as isolated mosaic perfusion (e.g., constrictive bronchiolitis) may be difficult to detect on HRCT. The subtle increase in lung lucency associated with these diseases may be difficult to see, especially when the disease is diffuse in distribution [28]. Pulmonary vascular diseases such as pulmonary hypertension or chronic pulmonary embolism may also present with subtle findings. Centrilobular nodules or ground-glass attenuation or mosaic perfusion are often the only findings present and are typically much less severe than would be predicted by the patient’s advanced clinical symptoms. The lungs may appear completely normal in some patients with pulmonary vascular disease, in which case the only manifestation of pulmonary vascular disease may be extrapulmonary findings such as an enlarged pulmonary artery or right ventricular enlargement [29]. Lastly, pulmonary symptoms and pulmonary function test abnormalities might have one of several nonlung causes including pleural fibrosis, diaphragmatic dysfunction, and musculoskeletal abnormalities. All of these should be evaluated in patients with significant symptoms but no evidence of lung abnormalities on HRCT.
Awareness of common pitfalls in the diagnosis of ILD including the UIP pattern of fibrosis, cystic lung disease, airways disease, diffuse nodular disease, and lung diseases with subtle HRCT findings will better equip the radiologist to contribute to the multidisciplinary diagnosis of patients with ILD.
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Center for Evidence-Based Imaging Brigham and Women’s Hospital
What would you do if your hospital was going to run out of iodinated contrast? Reduce the amount of IV contrast used for each CT scan? Administer multiple doses of IV contrast from a single-use vial? Defer non-urgent contrast-enhanced CT? Utilize alternative modalities, such as ultrasound, MRI, or PET/CT?
In March of last year, supply chain disruptions in China resulted in an unexpected 80% reduction in global supply of iohexol (Omnipaque, GE Healthcare). Hospitals needed to make immediate decisions about ways to conserve contrast. Otherwise, they may run out. The American College of Radiology [1], Radiological Society of North America [2], and American Hospital Association [3] released statements, and AJR continues to publish all of its research regarding the contrast media shortage as free and open access [4].
The situation was rapidly evolving, but getting more inventory wasn’t an option. As part of the response to the contrast shortage, our hospital system created and implemented an electronic health record (EHR) -based solution to help reduce iodinated contrast usage by targeting referring provider CT ordering patterns [5].
First, we added a sidebar to the ordering panel that presented an alert describing the shortage (Fig. 1), including the following strategies for imaging patients (Intervention 1; May 10, 2022):
Fig. 1—Screenshot from electronic health record shows sidebar text displayed to referring clinicians after placing orders for body CT (defined as CT of neck, chest, or abdomen and pelvis) that describes iohexol shortage and provides appropriate strategies for iodinated contrast media conservation.
Oncologic Imaging
Avoid contrast for chest CT done alone to assess metastatic disease, unless primary is thoracic malignancy
For chest/abdomen/pelvis restaging exams, consider combining non-contrast CT chest with abdominal MRI
Consider abdominal MRI for assessment of hepatic metastases
Non-Oncologic Imaging
CT for pulmonary embolism (PE)—utilize risk scoring methodology, such as Wells criteria or pulmonary embolism rule-out criteria (PERC), before pursuing CT
CT chest for lung parenchymal disease does not require IV contrast
In case of suspected musculoskeletal infection, use MRI
Emergency Imaging
Neuro
CTA head/neck—contrast needed to assess large vessel occlusion in patients within stroke treatment window. For subacute stroke outside window, please consider non-contrast head CT, followed by MRI, when appropriate
Reconsider CTA utilization for low-yield indications, including headache and dizziness
Thoracic
CT for PE—utilize risk scoring methodology (i.e., Wells or PERC)
CT chest for lung parenchymal disease doesn’t require IV contrast
Abdomen/pelvis
Pancreatitis and pyelonephritis—CT rarely indicated for these diagnoses
For primary hepatobiliary concerns, right upper quadrant ultrasound remains an excellent choice, unless high likelihood that CT also needed to explain symptoms
GI Bleeding—reserve CTA for patients with bright red blood per rectum or hemodynamic instability in whom acute intervention might be needed
Trauma
CT torso with IV contrast is needed to assess for parenchymal or vascular injury.
Consider non-contrast CT torso imaging (or radiography) in patients with low suspicion for parenchymal or vascular injury, such as elderly patients with ground-level fall and suspicion for rib fracture or thoracic/lumbar spine fracture
Next, we required referrers to enter additional clinical information into a free text field describing why iodinated contrast was needed for the CT (Intervention 2; May 16, 2022).
The number of patients undergoing contrast-enhanced CTs per day decreased from 726 prior to the interventions, to 689 after intervention 1, to 639 after intervention 2 (Fig. 2).
Fig. 2—Box-and-whisker plots show changes during preintervention and postintervention periods in number of patients who underwent contrast-enhanced CT examinations per day. Centerlines represent medians, ends of boxes represent interquartile ranges, ends of whiskers represent interdecile ranges, and dots beyond ends of whiskers represent outliers.
The overall number of patients undergoing CT per day decreased, as did the percentage of CT exams performed with IV contrast. These decreases were seen for all CT, as well as body CT alone (neck/chest/abdomen/pelvis). As expected, there was a decrease in requests for contrast-enhanced CT and a corresponding increase in requests for non-contrast CT.
In summary, an EHR intervention was able to reduce the number of contrast-enhanced CTs per day by 12%, the total number of CTs performed per day decreased 2.7%, and the percentage of CTs performed with IV contrast per day decreased from 53.8% to 48.6%. This simple intervention was implemented within weeks of the onset of the shortage and led to rapid practice change. Along with other conservation strategies, our health system was able to avoid rationing and continue near normal operations.
References
Wang CL, Asch D Cavallo J. Statement from the ACR Committee on Drugs and Contrast Media on the Intravenous Iodinated Contrast Media Shortage. J Am Coll Radiol 2022; 19:834-835
Grist TM, Canon CL, Fishman EK, Kohi MP, Mossa-Basha M. Short-, mid-, and long-term strategies to manage the shortage of iohexol. Radiol 2022; 304:2
Glazer DI, Lucier DJ, Sisodia RC. Electronic health record order entry–based interventions in response to a global iodinated contrast media shortage: impact on contrast-enhanced CT utilization. AJR 2022; 220:1
