Learning from our Patient Teachers

I'm making the most of my transition back to academia by becoming a mentor in Weill Cornell's innovative LEAP program. The acronym stands for Longitudinal Educational Experience Advancing Patient Partnerships and involves partnering medical students with patients, not as care givers but as observers of the care process. A total of 250 "patient teachers" have been recruited and this year, for the first time, every first year medical student will participate, making home visits, going to doctor's appointments and understanding the wider world which our patients navigate. Monthly mentoring sessions will be student run and are expected to be a forum for sharing patients' stories as well as an opportunity to learn about all aspects of the chronic condition with which most of these patient teachers live.

The kick off session was abuzz with the collective energy of more than a hundred brand new doctors to be. The program director, internist Keith Lascalea, reassured the students that, while following one or two patients might seem overwhelming, by the time they were interns they'd be juggling 10 with no problem. He warned about managing social media connections with patients and reminded the students that they are not the patient teacher's physician and not to do any lumbar punctures in the home!

He then turned the podium over to the patient teachers. Mr W, a retired science teacher, joked about his medical student getting seasick as she followed his colonoscopy and quoted "The King and I" which probably meant nothing to the millennial audience but the room was hushed as he said, "You give meaning to our illness. While we're sick we can help you learn. As I look at your faces I realise that the future is going to be better because of you and because of this place".

Next up was a young woman who could easily have been one of the med students. Describing how her medical students had helped her through difficult visits to discuss lung transplant to replace her pulmonary fibrosis-ravaged lungs, she said "I hope this teaches you not to judge a book by its cover, when you look at me you don't see my lungs". 

Lastly, the mother of a chronically ill child described how much it meant to have her child's medical team, including the students, see the challenges they faced in their daily life away from the clinic setting. She teared up as she left the podium.

Listening to these stories I thought about the responsibility and honor we are afforded by our patients' trust in us.  Do we have any more powerful resource in our quest to learn how to be diagnosticians and healers than the patients we treat? Are those of us for whom first year of medical school was a lifetime ago connected enough with that energizing resource?

Sometimes the irritations of modern practice can seem overwhelming. Logging back in to the EHR for the 20th time in a day when my password requires 12 characters, one ancient rune symbol and several emoji; remembering to check the boxes for PQRS and trying to figure our exactly how many CME credits for MOC I need if the month has an "r" in it can leave me just a little frazzled.

Reconnecting with our patients, especially through their unique ability to teach us, puts those minor stresses in sharp perspective. Learning from their ability to manage their illnesses with humor and grace should humble and inspire us. 

Connections that are remote but real.

Reading screening mammograms, all alone in the breast imaging center on a Sunday, might on the surface seem as disconnected as it's possible to be from the patients whose studies I'm interpreting. And yet this apparently "Imaging 2.0" experience is still a chance to deliver value around the interpretation.

 

Screening means looking for disease before it has made itself clinically apparent. My colleagues who are reading CT and X-Ray today are encountering a wide range of patient complaints and disease entities. While I have only one enemy to track down, it can be a Protean opponent. This one disease entity, breast cancer, might reveal itself in 3 different women in 3 different ways today or I may not encounter it at all. It might present in the first set of images or the last. I know that over time I will see it in about 3-4 of every thousand mammograms I read but I'll never know in advance where it lurks.

 

For me, the automation of the image viewing and reporting process is what allows me to focus on the images. We have so many boxes to check, log ins to remember and buttons to push, all with very laudable goals, the interpretation of the images can easily feel like an afterthought. So it's vital to corral all the IT and QI demands and organise my work environment so that my eyes and my attention are laser-focused on the task that is my unique duty as a radiologist.

 

At the same time, I want to make the most of the information that is available to me. Yes, these are screening mammograms, and I’m really tasked with decoding the images. But a picture of the patient pops up in Epic and the stories in the patient history sheet are a constant reminder that these women are my patients and they're depending on me to get it right for them. "Do you have any family members with breast cancer?" Mother, aged 32. "Number of pregnancies" 3 "Number of live births" 1 "Are you being treated for any other cancer?" Lung. Each of these data sets is not only a patient, but also potentially a friend, a relative, a colleague, or a community member, even if they're a stranger to me.

 

I have often been asked why we don't read screening mammograms while the patient is still in the office. I know there are practices who do, and I know that to our patients it can seem like those of us who batch read are putting our convenience ahead of their very understandable desire to know their results as soon as possible. The truth is much more nuanced. Batch reading allows me to focus and reduces the number of times I ask for extra images. It also means I can be available to more patients overall to read their mammograms.

 

What I do "get" is that, with changing benefit design, patients are now paying much more out of pocket for their care. Even though their screening mammogram is "free" with no copays or deductibles, any "call back" diagnostic mammogram can end up costing them and add to a sense that we are not putting their needs first. That's why I am actively working on payment models that would align the principles of high quality breast screening with our patients' priorities. The remote but real connections that I make with the patients whose screening mammograms I interpret are a powerful incentive to deliver the most effective care possible.

Getting uncomfortable..in a good way


I turned 50 last month. In thinking about how best to celebrate this milestone I've decided that it's going to be about forcing myself to go beyond my comfort zone. Getting on a bike in NYC for the first time? Sure! Advocating for new ways that radiologists can deliver value and for payment policy that aligns incentives? Absolutely. With input from all our stakeholders: patients and colleagues and with the goal of the highest value care front and center. Let's do this.

 I think all of us in radiology have been feeling out of our comfort zone lately. Healthcare is in a state of flux. We're just starting to feel the impact of the ACA with millions of new healthcare beneficiaries and a shift from volume to value that has often seemed to cast us as part of the problem. Rapid growth in utilization of advanced imaging as the new Millennium dawned, growing awareness that there might be a price to pay for the exquisite resolution offered by newer CT scanners and widespread questioning of the benefits of screening mammography have all chipped away at the notion that radiologists have value to deliver in healthcare. Our protestations have often felt like they fell on deaf ears. Nobody seemed to be interested that much of the growth in imaging was happening in the offices of self-referrers churning out studies on their own machines at 4 times the rate they'd refer to us. Our Image Gently and Image Wisely programs that were at the forefront of improving radiation safety awareness seemed to get far less coverage than alarmist reports of CT scans causing cancer. Real, solid science demonstrating that mammography saves lives was buried under report after misleading report that confuse our patients.  All this plus a sustained attack on reimbursement for what we do has left us feeling decidedly less than comfortable.

 

But I am proud to say that as a specialty we have decided that rather than dig in and whine about our predicament we have chosen to embrace the possibilities of change and the events of this past week have shown us a path forward where we are very much part of the solution in the delivery of the highest value imaging care for our patients: a big Imaging 3.0 (http://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3) success.

 

If you're not a physician who has been subject to the slings and arrows of the flawed payment formula called the "SGR" you might have missed the complex negotiations that aimed to finally fix this flawed system. I won't belabor the details but a well-intentioned attempt in the late 1990s to make sure that Medicare spending did not outstrip spending on other programs has since 2002 led to a series of potential cuts in physician reimbursement. Each time a double digit cut would loom it would be averted at the last minute and existing payments restored. Each temporary fix or patch would last only a short time and then the whole sorry saga would start again. Each fix came with a price. The difference between what would have been paid under the proposed cut and the restored payments was chalked up as a "debt" that would have to be paid back before any permanent fix could be enacted. This year, some internal Government accounting magic reduced the debt by more than half to a relatively manageable (in overall healthcare spending terms at least) $138 billion. This galvanized physician groups and lawmakers alike to fix the payment formula and use the fix to embed new incentives for value rather than volume into the system.

 

At the ACR we saw this as an opportunity to drive appropriate imaging for Medicare beneficiaries through the use of our evidence based, educational point of care decision support toolkit. This leverages 20 years of Appropriateness Criteria development by ACR physician volunteers in collaboration with other physician groups. It has been shown to reduce advanced imaging utilization with increased appropriateness and importantly to reduce costs. Ever since ACR members flooded Capitol Hill at last year's ACR leadership meeting and demonstrated the tool to their representatives we have been telling the story of how we as radiologists can deliver value in the new world of healthcare. 

 

Our dysfunctional Congress rarely delivers these days and the SGR reform, which had seemed so promising, looked in recent weeks to be dying on the vine. Senator Max Baucus, a key champion, left for his new post as Ambassador to China. House Republicans looked to tie reform to yet another attempt to roll back Obamacare and Senate Democrats wanted to tap unused war funding to pay for it. It became clear that all we could hope for was another temporary patch. Another "bandaid" was opposed by important groups such as the AMA and I respect their desire to see this problem fixed for good. But at the ACR we decided that the momentum around the use of CDS was not something we could afford to waste, not for the future of our profession and not for our patients. The SGR patches are typically enacted as "clean" bills i.e they do not include any other provisions. Our tireless campaign to tell the story of appropriate imaging's value paid off however and the language in the abandoned full reform bill that mandated the use of CDS for advance imaging made it into the patch.

 

Is this out of our comfort zone as radiologists? For sure. We will probably do fewer studies overall although in some cases, lung cancer screening with CT for example, we may do more. But it will be the right imaging. We must make ourselves readily available to our colleagues to help them navigate those scenarios where the AC inevitably do not always have an answer. But we will, by doing this, immeasurably increase our profile and relevance. We must develop and advocate for future payment policy that recognizes and incentivizes the value added activities that only radiologists can deliver. This advocacy will ensure not only the future of our specialty but also the improved health of our most important constituency: our patients.

 

So here's to getting out of our comfort zone!

Imagining the possibilities

I heard Virgil Wong speak at the NYeHealth Digital Health conference last Fall. Virgil is an artist who trained at the prestigious Rhode Island School of Design. Studying abroad in Rome he became fascinated by human anatomy leading to a yearlong sojourn in the anatomy lab. Since then he has combined his artistic vision with information technology in various iterations leading to a truly innovative health IT concept called the Medical Avatar (www.medicalavatar.com).

Check out Virgil’s Ted talk here

The notion that patients' care and outcomes can be impacted by how they view their data seemed like an obvious Imaging 3.0 fit. I recently met with Virgil to explore this further. We talked about the use of a "time travel" concept that shows patients what they will look like if certain conditions go untreated or behaviors unmodified. Virgil currently does research at Columbia University on the impact that such visualization techniques can have on engagement, disease prevention and chronic disease management in order to optimize patient physician communication, reduce misdiagnoses, and decrease hospital readmission rates.

The symptom tracker feature of the medical avatar (http://medicalavatar.com/features/visual-symptom-tracking/) provides patients and their healthcare providers with a novel way to describe, record and track symptoms. Think about how we might benefit from the ability to glean more accurate information from our patients about why they are seeking care.

My conversation with Virgil reminded me once again of how fortunate we are as radiologists to spend our days working with such powerful images and technology. Which of us has not looked at a set of images and felt incredible professional satisfaction from being able to deliver just the information that can turn the corner in making a diagnosis?

Essential to the Imaging 3.0 philosophy is the imperative to communicate the value of imaging to our colleagues and most importantly to our patients. When we start with exquisite renderings of anatomy and hypersensitive recognition of physiology, how is it that the product we deliver to the world is often just words on a page? As we struggle to think about how to tell the story of what we can contribute, are we failing to leverage the power of the images that we interpret?

Much of my time as the ACR's Economics Commission Chair is occupied with discussions of arcane payment formulae and mitigating drastic cuts to reimbursement. The fuel that keeps me going is my persistent belief that what we get to do as radiologists is cooler (and more valuable) than any other field of medicine and that we owe it to our patients to keep our specialty at the forefront. Am I biased? A little, but try imagining healthcare without CT or MRI. The challenge I issue to us all is to find creative ways to share the beauty and power of what we create to help our patients. The work of visionaries like Virgil Wong can help and inspire us.

Digital health in NYC

Last week I attended the NYeHealth (http://nyehealth.org) Digital Health Conference. What a phenomenal conglomeration of smart people and great ideas. I left feeling so inspired and full of ideas about how to leverage data and technology to drive better care.

George Halvorsen of Kaiser Permanente gave the keynote address on Day 1 (https://speakerdeck.com/nyec/keynote-address-george-halvorson) . His take home on how we improve the healthcare system? "Make the right thing easy to do". Jim Messina headlined on the second day with juicy details of the Obama re-election but more importantly, insights into the way that data fundamentally informed the success of the campaign. His message: we need a similar rigor in designing the healthcare system of the future.

NYeC.jpg

There were elegant apps from medical entrepreneurs like Virgil Wong (http://medicalavatar.com) which uses a "ghost of Christmas future approach to show smokers what will happen to their bodies if they don't quit. It actually works! (http://virgilwong.com/research/).

 Dr Heather Evans, a trauma surgeon, shared her experience using Googleglass including connecting to her colleague doing a live hernia repair. The possibilities around documenting the care process and education are really exciting.

 I was really delighted to attend a session targeted to connecting socioeconomically challenged populations with health IT (https://speakerdeck.com/nyec/promoting-the-utility-of-patient-portals-for-safety-net-populations-with-low-literacy).

I've blogged before about my work at St Barnabas in the Bronx (http://drgeraldinemcginty.com/blog/2013/10/28/good-fundamentals). While I know that the innovations I saw at the conference could be really influential in improving population health I also know there are significant hurdles to be overcome before they can be made available to people living in poverty and facing complex health issues.

 My main takeaway was that there is a vibrant start up health IT community in NYC. I feel fortunate to be practicing here.

 

Celebrating Radiology

Friday the 8th of November has been designated as the International Day of Radiology ( http://www.internationaldayofradiology.com ). It was on this day in 1895 that Wilhelm Conrad Röntgen discovered X-rays. #IDOR2013 represents an opportunity to recognize the tremendous contribution to society attributable to this discovery and subsequent imaging innovations. With concerns over the rising costs of healthcare and radiation risk looming in patients’ minds it can be easy to forget the innumerable ways in which imaging has improved all our lives.

The occasion is also making me reflect on the reasons I chose a career as a radiologist and why I still love the clinical part of my job. As a medical student, I spent one of my summers working as a nurses’ aide on a surgical ward at East Birmingham Hospital (now Birmingham Heartlands Hospital) in the British Midlands. The experience of performing the tasks of intimate patient care, washing and changing, as well as my relative invisibility to the often aloof medical team taught me lessons I have never forgotten. The nursing staff was very kind and tried to make sure I also learned as many relevant lessons as possible for my future career. As such I was often dispatched to “X-Ray” to accompany patients. It quickly became apparent to me that the answers to the patients’ clinical problems often materialized in the imaging department. Add to that my love of anatomy and my future pathway was clear.

My training in radiology at the University of Pittsburgh Medical Center was superb. I came from Ireland where the hospital at which I did my internship did not

even have a functioning CT scanner.  Arriving in Pittsburgh I was wide-eyed to see the multiple high tech machines whirring 24 hours a day providing vital information as Dr Tom Starzl and his team transplanted livers, small bowels and even animal organs giving people a second chance at life.

When it came time to choose a fellowship I realized that for me, it was important to combine imaging with patient contact as much as possible so I pursued a women’s imaging fellowship with Dr. Dan Kopans at the Massachusetts General Hospital. Again I saw how imaging, specifically the early detection of breast cancer, could be lifesaving.

These are challenging times for radiologists. We have been seen as contributing to the problem of increasing healthcare costs and as too wedded to a payment system that rewards volume but is neutral on value. My role as the American College of Radiology’s Economics Commission Chair has provided me with the opportunity to help turn around that misperception. I am so proud to be part of our Imaging 3.0 initiative (http://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3) that seeks to place radiologists right where they belong, at the center of the delivery of high value care. It’s a place that has always been clear to me and the International Day of Radiology is a great way to celebrate who we are as a specialty.

 

Good Fundamentals

 

Over the past couple of months I have been working at St Barnabas Hospital in the Bronx as an advisor. The SBH leadership has a vision for a more community focused health system and recently embarked on a multiyear transformation project designed to achieve that goal. My perspective as a private practice physician from a very different geographic and socioeconomic setting was welcomed enthusiastically. I hope I've contributed some value. I am confident, however, that this committed group of individuals will be able to improve the care they deliver to their community because they are starting with such good fundamentals despite the hurdles.

Some of the challenges that a health system like SBH faces were an eye opener. For example, in the poorest Congressional district in the nation the community served by SBH is actually poorer and sicker than its Bronx neighbors. Speaking with Virginia Delgado -Torres, Director of Community Physician Relations, about how to communicate with the community most effectively I learned about SafeLink. This valuable program established (https://www.safelinkwireless.com) by the Stimulus Act of 2009 provides cell phone minutes free of charge to the poor. Unfortunately those minutes are delivered in bundles at the beginning of the month and once they run out it can be impossible to reach patients until they are topped put the next month. Thinking creatively about how to work around roadblocks like this will be a critical part of SBH's strategy.

An area of particular focus for me was the Breast Clinic run by surgeon Dr Bert Petersen. I worked with Burt to look for ways in which the ACR's Imaging 3.0 philosophy could help him and his team deliver more effective care. Imaging 3.0 relies heavily on Information Technology and we were able to identify several areas of opportunity. For example simply by restructuring the breast imaging order set in the Electronic Medical Record he could save valuable time previously spent hunting under different modalities.

What was really encouraging was to hear him commend the Radiology Department for their willingness to see add-on patients for procedures. A young woman with a breast abscess relaxed visibly when told that she could have an aspiration under ultrasound guidance performed the same day rather than miss school again tomorrow. That is definitely Imaging 3.0 in action. SBH made the difficult and controversial decision to discontinue its Radiology residency earlier this year. Knowing this it was important for me that the Institution recognize the value that high quality imaging can deliver. I saw many signs that that was the case and am delighted that leadership has expressed an interest in learning more about Clinical Decision Support through ACRSelect.

 My involvement with the transformation project at SBH is now winding down as I transition to a new position. It is an institution with which I hope I'll always remain connected. I mentioned the good fundamentals and those will be my abiding memories of my short time at SBH. The security guard who flashed me a huge smile and waved every time I drove in. The thoughtful way that the best parking spots are reserved for patients and visitors. The warm welcome from every person I met there. Whatever the challenges ahead, the culture embedded in the people at SBH will prove its greatest asset.

A product I like

 

As Managing Partner in a growing multispecialty group on Long Island and a technology afficionado I took particular interest in IT solutions that could potentially change the game for our practice.


A particular peeve of mine was the scheduling process. Hearing our staff patiently guide callers through dates and times available on calls that could take 10-15 minutes made me gnash my teeth. When my Dad, who grew up in a time before television, can book a flight on line it baffled me that we still required our patients to call us to schedule an exam. Sure enough it seemed there was an emerging technology solution. Zocdoc was gaining lots of media attention for its online scheduling platform for doctors. Alas, at that time Zocdoc's pricing model failed to recognize the nature of most radiology appointments which are made FOR a particular test, not WITH a particular doctor.

I was fortunate shortly after to meet Josefina Jervis, CEO of Opendoctors247 who took a much more creative approach to meeting our scheduling needs. Backed by the power of Sterling Infosystems, a global employee health verification company, Opendoctors was able to bring a collaborative approach to making online scheduling available for our patients.


We decided to pilot full online scheduling for screening mammography. Many practices say they offer online scheduling when in fact what they offer is the ability to send in a request for an appointment and receive a call or email. That does not meet my criteria for online scheduling. I wanted busy women to be able to sit down at 9pm once everything else was done and schedule their all-important mammogram. We know that improving access to screening results in higher compliance and being able to schedule your mammogram at your convenience seems like a no brainer.

Were there naysayers? You bet. Concerns were rife that that women would book screening studies when they needed a diagnostic mammogram, worries expressed that the interface between OpenDr and our RIS would misfire and cause either empty slots or, worse, double booking. In the end, through a careful process of developing the questions that direct patients through the site and a patient yet persistent approach to working with our long established and change averse RIS provider, Josefina and her team overcame everyone's doubts.

Since the initial implementation, ultrasound, x-Ray, DXA, CT and MRI scheduling have been added. To facilitate the implementation of scheduling of advanced imaging (which often requires pre-authorization) OpenDr has added a new module that manages workflow, permitting those patients who have already obtained their pre-auth to see closer appointments than those who haven’t yet obtained the pre-auth. OpenDrs has also developed the ability to transmit reports to both patients and providers and can even integrate images into those reports.

I should stress that I do not have a financial relationship with the Company, I just like a good product that meets a need. OpenDoctors247 does just that.

Using our disruptive powers for good

“Doctor, Mrs S is on the phone. She has a question about her biopsy tomorrow..”

On my calendar today I have a note to participate in the JACR’s first ever Tweet chat, the topic is disruptive physician behaviour. I imagine there will be some head shaking tales of colleagues who apparently were raised by wolves. I have certainly experienced that.

But disruptive behaviour doesn’t have to be negative. In the technology world “disruptive” has a much more positive context. So while we definitely need to address the issues of bad physician behaviour I think we need to channel our powers of disruption for good going forward. What if we disrupt the hackneyed perceptions of radiologists as grumpy and greedy? We might be surprised at how good it feels.

I contributed to a piece in Health Imaging magazine on patient engagement and among other things discussed how I routinely share my cell phone with patients. It’s printed on my business card. Why? Well a number of reasons, the primary which is totally selfish. I am so inspired by the interactions I have with my patients. They typically fall over themselves to thank me for being available and everyone likes positive feedback right? It also allows me to advocate for the right care and hopefully save the system from the costs associated with unnecessary imaging. It also helps me become a better communicator so that I can persuade patients who might otherwise not be willing to accept my recommendations to do so.

So yes, “please put Mrs S through…”

http://www.healthimaging.com/topics/health-it/prescription-patient-engagement?nopaging=1

 

 

 

 

Radiologists as Gatekeepers? No thanks..

There has been a lot of discussion in the imaging community about Dr Saurabh Jha’s opinion piece published last week in the New England Journal of Medicine (From Imaging Gatekeeper to Service Provider — A Transatlantic Journey http://www.nejm.org/doi/full/10.1056/NEJMp1305679).

Dr Jha makes some excellent points about how radiologists must move to the center of the care delivery process if we are to thrive in the new value-based healthcare universe. The Imaging 3.0 initiative at the American College of Radiology (http://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3) aims to help radiologists do just that. I’ve been fortunate enough to work closely with ACR board of Chancellors Vice Chair Dr Bibb Allen Jr on this project and it is already inspiring radiologists all across the country to look at how they can enhance their value in their own practice settings.

What seemed to generate most discomfort was the idea that radiologists should embrace the role of gatekeepers. Those of us who are old enough to remember the “good old days” of Managed Care in the 1990s shudder to think that we’d play that role. I don’t think Dr Jha meant it in those terms but some of the Twitter activity suggests that that was how it was read. You can see a summary here http://storify.com/DrGMcGinty/radiologists-as-gatekeepers-no-thanks

Rather than act as a gatekeeper I want to be an integral part of the care team. I am fortunate in that I already work closely with my physician colleagues to determine the best course of care for our shared patients. As a breast imager, I examine patients, consult with them on their imaging findings and regularly discuss their care with both their primary care providers and the specialists to whom they are referred.

One Tweeter, a young Emergency Department physician, called the concept of radiologists being involved in guiding appropriate imaging “a laughable concept” he goes on to say “in what fairy tale land will radiologists start examining pts and taking liability for refused scans?” I am acutely aware that any decision I make carries a potential liability risk but that doesn’t mean I want to subject my patients to unnecessary imaging that might discover false positive “incidentalomas” that will add to rather than reduce their concerns.

@DrPaulDorio probably put it best when he suggested that an alternative to “gatekeepers” might be “facilitators” or “collaborators”. I actually like “clinical colleague”, pretty much says it all for me.

 

 

A great Radiology Leader retires

There was announcement in today’s ACR email blast that CEO Dr. Harvey Neiman is retiring. I have known Harvey since I was a second year resident and rotated to West. Penn. Hospital in the Bloomfield section of Pittsburgh to learn obstetric ultrasound. Harvey and his colleagues Ellen Mendelson and Marcela Bohm-Velez practiced there at an extremely high level in a very busy environment and yet found time to publish and teach. I remember being so inspired by their energy and drive.

Harvey’s contribution to the profession of Radiology has been immense. Chair of multiple Commissions (including Economics which is now my responsibility) and subsequently Chair of the Board of Chancellors he could have stopped there and been a giant. Instead he decided he wanted to take on running the organization as CEO. The full list of his accomplishments in this role is long and nicely detailed in the press release. Among the highlights for me are that he has had an expansive vision that has made the College a premier professional organization, a definitive voice on imaging quality and a vital educational resource for its members.

I know there is great sadness throughout the organization at the thought that Harvey will no longer be at the helm of the ACR. As Economics Chair I will miss his wisdom and perspective. I will always remain inspired by his commitment to serve our specialty and our patients.

 

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Twitter: a game changer or a time waster?

In my column in this month’s ACR Bulletin I report on a Tweet Chat that we held back in April on the topic “Is Fee for Service dead”. It was a lively discussion and I used many of the great ideas that emerged in preparing my address to the College’s  Physician leadership for the annual Leadership conference.

Twitter is only 7 years old and yet it has emerged as a communications game changer. It’s my default source for a quick read on major news and events. It’s also a time efficient way to scan what is happening in the health policy world in which I live as the ACR’s Economics Commission Chair. My follower count remains modest and is significantly less than that of my 13 year old niece! That said, I consider Twitter a useful channel to spread the word about how imaging delivers value in patient care. Right now I am building my followers within the healthcare community with an emphasis on imaging. Eventually I hope to extend my reach to patients in the spirit of our Imaging 3.0 initiative that aims to fully engage patients in their imaging care.

There are many physicians using Twitter to both gather and disseminate information. Yet not all are convinced. One busy private practice radiologist had this to say: “Twitter! You have got to be kidding; some of us actually have to work all day and hardly get a chance to use the bathroom, much less fool around with social media”.

While it is certainly possible to while away a lot of time on social media, as I say in my Bulletin article, Twitter is not just @KanyeWest and @KimKardashian. If anything, the  busier I get, the more I want to know the message in 140 characters or less.

 

 

 

 

Milestones

I achieved two big milestones in the last week. My husband John and I celebrated our 25th wedding anniversary and, because we squeezed in our wedding the day after we finished our finals, I have now been a doctor for more than a quarter century.

The past 25 years have been witness to an incredible explosion of technology in my chosen specialty. Xeromammograms were still around when I graduated from medical school and it wasn’t until well after I had completed my fellowship in the mid-90s that MRI became widely used for imaging the breast. Now I am looking at 3d mammograms and wondering when MR spectroscopy for breast will mature for routine use.

As a surgical intern, I watched several young women die of breast cancer. I hope their counterparts today would have a much better chance of survival due to the combined benefits of mammography screening and more effective therapies.

Much of that first year as an intern is a blur but even still there are so many patients I remember vividly. I also remember the radiologist who told me he couldn’t image my patient who I believed had brain metastases from breast cancer because he was going to the horse races. He inspired me to become what I hope is a very different type of doctor!

Xeromammograms used a technique similar to photocopies but needed a higher radiation dose and eventually were replaced by film-screen mammography. Advocates of the technique argued for it's ability to demonstrate calcifications and the fact that no darkroom or lightbox were needed.

Radiology's past and future leaders

One of the most fun things that I do as the ACR's Commission on Economics Chair is a bimonthly virtual journal club with the members of the Resident and Fellow section. We take a few articles on a particular economics topics related to imaging and use them as a basis for discussion. Past topics have included pricing and how it influences behaviour in healthcare and the issue of utilization management comparing Radiology Benefit Managers with Decision Support tools.

We've had some great guest hosts and last night we were particularly honored to have Dr Ron Evens join us. Ron is a legend in radiology circles having become Chief of the prestigious Mallinkrodt Institute of Radiology at 31 and eventually going on to run the entire hospital.  He was the very first Economics Commission Chair for the ACR and also Chair of the Board of Chancellors.  This is a nice article about the history of the MIR with a great picture of  very young Ron and Sr Geoffrey Hounsfield

http://www.mir.wustl.edu/graphics/assets/media/Focal%20Spot%20Summer%202006/75YearsofRadiology_Part2.pdf.

Ron gave us a fascinating historical perspective but his continued enthusiasm for teaching and the way he connected with the residents and fellows on the call was what was really inspiring for me. The evening ended on an amusing note when one of the residents offered me a very special thank you.

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Dipping my toe into blogging

As Chair of the American College of Radiology's Commission on Economics I write a monthly column for the ACR Bulletin ( find it at http://www.acr.org/News-Publications/Publications/ACR-Bulletin). It was something I was dreading but I have surprised myself by really enjoying it.

When I wanted to craft a response to Peggy Orenstein's New York Times article on breast cancer, Twitter didn't allow me to adequately express my concerns about how the science was presented as well as my respect for Ms Orenstein's personal journey and her writing in general. So I decided to take the plunge and set up this blog.

My fledgling website is definitely a work in progress and I don't know how much I'll actually write here but it is certainly an interesting place in which to express ideas.

One thing I realized in my background research for my post on Ms Orenstein's article was that she is also the author of the fabulous book "Cinderella ate my Daughter". I have four smart and beautiful nieces and I shudder when I see the barrage of messages they receive that don't celebrate them as intelligent women in formation.

Transient

A breast imager's response

It's always difficult when I see a patient present with metastatic breast cancer who has missed a year of screening. Last week as I was performing biopsies on my patient for her tumour in the breast and the enlarged lymph node in the armpit, an unspoken question hung between us. If she had come for her mammogram last year, would her tumour have been diagnosed before it spread outside the breast?

That coincided with Peggy Orenstein's article in the New York Times in which she wondered whether the baseline mammogram she had in 1996 had in fact saved her life. Her mammogram was a "screening" mammogram, in other words, she was not feeling a lump. Every person's course is unique; I don't know Ms. Orenstein's situation, but to me, finding breast cancer in an otherwise healthy 35 year old has to be better than not knowing about it. 

I respect Ms. Orenstein's personal perspective; she has been through a major health concern. Much of her article asks whether screening all women over 40 on an annual basis is worth it.  My worry is that the science that demonstrates the value of screening is not being presented and represented clearly. Full disclosure: statistics has never been my strong suit, but I certainly know that several large trials and numerous population based studies have proved that mammography screening saves lives from breast cancer.  We can definitely debate whether as a society we want to pay for mammography screening, and whether the number of lives saved is enough to justify the cost. But if we don't screen, there will be women whose breast cancers are not diagnosed until they are palpable (able to be felt) and are larger than they would have been had they been picked up on mammography. 

Ms. Orenstein was unhappy with the response of Nancy Brinker from the Komen Foundation and tweeted me about that. Nancy Brinker makes the point that mammography is not perfect, but is still the best screening test available to us. As a breast imager, who also finds cancers on ultrasound and MRI that are invisible on mammograms, I could not agree more. But mammography is a widely available and relatively inexpensive way to find disease before it presents clinically. It also needs to be stressed that breast cancer is a disease where earlier treatment leads to better outcomes. That's the definition of a good screening test; you find it, and you can intervene and, thus alter the natural history of the disease.

When I tweeted about the article originally I said: "Ask your doctor if she still gets a mammogram every year, I bet she does". I do.