Radiology 2010

Where we go from here

In the world of medical science and technology, all eyes are fixed on the future. So, as 2009 comes to a close and many industries are looking back at their accomplishments throughout the year, rt image chooses to look forward at what lies ahead. We asked the experts to share their insight on the future of radiology in terms of technology, politics, education, and jobs at the start of the new decade.

Learning Curve
Education programs embrace change

Educators hold the future of the profession in their hands – or classroom, more accurately – and they take that responsibility very seriously. In 2010 and beyond, organizations, professors, and program directors are making major changes to the way they teach and guide students through this ever-evolving field.

Residency Programs

Students entering radiology residency programs next year will be the first class to operate under the new structure of the American Board of Radiology’s certification examination. Until now, residents were given written physics and diagnostic exams some time between their second and fourth years and an oral exam at the end of their fourth year. The Board’s major changes are to have a core exam, administered by computer, 36 months after beginning a residency, and a certifying exam, also computerized, taken 15 months after completion of a residency program. According to the Board’s overview of the changes, dated June 2008, exam content will be based on the student’s training profile, experience, and planned practice emphasis.

Levon N. Nazarian, MD, professor of radiology and program director of the diagnostic radiology residency program at Thomas Jefferson University in Philadelphia, doesn’t foresee many changes to the curriculum for the first three years of residency, except perhaps to alter the manner of teaching toward the new style of testing as opposed to the traditional oral exam.

The real change, which will occur in the fourth year is two-fold, Nazarian says. The first is the on-call schedule. Fourth years are going to take on more call than they used to, which may also benefit patient care. “By changing the board structure you actually can make available your most experienced residents,” Nazarian says.

The second, and conceivably more controversial, change is that fourth-year residents will be able to dedicate more time to subspecialty training in one or more areas. Nazarian says his program intends to offer this form of “mini-fellowship” to fourth-year residents, but he notes some potential pitfalls to the system. Allowing residents to choose one or more areas of focus could result in one subspecialty being overburdened with residents while another is left without any. Also, fellowships could risk becoming less in demand.

“The effect of these changes really remains to be seen,” Nazarian says. “For example, what is the job market going to be like? Let’s say the job market is really hot for graduates. They do that mini-fellowship, and then they take a job to be the neuro person since they did a year of neuro in their residency. But if the job market is tight, then graduates may still feel that in order to make themselves more attractive as employees, they’re going to have to do fellowships.”

To discourage students from choosing to forgo a fellowship, Valerie P. Jackson, MD, FACR, John A. Campbell professor and chairman of the Department of Radiology and Imaging Sciences at Indiana University School of Medicine in Indianapolis, says her program intends to elevate and differentiate the fellowships from the fourth year of residency. “They’d have maybe more experience working with surgeons or medicine clinicians or pathologists or whatever related to the area of their subspecialty,” she says.

Many educators believe it was time for a change. Jackson says the requirements for residency training hadn’t changed in more than 30 years. Radiology practice, however, has changed dramatically during that time, and broad general radiology isn’t practiced as commonly.

“It turns out that when most radiologists go into practice, they don’t practice every aspect of radiology,” Jackson says. “They tend to focus on one, two, three, or maybe four areas and then do some more general stuff. They’re not just trying to learn a little bit about everything and practice a little bit about everything.”

Interest in the field has steadily climbed for the past five to six years, with Jefferson’s program receiving record applicants. Nazarian says the program has close to 800 applicants for only seven spots available in the upcoming match.

“The number and quality of applicants is just unprecedented this year,” he says. “We just cannot possibly accommodate the number of people that deserve interviews. It’s amazing.”

RT Programs

Earlier this year, the American Registry of Radiologic Technologists (ARRT) board of trustees voted to require that beginning Jan. 1, 2015, candidates applying for certification in radiography, nuclear medicine, radiation therapy, MRI, and sonography must have earned, at minimum, an associate’s degree.

Cindy Daniels, MS, RT(R)(ARRT), the director of education requirements and registration for the ARRT, says that the rapidly-changing profession will benefit from technologists’ having the core knowledge developed while earning an associates degree.

“We feel that it’s important to patient care that technologists be able to demonstrate those good communication skills – writing, English, sociological understanding, and psychological insights – even though they may not directly impact the profession as far as the sciences and the math that we use day to day,” she says. “The requirement is intended to prepare the graduates and people entering the profession for the next generation of where things in the profession are going.”

Aimee Phillips, MS, RT (R)(M)(CV)(QM)(ARRT), staff development specialist at Marietta Memorial Hospital (MMH) in Marietta, Ohio, and a member of the MMH School of Radiologic Technology Advisory Board, believes that the requirement will encourage students to think beyond their short-term career goals.

“I feel that this will instill in future radiographers the importance of education,” she says. “Individuals will see that by obtaining more education, they can move into areas such as management, PACS/IT, education, and even staff development.”

While this requirement will not affect degree-awarding programs, there is concern among hospital-based certificate programs that their students would not be interested in earning an associate’s degree.

Kevin Powers, EdS, RT(R)(M), director of education for the American Society of Radiologic Technologists (ASRT), assures that meeting the requirement shouldn’t be an impossible burden for these programs.

“It’s different for us, but it’s not uncommon for other professions,” he adds. “There are unique opportunities for linkages between academic intuitions and some of the hospital-based programs that would be of mutual benefit to both organizations.”

Between 2005 and 2007, there were rumblings about a possible shortage of radiographers in the job market. Going into 2010, however, the concern is quite the opposite.

“We’ve flooded the market,” says Leslie Winter, MS, RT(R), CEO of the Joint Review Committee on Education in Radiologic Technology (JRCERT). “Our programs are having problems placing students. Their job placement rates are not as good as they were back in ’05.”

Winter says the number of JRCERT-certified programs is at an all-time high of about 750 programs, which she attributes to the poor economy.

“People were looking for career changes or lost their jobs and were looking for a second career,” she says. “They flooded to the community colleges, and we saw a huge influx of new programs.”

The focus of RT programs has begun to change as well. Schools are putting more emphasis on digital imaging rather than cut-sheet film, and both radiography and radiation therapy programs are integrating courses dedicated to CT.

“CT, as well as MR, needs to be integrated to some degree in the entry-level preparation for radiation therapy technologists, because they’re finding more and more of the hybrid equipment being installed in the radiation therapy arena,” Powers says.

As technology continues to change, educators will update and alter the information they provide students. At the end of 2010, Powers says the ASRT will begin the process of revising the radiography curriculum, which is updated every five years to keep up with the industry.

– Stephanie Twining


View from the Hill
A look at legislation, regulation, & medical imaging

As 2010 approaches, medical imaging professionals might want to keep an eye on legislative and regulatory developments in Washington. As the debate over healthcare reform reaches a crescendo, other bills pertaining to the imaging field are also working their way through the system.
By a 220-215 vote on Nov. 7, the House of Representatives narrowly passed its version of healthcare reform legislation, which is now under consideration in the Senate.

Christine Lung, CAE, vice president of government relations and public policy at the American Society of Radiologic Technologists (ASRT) in Albuquerque, N.M., says she expects that healthcare reform will not make its way onto the president’s desk until next year. She predicts that a bill will be up for a final vote in the Senate by the second week of this month. If the Senate and House versions differ, they will have to be reconciled in a conference committee, which may take another week. “That pretty much puts us at the end of December,” says Lung.

The political situation is in such flux that nobody knows what the final version of healthcare reform legislation will look like, says Leonard Berlin, MD, FACR, professor of radiology at Rush University College of Medicine in Chicago. But one thing that is evident, he adds, is that, under healthcare reform, a high percentage of the 45 million Americans currently without medical insurance will get some kind of coverage. Even without taking all of those newly insured people into consideration, the number of radiologic procedures will continue to grow.

Meanwhile, Berlin says, there is pressure from the government, insurers, and the medical community to constrain the overutilization of imaging procedures. One of the reasons for overutilization is the practice of defensive medicine, as the result of medical malpractice litigation, but Berlin points out that current healthcare legislation does not address tort reform.

Self-referral is another factor to which overutilization is attributed.

According to Lung, the version of healthcare reform in the Senate contains a provision calling for the General Accounting Office to study self-referral, which will probably play a role in future legislation on medical imaging.

Lung says another possible element of healthcare legislation would be a tax on medical equipment manufacturers, which will reduce their ability to invest in research and development.

Controlling Costs

Michael M. Graham, PhD, MD, president of the Reston, Va.-based Society of Nuclear Medicine says that, as a general matter, the Centers for Medicare and Medicaid Services and supporters of healthcare reform have taken the view that the cost of medical imaging is out of control.

“The trouble with this view is it doesn’t look at the benefit side of medical imaging; it’s only cost-based, and they’re likely to make things worse rather than better in many situations. The patients will be denied appropriate medical imaging, and then either things will be badly delayed until the tumor grows a whole lot more, or they’ll have to have exploratory surgery, or they just plain won’t get adequate treatment,” says Graham.

The use of radiology benefit managers is one possible option for constraining healthcare costs. “This is almost identical to the pre-authorization that we currently have with most large insurance companies, and it’s had actually very little impact on utilization, at least in academic centers. It may have somewhat greater [impact] in non-academic centers, but it has had the effect of increasing the annoyance factor significantly,” says Graham. “I think it’s a misplaced approach.”

Graham says changing assumptions about the utilization rate of advanced diagnostic imaging equipment is another approach to cutting costs. The greater the amount of time a piece of imaging equipment is assumed to operate, the more its costs can be spread out, thus reducing the amount to be reimbursed.

Beginning next year, the CMS will assume that CT and MR scanners costing more than $1 million are being used 90 percent of the time. While assuming that a piece of equipment is running nearly around the clock may be feasible for large hospitals in urban areas, Graham says, it is not realistic at rural facilities, some of which may be forced to shut down as a result of reduced reimbursement. Lung expresses concern that physicians’ offices and outpatient imaging centers may seek to employ less-qualified personnel as a cost-saving measure.

Supplying Molybdenum

Another bill to watch is H.R. 3276, the American Medical Isotopes Production Act of 2009, which the House passed on Nov. 5. “The essence of it is to attempt to allow us to move towards a domestic supply of molybdenum-99 [Mo-99]. That’s a critical isotope for nuclear medicine, in that it decays into technetium-99m, which is the agent we use in about 80 percent of our studies,” explains Graham.

At present, there are no domestic sources of Mo-99, and a Canadian reactor where it is produced shut down earlier this year. Graham says, “It has definitely impaired patient care throughout the United States, and it has slowed down our ability to deliver care at practically every institution that provides nuclear medicine.”

If it becomes law, H.R. 3276 would authorize the Department of Energy to spend $163 million over five years to fund domestic projects to supply Mo-99 without using highly-enriched uranium.

– Mark D. Marotta


Future Factory
Trends in patient-centric, ultra-small, and eco-friendly design

The ultimate goal of all technology is to integrate into daily life with effortless use. Industries spend their time, talents, and resources on transforming forward-thinking concepts into light, powerful, and simple-to-use technology.

Two of radiology’s biggest companies, GE and Philips, are leading the way in advancing imaging technology in similar ways. Patient-centered and patient-friendly design is becoming a popular area of focus. Precious space and time are saved as imaging equipment is becoming smaller, more portable, and more intuitive for specific applications. Nature is also benefiting from these innovations because technological refinement means reduced radiation doses and increased energy efficiency.

Redressing Radioiogy

Professionals in the radiology field have intimate knowledge and familiarity with the workings of their equipment. But patients undergoing scans or therapies don’t have this advantage. These big, bulky imaging machines can strike fear in the hearts of patients undergoing treatment. MRI systems are notorious for discomfort and claustrophobia. Pediatric patients are especially prone to negative emotions about such treatment. Fidgeting, hyperactivity, and other reactions can cause delays, imaging errors, or repeat examinations.

Kristen Cusolito, director of Ambient Experience Solutions for Andover, Mass.-based Philips Healthcare, says that her company’s relaxing and supportive design solutions have provided an alternative to situations where sedation would be traditionally used.

Philips Healthcare has been addressing this patient-focused trend for three years now with Ambient Experience. “Traditional imaging spaces can be an afterthought,” Cusolito says. “They’re designed just utilitarian, and oftentimes the spaces have a lot of equipment in it that isn’t even relevant to your particular medical procedure.”

Cusolito explains that Ambient Experience seeks to improve the patient experience, as well as the staff environment. “We use lighting, music, and projection in many of our designs to help provide a relaxing, soothing, supportive environment,” she says. She believes that these choices are “positive distractions” that empower the patient in situations where they may feel helpless or worried. Additionally, the Ambient Experience team offers workflow, design, and storage solutions to healthcare providers, Cusolito says, which provide them with strategies and tools to improve the working environment for their staff.

The Ambient Experience has been implemented in a variety of healthcare settings, including MR and CT suites, pediatric departments, and what Cusolito describes as an “imaging spa” in Chicago. Though the future of radiology has arrived in these places, the market for design strategies and solutions remains open.

GE Healthcare, headquartered in Waukesha, Wis., has recently stepped up to offer similar patient-centric design solutions with the Adventure Series. Through this series, GE aims to naturally diminish anxiety for pediatric patients.

In this solution, imaging rooms are transformed into jungle adventures, cozy campsites, or pirate islands. Cartoon characters featured on the walls and throughout the suite also provide a friendly face to look at during the long, uncomfortable procedures. The pilot program was developed alongside child specialists and design firms and is still in its initial trial phase.

What Technologists Want

Radiologic technologists will also benefit from radiology redesign. Calmer patients make their job easier and help procedures run more smoothly. Sleeker machines embedded with multiple technologies can also help to solve space issues for critical care and surgical environments.

Flat detector (FD) technology is the latest addition to fluoroscopy and C-arms, where they potentially have the most impact. The industry has been moving away  from Image Intensifiers (II), which have become harder to make and control, and offer comparatively poor image quality. Flat detectors, in C-arms, are especially beneficial because they’re unaffected by magnetic distortions, unlike IIs. The thin detector and small generator of Philips’ Veradius mobile C-arm is one recent solution that offers surgeons and radiologists an expanded field of view and a wider range of applications.

“It allows [the surgeon] a lot more room to work in and around the imaging platform,” says Scott Buckhart, vice president of general X-ray and surgery for Philips Healthcare. “Going from 12 to 15 inches down [in an II] to 2 or 3 inches [in a flat detector] is an amazing breakthrough,” he says. “Our generator is about half the size of what some other big companies use, yet we’ve gotten that refined to the point now where we can go toe-to-toe or actually show superior image quality.”

The future of flat detector technology will help redefine and expand applications for use with these machines. Philips is pioneering 3-D scans in C-arms – by combining the static and live images – which will eliminate the need for confirming CT scans or other procedures, says Buckhart. For the future, Buckhart says that Philips hopes to offer image-guided technology in conjunction with the 3-D reconstructions and flat detector mobility.

“Some of the physicians have told us, for example, that half of the needle sticks that they do will miss the mark for specific kinds of therapy,” he explains. If the flat detector could spin around the patient to get a 3-D reconstruction, the same C-arm – equipped with image-guided technology – would help deliver chemotherapy more effectively, or be used for seeding prostate cancer. Buckhart adds, “It opens up a whole new realm of precision in terms of the physician having to know the anatomy or feel his way there, but now he gets precise instrumentation, much like a jet pilot would.”

The increase in portability and mobility also means that machines will be lighter, perhaps small enough to carry around. GE’s Vscan ultrasound was unveiled in October by GE’s CEO, Jeff Immelt, at the annual Web 2.0 Summit in San Francisco. Roughly the size of a smart phone when closed, this product will help make point-of-care imaging a reality.

“GE’s goal is to improve the quality of care by increasing access to important healthcare technologies, and this pocket-sized visualization tool will help do that with its portability and high image quality,” says Al Lojewski, general manage of cardiovascular ultrasound for GE Healthcare. According to Immelt’s presentation at the summit, this device replaces an ultrasound unit that would have weighed several hundred pounds in 1995.

Developed for a variety of clinical settings, Lojewski claims, “Vscan has the potential to redefine the way doctors examine patients.” For primary care, Lojewski believes that this hand-held technology could become as essential as the physician’s stethoscope by providing an immediate look inside the patient’s heart and body.

Ultimately, the Vscan could lower the healthcare costs by reducing referrals for specialists. Though not available for commercial sale in the U.S. yet, the Vscan has been granted 510k clearance by the FDA.

What the World Needs

Radiology’s current move from film- and cassette-based imaging to digital technology has been a major improvement both in terms of interoperability and environmental conscientiousness. Digital X-ray detectors, flat panels, and PACS/RIS solutions have solved time issues and eliminated the use of caustic chemicals that developing film involved. The imaging industry has been focusing on energy-efficient and low-dose technology for some time, and radiology’s next hurdle is the widespread and standard use of these machines. Refinement of these technologies is a constant trend, and affordability remains an underlying issue.

Philips offers the Dosewise concept, which Buckhart describes as a set of beliefs, approaches, and technologies to manage dosing in their products. The concept includes technology such as SmartBeam, grid-controlled fluoroscopy (GCF), and intelligent exposure control (IQX). Buckhart says each of these work to “condition the X-ray beam to do something to optimize it for a given patient.”

The company’s fluoroscopy machines, such as the mobile Veradius C-arm, feature grid-controlled functions and in-pulse control that block out scatter and soft X-rays, which are emitted as the pulse charges to full power, but contribute nothing to image quality. According to Buckhart, this practice saves as much as 50 percent of the dose. “In some cases,” he adds, “compared to straight fluoro – non-pulsed fluoro – you can save up to four or five times the dose.”

Saving the dose also means saving energy. The Veradius generator size also contributes to its energy efficiency, since miniaturization and radiation dose control go hand-in-hand with optimal energy use. And depending on the age of the machine, some older Philips imaging equipment can even be retrofitted with DoseWise technologies.

As companies refine these features, gaps begin to close between access, image turn-around, diagnosis, and care. The path from physicians to their patients is more direct than ever. GE, Philips, and other companies steadily improve the look and efficiency of their technology, and patients and staff alike continue to experience the benefits.

– Kelly Olsen-Stanko


Occupational Hazards
Turbulence ahead for the radiology job market

Despite the lengthy menu of possible job-creation tools that the Obama administration has laid out, economists acknowledge that it will take more than that to bring the recession to a screeching halt, let alone reverse its course.

What’s Next on the Agenda?

While the plight of working radiologists, as with most healthcare professionals, does not necessarily garner public sympathy as one of the few “untouchable” professions in the recession, neither is the medical imaging industry an inexhaustible well to alleviate the financial crisis across every other sector. Yet, continuing in a trend laid down by past administrations, the Obama administration seems to have targeted the profits of the radiology field with renewed vigor – and set a new job market crisis into motion.

“Everything hinges basically on what Obama does next and where the healthcare legislation winds up – in particular, with high-end imaging, with MR, CT, radiation therapy, and his concepts of cutting those fees,” says Robert Russo, MD, FACR, CEO of Robert D. Russo, MD and Associates Radiology in Bridgeport, Conn. “It’s important to remember that radiology practices are really high-volume, low-margin operations. The profit is built on the volume that we do, so if Obama goes in and cuts the fees significantly, then we lose our margin no matter how high the volume is.”

Russo continues, “The real problem is that the restructuring in medicine happens almost instantly, while the restructuring with the insurance companies and primary care doctors happens over time. For example, if I look at my referral base, which is significantly primary care doctors, they’re already working 60 to 70 hours a week. If Obama goes out and increases their workload even 10 percent, they’re simply not going to be able to handle it. As a radiologist looking at this, the argument is we’ll make it up in volume, but we really won’t because there’s nobody to hand us that volume.”

The Elephant in the Room

With many radiologists still reeling from the aftershocks of the 2005 Deficit Reduction Act (DRA), new healthcare reform proposals are poised to seriously impact the livelihood of radiologists nationwide. The real possibility of further cuts to Medicare reimbursement rates for diagnostic imaging has forced some hospitals and imaging centers to reconsider the application of those funds: the purchase and maintenance of imaging equipment and the salaries of their imaging staff.

With the threat of a possible Medical Technology Tax on the horizon, many managers may have already allocated those funds to machine over manpower.

“We have a different demand pattern than we had in the past,” says Peter Reimer, vice president of Global Marketing/CT at Andover, Mass.-based Philips Healthcare.

“In the past, most of the imaging systems modalities and the vendors developed products for the very high-end market, with the focus on the innovators on the healthcare provider side. Later, these products were cost-price reduced and found their way into the mid-tier of the imaging systems market – the community hospitals and more rural hospitals. This doesn’t really work anymore; instead we are seeing a need from innovators to stretch clinical boundaries, to explore what is possible beyond clinical capabilities of the equipment.”

A Changing Landscape

Another severe impact on the radiology job market is the changing need for radiologists. The subspecialization of radiology has become broken into such focused areas that an imaging center or community hospital can no longer support a full-time subspecialist radiologist – there simply isn’t enough work to support one. The radiologists excelling in this survivalist economy are those that have become the “Swiss army knife” of radiology – the jack-of-all-trades, yet master of none.

“This job market has two arms to it,” says Russo. “It’s got the arm that says, ‘Look I’m a good general radiologist. I’m capable of doing subspecialty work and general radiology and therefore I’m attractive.’ On the other side, it has subspecialty people that are only interested in doing subspecialized work.”

He continues, “I see there is probably going to be a little bit of a shift in the job market – two or three years ago, everybody wanted an invasive radiologist, but then fees were cut, and those invasive radiologists are no longer making all the money they used to make. Now, groups want somebody that can do that invasive work, as well as help them out in the high-volume crunch time periods.”

Another upcoming problem is of the literal landscape of the 2010 job marke