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OBJECTIVE. Many models have been used to understand radiology practice, including economics, engineering, and information technology. Each has advantages, but each also has drawbacks, failing to illuminate important aspects of radiologists' work. A model that offers additional insights is ecology. CONCLUSION. By looking at radiology practice through the ecologic concept of symbiosis, radiologists can gain new understanding and appreciation of aspects of their work that can render it more fruitful and sustainable.

Objective: The full spectrum of organized radiology consists of numerous organizations with varied missions targeting their respective members., Conclusion: This article highlights many of these organizations, discusses the benefits they can provide to radiology trainees and junior faculty, and provides a road map for progressive participation among trainees to junior faculty as they advance through training.

Objective: The purposes of this article are to describe concepts that radiologists should understand to evaluate machine learning projects, including common algorithms, supervised as opposed to unsupervised techniques, statistical pitfalls, and data considerations for training and evaluation, and to briefly describe ethical dilemmas and legal risk., Conclusion: Machine learning includes a broad class of computer programs that improve with experience. The complexity of creating, training, and monitoring machine learning indicates that the success of the algorithms will require radiologist involvement for years to come, leading to engagement rather than replacement.

Objective: The aim of this bibliometric study was to assess the characteristics and quality of radiologic randomized controlled trials (RCTs) over the past 20 years., Materials and Methods: A PubMed search was conducted to identify radiologic RCTs (defined as RCTs in which the first author or corresponding author is affiliated with a radiology department) published between 1995 and 2014. The following information was extracted from each article: journal, radiologic subspecialty, imaging technique, number of subjects, study result, funding, number of authors, number of institutions, country of origin, and methodologic quality (assessed using the Jadad scale)., Results: A total of 358 radiologic RCTs were published between 1995 and 2014. Dramatic increases in the numbers of radiologic RCTs were found, from 43 conducted in 1995-1999 to 172 conducted in 2010-2014. One-hundred seventeen (32.7%) RCTs were concerned with the field of vascular and interventional radiology; 78 (21.8%) evaluated more than one imaging technique; 164 (45.8%) had a sample size of 50-150 subjects; 246 (68.7%) showed positive study results; 185 (51.7%) were not funded; 179 (50.0%) had four to seven authors; 263 (73.5%) were single-center trials; 88 (24.6%) had a first author or corresponding author located in the United States; and 187 (52.2%) were of low quality. In the time trend analysis, the following variables showed a significantly positive trend: abdominal imaging subspecialty, CT as the imaging technique, more than 150 subjects, more than seven authors, and high methodologic quality., Conclusion: The quantity and quality of radiologic RCTs have significantly increased over the past 2 decades; however, the methodologic quality remains suboptimal.

Objective: Our institution implemented a read priority scoring system to combat the known limitations of traditional methods for the prioritization of examination interpretations by radiologists. We aimed to determine the impact on report turnaround time (RTAT) and RTAT variability., Materials and Methods: On examination completion, technologists entered a read priority score (1-9) using provided definitions. We retrospectively reviewed the median RTAT and RTAT variability (i.e., interquartile range length) for radiology examinations (n = 615,541; 2011-2014). We used Spearman correlation coefficients to determine the relationships between read priority scores and the median RTAT and the RTAT variability by year. We compared median RTAT and RTAT variability between early (2011) versus late (2012-2014) adoption phases using distribution-free random permutation tests., Results: Ranked correlations showed yearly improvement, leading to a near-perfect ranking of median RTAT (r = 0.98, p < 0.001) and a perfect ranking of RTAT variability (r = 1.00, p < 0.001) by nine levels of priority. Eight of the nine priority levels showed a reduction in median RTAT between the early and late phases, and the three most urgent levels--that is, 1, 2, and 3--improved by 23%, 5%, and 70% (all, p < 0.001), respectively. Only one priority level (4, defined as outpatient urgent [8% of studies]) showed significant worsening by 15% (p < 0.001). The three most urgent levels of priority also showed improvements in RTAT variability (61%, 17%, 71%, respectively; all, p < 0.01). Only the lowest level of priority (9) exhibited a significant worsening in RTAT variability by 9% (p < 0.01)., Conclusion: A reading priority scoring system with defined clinical scenarios yielded desirable prioritization of examination interpretations by radiologists as evidenced by appropriate and improved stratification of RTATs and RTAT variability.

Objective: Radiology residency education must evolve to meet the growing demands of radiology training. Resident opinions are a major resource to identify needs. However, few published data are available on a national level investigating the radiology resident perspective on factors that influence the resident experience. Our study investigates factors that affect residents' satisfaction with their residency experience and education., Materials and Methods: A 67-item survey was sent to all radiology residency program directors and coordinators in the United States to be distributed at their discretion. Questions were multiple choice, free-text answer, or 5-point Likert scale. Statistical significance (p < 0.05) was determined using chi-square test, t test, and logistic regression analysis, respectively., Results: Two hundred seventeen radiology residents responded to the survey (range, 212-217 responses per question). Overall, 77.8% (168/216) of residents were satisfied with their residency programs. Subcategories that showed a statistically significant correlation with overall satisfaction, in decreasing strength according to the odds ratio (OR), include the program director or administrative office (OR, 72.2; 95% CI, 27.4-221.9), the daily workstation experience (OR, 30.5; 95% CI, 12.8-80.9), the faculty (OR, 19.5; 95% CI, 8.9-45.4), educational conferences (OR, 7.9; 95% CI, 3.9-16.4), work hours (OR, 6.4; 95% CI, 3.2-13.2), teaching opportunities (OR, 6.5; 95% CI, 3.1-13.8), research opportunities (OR, 5.1; 95% CI, 2.6-10.6), personal study (OR, 2.1; 95% CI, 1.1-4.1), and compensation (OR, 1.9; 95% CI, 1.0-3.7)., Conclusion: Our study provides incremental data to the existing literature that offers insight into factors that contribute to a successful radiology residency program.

Objective: The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement., Materials and Methods: We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics., Results: Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact., Conclusion: Among 380 communication errors in a radiology department, 37.9% had a direct impact on patient care, with an additional 52.6% having a potential impact. Most communication errors (52.4%) occurred at steps other than result communication, with similar severity of impact.

Objective: The goals of the 2010 Patient Protection and Affordable Care Act (ACA) can be summed up by the Triple Aim, as defined by the Institute for Healthcare Improvement: Improve population health, optimize the patient experience, and reduce the costs of care., Conclusion: Despite recent reimbursement reductions, radiologists have increasing opportunities to participate in value-based payment programs and should leverage those opportunities.

Objective: In this article, we define value in the context of reimbursement and explore the effect of shifting reimbursement paradigms on the decision-making autonomy of a women's imaging radiologist., Conclusion: The current metrics used for value-based reimbursement such as report turnaround time are surrogate measures that do not measure value directly. The true measure of a physician's value in medicine is accomplishment of better health outcomes, which, in breast imaging, are best achieved with a physician-patient relationship. Complying with evidence-based medicine, which includes data-driven best clinical practices, a physician's clinical expertise, and the patient's values, will improve our science and preserve the art of medicine.

OBJECTIVE. The purpose of this article is to discuss issues surrounding the implementation of digital breast tomosynthesis (DBT) into a clinical breast imaging practice and assist radiologists, technologists, and administrators who are considering the addition of this new technology to their practices. CONCLUSION. When appropriate attention is given to image acquisition, interpretation, storage, technologist and radiologist training, patient selection, billing, radiation dose, and marketing, implementation of DBT into a breast imaging practice can be successful.

Objective: It has been suggested that radiology reporting practices would be improved if radiologists were to discuss the results of an examination directly with the patient. The attitudes and preferences of patients with regard to direct communication with the radiologist are not well-defined. The purpose of this study was to survey patients about their preferred method of receiving radiologic results., Materials and Methods: An anonymous survey was distributed to adult patients undergoing contrast-enhanced CT or MRI over a 2-week period in June 2013., Results: The response rate was 58.4% (642 responses). For normal examination results, the preferred mode of communication was a telephone call from the ordering physician (34.1%); only 12% of respondents opted for a telephone call from the radiologist, and 2.6% chose a face-to-face meeting with the radiologist. For abnormal test results, the preferred mode of communication was also a telephone call from the ordering physician (49.8%); 14.4% of respondents selected a telephone call from the radiologist, and 8.3% chose a face-to-face meeting with the radiologist. Patients preferred receiving very detailed versions of radiology reports for both normal (46.4%) and abnormal (81.8%) test results. Patients also expressed a desire to have access to at least key images from their examinations., Conclusion: Patients prefer receiving both normal and abnormal examination results from the physicians who ordered the examination rather than the radiologist. They also prefer to receive very detailed examination results rather than a brief summary in lay terms.

Objective: As patients and information flow through the imaging process, value is added step-by-step when information is acquired, interpreted, and communicated back to the referring clinician. However, radiology information systems are often plagued with communication errors and delays. This article presents theories and recommends strategies to continuously improve communication in the complex environment of modern radiology., Conclusion: Communication theories, methods, and systems that have proven their effectiveness in other environments can serve as models for radiology.

Objective: Severe acute respiratory syndrome (SARS) was a highly virulent atypical pneumonia caused by a novel coronavirus that resulted in a pandemic in 2003. Singapore was one of the most severely affected countries, and SARS took a heavy toll on our health care system. The lessons learned during the pandemic have shaped our national contagion response plan and have proved valuable in subsequent epidemics. We describe the lessons learned for the radiology department., Conclusion: Our experience with SARS has shaped and changed our daily practice of radiology.

Objective: The purpose of this article is to describe a step-by-step approach to the successful mentorship of trainees completing retrospective radiology research projects. The topics addressed include selection of a mentor and mentee and the selection, planning, initiation, and completion of a retrospective research project., Conclusion: Mentoring a trainee in the completion of a retrospective research project is an ideal way to introduce a trainee to academics. The goals of such a project given the time constraints of radiology residents include completion of an educational exhibit, an oral scientific presentation, and a published manuscript.

Objective: Sitting can be dangerous to one's health, and radiology tends to be a sedentary profession., Conclusion: By adding a mixture of technological and behavioral changes to our workplaces, we can put a large dent in the amount of sedentary time we spend at work.

Objective: In the era of health care reform, our value-added to patient care, its corresponding level of reimbursement, and the stature of radiology as a specialty will likely be grounded in the scientific evaluation methods of health services research., Conclusion: We need to create more opportunities for training, provide resources and incentives for the brightest candidates to enter this field, and cultivate enriching environments for health services research in all academic radiology departments.

Objective: This article will take a big-picture view of the issues of utilization, cost, value, quality, innovation, self-referral, specialization, commoditization, competition, and corporatization and suggest how they are closely interrelated., Conclusion: These issues may have a major effect on the practice of radiology. It may be both presumptuous and platitudinous to suggest that our profession currently faces some of the greatest challenges in its history.

Objective: Both horizontally oriented interventions (aimed at improving culture and environment in an effort to reduce the number of human errors potentially leading to patient harm) and vertically oriented (aimed at a specific area of errors) are needed to create a comprehensive safety program in radiology. Our objective is to describe horizontal interventions introduced to improve safety in radiology., Conclusion: Horizontal interventions--such as operational rounds with radiology leadership, safety coach programs, error prevention training, and a lessons-learned communication program--can successfully improve the safety culture and performance in radiology.

Objective: This article will identify strategies and tactics that can be used to enhance CT capacity. The potential financial benefits to the organization and the impact on market share will be discussed., Conclusion: Many organizations are challenged to meet stakeholder demands of providing additional CT capacity and reduction of patient waiting lists. However, much can be achieved through workflow redesign, the addition of key personnel, and implementation of information system platforms and databases.

Objective: We sought to determine the extent of managed care involvement among radiology practices of different types, locations, and sizes; the factors associated with differences in involvement; and the impact of managed care on professional, organizational, financial, and hospital-relations aspects of radiology practices., Materials and Methods: A survey was mailed in 1999 to a sample of 970 radiology practices; completed, usable surveys were returned by 66% of the practices. Three indicators of managed care were used: a practice's percentage of managed care (HMOs plus preferred provider organizations), local area HMO penetration rate, and self-reported perceived effect of managed care., Results: Percentage of managed care averaged 30% but was 40% for multispecialty groups. It was relatively high in large metropolitan areas, for practices with no hospital activity, and for practices with any owners who were not practice members. The three measures of managed care were only moderately correlated (correlation coefficient, 0.25-0.33). None of the managed care variables had a statistically significant effect on days provided for vacation and continuing medical education, promptness of payment, years required for practice ownership (partnership), and percentage of practice members who were owners. Higher percentage of managed care was associated with higher collection rates, whereas greater perceived impact of managed care had the opposite association. Two thirds of practices belonged to at least one managed care-related organization such as an independent practice association. Most radiology practices reported no involvement in the managed care negotiations of hospitals, which was true even when the hospital's negotiations included the radiologists' fees or when the practice determined its level of involvement., Conclusion: Many negative outcomes most feared by radiologists regarding the effect of managed care have not materialized. Perceptions of practices as to the effect of managed care seem to reflect negative aspects of their general situation, not only realities of managed care.

OBJECTIVE. A computerized reporting system based on keyed entry of acronyms and eponyms was developed to reduce transcription delays and speed report output for a solo radiology practice that covers several community hospitals in a large region. The purpose was to improve practice outcomes, quality assessments, continuing medical education, and billing efficiency. SYSTEM AND APPLICATIONS. Over a 10-year period, problems in accurate reporting, transcription delays, slowed report deliveries, and incomplete or lost billings were described to computer programmers. These programmers composed 31,000 lines of computer code designed to address the problems. The resultant program was applied to 100,000 imaging procedures. Entry of commonly used clinical acronyms, eponyms, and other symbol strings chosen by the interpreting radiologist triggered the immediate printing of a report's text at the radiologist's desk. After the reports were proofread, electronically authenticated, and/or hand signed, they were sent to distant locales by facsimile transmission. During new case interpretations, potentially erroneous statements of fact or judgement were prevented by enabling the interpreter to instantly review old reports, informative elements of a patient's history, and pertinent medical literature, all of which was placed in various caches of the computer's memory. Billing labor was reduced by automatically providing the number identifying each procedure and the diagnoses made during image interpretation. OPERATION. The acronym/eponym-based reporting system was time- and cost-effective. The new system reduced typing strokes by 84%, and reports were generated in 1 min, while the studies were being interpreted. With the retrieval and monitoring techniques operating on old, stored information, new reporting errors, as well as some diagnostic oversights, were reduced by 50%. Counting the acronyms and symbols representing imaging quality and technical problems showed an 11% mistake rate. Modem transmission of automatically included current procedural terms and disease classification numbers reduced billing labor by 50% and reduced lost charges to zero. The same messaging mechanism of the program sent the text of interpretations to remote clinics and hospitals a few minutes after the radiologist's interpretation was made. CONCLUSION. My experience suggests that a computerized reporting and messaging system based on acronyms and eponyms is a time- and cost-effective technique for managing a solo radiology practice. By using a programmable relational data base, one can modify the system to include educational, quality improvement, and billing functions.

Objective: The American College of Radiology (ACR), the principal professional organization of United States radiologists, receives numerous requests for information on the characteristics of radiology groups. This report describes the basic characteristics of radiology groups in the United States. We defined radiology groups as any practice with two or more radiologists or radiation oncologists, including academic departments, units in multispecialty groups, and staff of government facilities., Materials and Methods: To collect basic information on radiology groups, the ACR conducted a mail census of all identified radiology groups in the United States during late 1991 and early 1992. Follow-up was conducted by mail and telephone. To make the responses accurately representative of all radiology groups, we weighted the approximately 2000 responses to correspond to known control totals for the number of groups of each of seven size categories in each of the four census regions (Northeast, Midwest, South, and West). These control totals were obtained from the ACR's 1990 Manpower Survey, which showed a total of approximately 3200 radiology groups., Results: Approximately one fourth of all groups have two radiologists, one fourth have three or four radiologists, one fourth have five to seven radiologists, and one fourth have eight or more radiologists. Academic groups were relatively large; almost 50% had 11 or more radiologists. Nonmetropolitan areas had very few large groups, and metropolitan center cities had relatively few small groups. Ninety-two percent of all groups practiced at hospitals, and 73% of all groups practiced at nonhospital offices or centers. The median number of practice sites for all groups was three, including both hospital and nonhospital sites. Eighty-eight percent of all groups provided diagnostic radiology services, 23% provided radiation oncology, 12% offered both, and 11% were oncology-only groups. Relatively many academic groups (25%) were oncology-only groups; very few radiology groups (2%) in multispecialty practices were oncology-only groups. The diagnostic radiology techniques available from the largest percentages of groups were general radiography (plain film), sonography, mammography, and CT. One eighth of academic groups that provided diagnostic services did not report providing mammography, compared with only a few percent of all groups in the United States that provided diagnostic services., Conclusion: Half of all groups have two to four radiologists, and this has not changed since at least 1986. A substantial percentage of groups that perform diagnostic radiology do not provide MR, interventional, or nuclear medicine services. This is particularly true of relatively small groups. These characteristics may become the source of some problems as managed care becomes more prominent and larger groups, offering a full range of services and practicing at several sites, are favored by managed care organizations that seek to contract with one group for all their radiology services.

Analysis of relative value units (RVUs) was used to quantify patient-care productivity of radiologists in 19 multispecialty group practices and to determine how productivity is affected by certain characteristics of the practices. The RVUs used in this study are the professional component RVUs developed by the American College of Radiology and the Health Care Financing Administration and published as the Radiology Relative Value Scale. An RVU workload was calculated by multiplying the number of times each procedure was performed by the procedure's corresponding RVU; the sum of these products gave the overall professional RVU workload. Five productivity indexes were calculated. The physician index denotes the ratio of the total number of physicians in the clinics to the total number of radiologists. The availability index denotes the fraction of radiologists who are available to perform clinical work after deductions are made for time away from clinical work. The difficulty index measures, in RVUs per examination, the level of complexity of the overall examination mix. The examination index measures examinations per available radiologist, and the RVU index measures RVUs per available radiologist. Altogether, the 19 clinics reported 3,234,451 examinations performed by 299 radiologists. The computed overall indexes were as follows: physician index = 20 physicians per radiologist; availability index = 0.77; difficulty index = 2.27 RVUs per examination; examination index = 14,098 examinations per year per available radiologist; RVU index = 32,065 RVUs per year per available radiologist. When the clinics were grouped according to characteristics of the practices, the RVU index was higher for single-site practices, high-prepaid practices, outpatient-only practices, and practices without radiology training programs. Fifty-two percent of the RVUs were in general radiology, 37% in sectional imaging, and 10% in special procedures. The concept of RVU workload is timely because it undoubtedly will be used to compare workloads across medical subspecialties, and these workloads are likely to be related by third-party payers to compensation.

For a court to sustain a restrictive covenant with anticompetition as its major thrust does violence to our individual rights. There is no duty for a former employee not to compete as an incident of employment. Employers who seek to enforce restrictive covenants to protect their practice areas are asking the court to place on one side of the scales of justice the birthright of a newcomer to engage in the competitive marketplace and to place on the other side the right of the established group to have a public market area reserved exclusively for their benefit by prior claim. The court is being asked to take valuable legal rights to pursue competitive opportunities from one person or business and give them to the other person or business. In a legal sense, this is not easy to justify. Without something specific and private to protect other than public competitive opportunities, a restrictive covenant may violate public policy by casting a chilling effect on competition, may be abusive to constitutional equal protection, does violence to the concept of free enterprise, and tends to deny communities the services of highly trained professionals that may otherwise be hard to replace. The law of restrictive covenants varies from one state to another. Some jurisdictions have strayed from the traditional position detailed here and often are inclined to protect the employer's right to a service area for a specified term. The services of a local attorney should be obtained when it is necessary to deal with a contractual restrictive covenant.