Extreme Subspecialization Builds Its Own Knowledge Base
“The more you see, the better you are,” Javier Beltran, MD, FACR, says. “You’re exposed to so much pathology that you’ve seen it all, at the end of the day. It brings your expertise to another level.” Beltran is talking about what might be called extreme subspecialization. Beltran is a musculoskeletal radiologist. He estimates that he personally reads more than 10,000 musculoskeletal exams per year, with 95% of them being MRI studies. This is probably double the number that the typical subspecialist reads, and far more musculoskeletal exams than a general radiologist would read in a year, Beltran says.
On a particularly intense, up-until-midnight workday, Beltran says that he might interpret 100 exams. He’s exhausted after the effort, but such days have given him deep expertise in musculoskeletal-exam interpretation. He chairs the radiology department at a midsize hospital, yet he is a sought-after musculoskeletal lecturer around the world. 
Javier Beltran, MD, FACR It’s hard, however, to teach musculoskeletal interpretation without the appropriate studies to interpret. Even an extreme subspecialist can’t share knowledge with colleagues, residents, and fellows without a supply of cases to illustrate the various injury and disease states and how to spot them using the latest technology. This was the problem facing Beltran five years ago when, he says, he tumbled into his role with teleradiology provider Franklin & Seidelmann Subspecialty Radiology (F&S), Beachwood, Ohio. The tumble changed Beltran’s professional life. He put on another hat and joined F&S part time, as an interpreter and lecturer. In the bargain, he got access to the cases he needed to teach the residents and fellows at his hospital. Eleven years ago, Beltran was named radiology chair at Maimonides Medical Center in Brooklyn, NY. He also became a clinical professor of radiology at the Mount Sinai School of Medicine, with which the Maimonides hospital is affiliated. Maimonides, which was founded in 1911, is licensed for about 700 beds; Beltran says that the radiology department has 20 radiologists on staff and 16 residents, plus two funded fellowships and occasional unfunded fellowships. Before he joined F&S, Beltran says, it was difficult to find the musculoskeletal cases that he needed to teach and train his fellows and residents. Maimonides emphasized oncology and geriatrics (programs that met the needs of a somewhat elderly patient base), but the orthopedics department was somewhat weak, according to Beltran. There was a particular lack of sports-injury cases, but it was sports-medicine cases that the young musculoskeletal radiologists most wanted to see—and needed to see, in order to build practices later. With its much larger pool of cases from over 200 clients, F&S was able to supply the case studies that Beltran needed. “I requested permission from the hospital to incorporate these cases into the daily review with the residents, and the hospital granted it,” Beltran says. He had enough cases then to offer an musculoskeletal fellowship at Maimonides, which he did. Subspecialty Education and Training Once onboard at F&S, Beltran found his expertise being tapped to broaden the training of the musculoskeletal experts interpreting for the company. F&S hires subspecialists, then continues to train them into extreme subspecialization. Beltran says that he helped initiate what F&S now calls its All-star Lecture Series. One of Beltran’s contributions, of course, was to offer lectures on his subspecialty. “We select the best experts and we give a Webcast through the Internet,” he says. These Webcasts are seen by F&S physicians across the country. Beltran also lets his Maimonides residents and fellows participate. “It’s been working very well,” he says. The lectures are held once per month on different areas of subspecialization. Beltran says that he’s given three or four lectures to date. While musculoskeletal and neurological cases make up about half of the topics, the lectures have included cardiac imaging and breast imaging: areas that will receive more focus in the future, Beltran says. Beltran says that F&S radiologists are carefully vetted, licensed, and credentialed through a lengthy in-house process. They are already subspecialists when they join, but even so, the company routinely overreads for its newly hired physicians. Beltran says that the company also has a rigorous peer-review process. A component of this is random review of routine cases; a second part is mandatory review of any case in which there is “misinterpretation of a significant finding with impact on patient care,” Beltran says. This includes reexamining cases where surgeons discover a discrepancy between the radiology report and surgical findings. After these mandatory reviews, steps are taken to correct any areas of weakness, Beltran says. Research and Data Mining F&S also augments its subspecialist training by conducting research. For instance, does atrophy of the abductor digiti minimi (ADMA) signal that radiologists should look for calcaneal spur and/or plantar fasciitis as part of a progression to Baxter neuropathy, a heel condition? A study1 co-authored by Beltran using data developed through F&S suggests that the answer is yes. The study compared 100 ADMA patients and 100 patients without ADMA who underwent MRI exams for heel pain between August 2006 and January 2007. The patients were selected retrospectively from cases interpreted at F&S; the patients ranged in age from 10 to 92. This study is an example of research that is becoming increasingly common in radiology as archived cases are data mined to reveal significant correlations that may not be apparent on the surface. Typically, major hospitals and health systems have undertaken these data-mining efforts, but providers like F&S, which also have extensive case files, can now undertake data mining as well. Beltran says that this should not be thought of as a service that F&S offers. The company’s service is interpretation, but the ADMA study and others that F&S has done do “show potential clients that we’re not just reading, but have a research capacity,” Beltran says, “which gives us a higher status.” It also illustrates how the knowledge base at any high-volume imaging center or practice can build on itself as subspecialists dig down into the finer details of the diseases and conditions that they encounter. “I would not have been able to do this study based on the cases I read at my hospital, for instance,” Beltran says. What the Findings Mean With respect to the study itself, Beltran says that when radiologists see ADMA, now they will know to look for calcaneal spur and plantar fasciitis. The study found a clear association between ADMA and the presence of the other conditions. According to the study, this correlation supports the idea of the possible roles of calcaneal spur and plantar fasciitis in the progression to Baxter neuropathy. Beltran says that when he was lecturing recently in Davos, Switzerland, a physician commented that he had probably been missing the association between ADMA and a progression to Baxter neuropathy simply because he hadn’t been looking for it. “Once they realize the finding is there, then they realize its significance, and they will have to look for it,” Beltran says. “Once you learn it, you see it all the time.” He says that ADMA, in itself, does not indicate what treatment is needed, but does indicate that something else might be causing the problem. The patient then has to be assessed to see whether therapy or surgery is the proper treatment for the heel condition. Available Expertise Beltran makes the point that the databases and knowledge repositories accumulated by F&S subspecialists as they read have improved patient care. This has been particularly true for the small-to-midsize hospitals and radiology clinics that would not have subspecialist interpretation without enlisting a third-party provider like F&S, he says. “Extreme expertise outside the large cities—to find a person or recruit in a small town, to attract a fellow trained in musculoskeletal radiology or neuroradiology—might be difficult,” he says. “You might have a general radiologist instead, so the quality of the interpretation is not the same. The patient is in better hands with an F&S musculoskeletal subspecialist than with a general radiologist who doesn’t have the same in-depth knowledge.” He also notes that the interpretations that F&S provides are often requested by surgeons who have learned to doubt the expertise of some general radiologists. “If the surgeons see mistakes, they get upset, and they ask the hospital to get a radiology group with more knowledge; that’s where F&S comes into the picture. We have seen that quite often, and it’s driven by surgeons and referring physicians,” Beltran says. “The hospital administration then completes the deal, and suddenly the hospital is getting more patients because there is more reliance on interpretations. One thing leads to another, and the result is better patient care.” Beltran also says that in today’s radiology world, telemedicine is the norm, not the exception. “The technology can deliver the images wherever you are,” he explains. At Maimonides, he says, he’s been able to save half a radiologist FTE by having some radiologists read from home one day per week. At home, there are no interruptions. “They are significantly more efficient from home than when they’re here; I would say, in the range of 5% to 10% more efficient,” he says. With a worldwide shortage of radiologists continuing, Beltran says, the teleradiology or remote-interpretation model is a perfect offset. “In radiology, it’s so natural and easy to make the interpretation from anywhere you want to that it helps expedite the services,” he says. Not long ago, high-end, urban medical centers were the only place that cases with subspecialty imaging needs could be sent for interpretation. That’s not true any longer, Beltran maintains. With the deep focus and extreme subspecialization that some teleradiology practices have worked hard to create and enhance, the expertise needed to interpret complex and intricate imaging studies is available in small-population markets, as well as elsewhere.
Javier Beltran, MD, FACR It’s hard, however, to teach musculoskeletal interpretation without the appropriate studies to interpret. Even an extreme subspecialist can’t share knowledge with colleagues, residents, and fellows without a supply of cases to illustrate the various injury and disease states and how to spot them using the latest technology. This was the problem facing Beltran five years ago when, he says, he tumbled into his role with teleradiology provider Franklin & Seidelmann Subspecialty Radiology (F&S), Beachwood, Ohio. The tumble changed Beltran’s professional life. He put on another hat and joined F&S part time, as an interpreter and lecturer. In the bargain, he got access to the cases he needed to teach the residents and fellows at his hospital. Eleven years ago, Beltran was named radiology chair at Maimonides Medical Center in Brooklyn, NY. He also became a clinical professor of radiology at the Mount Sinai School of Medicine, with which the Maimonides hospital is affiliated. Maimonides, which was founded in 1911, is licensed for about 700 beds; Beltran says that the radiology department has 20 radiologists on staff and 16 residents, plus two funded fellowships and occasional unfunded fellowships. Before he joined F&S, Beltran says, it was difficult to find the musculoskeletal cases that he needed to teach and train his fellows and residents. Maimonides emphasized oncology and geriatrics (programs that met the needs of a somewhat elderly patient base), but the orthopedics department was somewhat weak, according to Beltran. There was a particular lack of sports-injury cases, but it was sports-medicine cases that the young musculoskeletal radiologists most wanted to see—and needed to see, in order to build practices later. With its much larger pool of cases from over 200 clients, F&S was able to supply the case studies that Beltran needed. “I requested permission from the hospital to incorporate these cases into the daily review with the residents, and the hospital granted it,” Beltran says. He had enough cases then to offer an musculoskeletal fellowship at Maimonides, which he did. Subspecialty Education and Training Once onboard at F&S, Beltran found his expertise being tapped to broaden the training of the musculoskeletal experts interpreting for the company. F&S hires subspecialists, then continues to train them into extreme subspecialization. Beltran says that he helped initiate what F&S now calls its All-star Lecture Series. One of Beltran’s contributions, of course, was to offer lectures on his subspecialty. “We select the best experts and we give a Webcast through the Internet,” he says. These Webcasts are seen by F&S physicians across the country. Beltran also lets his Maimonides residents and fellows participate. “It’s been working very well,” he says. The lectures are held once per month on different areas of subspecialization. Beltran says that he’s given three or four lectures to date. While musculoskeletal and neurological cases make up about half of the topics, the lectures have included cardiac imaging and breast imaging: areas that will receive more focus in the future, Beltran says. Beltran says that F&S radiologists are carefully vetted, licensed, and credentialed through a lengthy in-house process. They are already subspecialists when they join, but even so, the company routinely overreads for its newly hired physicians. Beltran says that the company also has a rigorous peer-review process. A component of this is random review of routine cases; a second part is mandatory review of any case in which there is “misinterpretation of a significant finding with impact on patient care,” Beltran says. This includes reexamining cases where surgeons discover a discrepancy between the radiology report and surgical findings. After these mandatory reviews, steps are taken to correct any areas of weakness, Beltran says. Research and Data Mining F&S also augments its subspecialist training by conducting research. For instance, does atrophy of the abductor digiti minimi (ADMA) signal that radiologists should look for calcaneal spur and/or plantar fasciitis as part of a progression to Baxter neuropathy, a heel condition? A study1 co-authored by Beltran using data developed through F&S suggests that the answer is yes. The study compared 100 ADMA patients and 100 patients without ADMA who underwent MRI exams for heel pain between August 2006 and January 2007. The patients were selected retrospectively from cases interpreted at F&S; the patients ranged in age from 10 to 92. This study is an example of research that is becoming increasingly common in radiology as archived cases are data mined to reveal significant correlations that may not be apparent on the surface. Typically, major hospitals and health systems have undertaken these data-mining efforts, but providers like F&S, which also have extensive case files, can now undertake data mining as well. Beltran says that this should not be thought of as a service that F&S offers. The company’s service is interpretation, but the ADMA study and others that F&S has done do “show potential clients that we’re not just reading, but have a research capacity,” Beltran says, “which gives us a higher status.” It also illustrates how the knowledge base at any high-volume imaging center or practice can build on itself as subspecialists dig down into the finer details of the diseases and conditions that they encounter. “I would not have been able to do this study based on the cases I read at my hospital, for instance,” Beltran says. What the Findings Mean With respect to the study itself, Beltran says that when radiologists see ADMA, now they will know to look for calcaneal spur and plantar fasciitis. The study found a clear association between ADMA and the presence of the other conditions. According to the study, this correlation supports the idea of the possible roles of calcaneal spur and plantar fasciitis in the progression to Baxter neuropathy. Beltran says that when he was lecturing recently in Davos, Switzerland, a physician commented that he had probably been missing the association between ADMA and a progression to Baxter neuropathy simply because he hadn’t been looking for it. “Once they realize the finding is there, then they realize its significance, and they will have to look for it,” Beltran says. “Once you learn it, you see it all the time.” He says that ADMA, in itself, does not indicate what treatment is needed, but does indicate that something else might be causing the problem. The patient then has to be assessed to see whether therapy or surgery is the proper treatment for the heel condition. Available Expertise Beltran makes the point that the databases and knowledge repositories accumulated by F&S subspecialists as they read have improved patient care. This has been particularly true for the small-to-midsize hospitals and radiology clinics that would not have subspecialist interpretation without enlisting a third-party provider like F&S, he says. “Extreme expertise outside the large cities—to find a person or recruit in a small town, to attract a fellow trained in musculoskeletal radiology or neuroradiology—might be difficult,” he says. “You might have a general radiologist instead, so the quality of the interpretation is not the same. The patient is in better hands with an F&S musculoskeletal subspecialist than with a general radiologist who doesn’t have the same in-depth knowledge.” He also notes that the interpretations that F&S provides are often requested by surgeons who have learned to doubt the expertise of some general radiologists. “If the surgeons see mistakes, they get upset, and they ask the hospital to get a radiology group with more knowledge; that’s where F&S comes into the picture. We have seen that quite often, and it’s driven by surgeons and referring physicians,” Beltran says. “The hospital administration then completes the deal, and suddenly the hospital is getting more patients because there is more reliance on interpretations. One thing leads to another, and the result is better patient care.” Beltran also says that in today’s radiology world, telemedicine is the norm, not the exception. “The technology can deliver the images wherever you are,” he explains. At Maimonides, he says, he’s been able to save half a radiologist FTE by having some radiologists read from home one day per week. At home, there are no interruptions. “They are significantly more efficient from home than when they’re here; I would say, in the range of 5% to 10% more efficient,” he says. With a worldwide shortage of radiologists continuing, Beltran says, the teleradiology or remote-interpretation model is a perfect offset. “In radiology, it’s so natural and easy to make the interpretation from anywhere you want to that it helps expedite the services,” he says. Not long ago, high-end, urban medical centers were the only place that cases with subspecialty imaging needs could be sent for interpretation. That’s not true any longer, Beltran maintains. With the deep focus and extreme subspecialization that some teleradiology practices have worked hard to create and enhance, the expertise needed to interpret complex and intricate imaging studies is available in small-population markets, as well as elsewhere.