Q&A: Roundtable with authors from ACR's 'Best of 2016' articles

The Journal of the American College of Radiology (JACR) editorial board, voted four articles into “The Best of 2016” based on their advancements to the field of radiology.

Radiology Business spoke with authors from each of the four original peer-reviewed articles to get some insight on each of their studies. 

• Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform (Ezequiel Silva III, MD; Geraldine B. McGinty, MD, MBA; Danny R. Hughes, PhD; and Richard Duszak Jr., MD)
• In-Person Communication Between Radiologists and Acute Care Surgeons Leads to Significant Alterations in Surgical Decision Making (Elliot C. Dickerson, MD; Hasan B. Alam, MD; Richard K.J. Brown, MD; Jadranka Stojanovska, MD; and Matthew S. Davenport, MD)
• Direct Interactive Public Education by Breast Radiologists About Screening Mammography: Impact on Anxiety and Empowerment (Jiyon Lee, MD; Lara A. Hardesty, MD; Nathan M. Kunzlera; and Andrew B. Rosenkrantz, MD)
• Strategic Expansion Models in Academic Radiology (Rajni Natesan, MD, MBA; Wei T. Yang, MD; Habib Tannir; and Jay R. Parikh, MD)

Radiology Business: What prompted you and your team to do research on the particular area of study? 

Ezequiel Silva III, MD: One is patients, two is facilities that provide care to patients and three is the physicians in which we market—the preferred physicians, physicians with whom we’ve collaborated on patient care and the physicians that manage rolls within facilities we serve. Bringing all that together is one of the goals of MACRA—to expand collaboration, to expand coordination of care, to expand efficiency. For radiologists, if we want to be in any position to contribute meaningfully to that transition, that can be purposeful. But your actions need to be driven by not just the information on the statute but also data informing implementation of the statute. The tools and actions can be put into the hands of radiologists to empower them to improve patient care and to improve the facilities we serve. If we’re not the ones driving that—and we’re the experts on imaging and we’re the experts of radiology—someone else will. Someone has to. There’s a baseline requirement for radiology to contribute and imaging to contribute, and we are the best physicians in our profession to make sure that happens properly.

Elliot C. Dickerson, MD: From an early stage, we found that there were benefits with in-person communication with our referring surgeon, especially in the acute setting. This is a setting that is already widely adopted in the tumor board model, so we wanted to prove that this was something applicable outside of that model.

Jiyon Lee, MD: This work did not start out as research, not at all. Even before the U.S. Preventive Services Task Force (USPSTF) changed its breast screening guidelines in 2009, I conducted community outreach to help educate others on breast imaging and how it’s used. I presented lay-friendly, illustrated and practical explanations in a structured talk about the salient details in a way that I would want if I were not a breast radiologist. As is customary for such community outreach, we solicited feedback from attendees. It was gratifying to hear the positive responses. That they wished for such education for others served as a clarion call that is understandable. Education should be objective and noncoercive. It’s commonly said that “Knowledge is power,” but I propose that it is a good, effective power only if complete and accurate.

Rajini Natesan, MD: As healthcare moves increasingly toward value-driven, patient-centered service, we have seen the traditional operating model of academic radiology face challenges of sustainability. With this being the case, the purpose of our paper was to identify and describe new, non-traditional models of expansion in the community for academic organizations. Here, we focused on three predominant expansion strategies, namely a brick-and-mortar strategy, a community practice acquisition strategy and then a partnership-based strategy. We then provided real-life case examples for each approach. The outcome of each approach is to build a value-driven, patient-centered system that is sustainable to the academic provider.

Give us some background and findings from each study.

Ezequiel Silva III, MD: When you talk about the law and MACRA, it has two pathways to it, one pathway is called the Merit-Based Incentive Payment System (MIPS), which we talk about how physicians are scored within that particular system. We also talk about the second pathway that is probably more far-reaching or enhanced. That pathway is going to take longer to develop—and it includes alternative payment models. We talk about the requirements to become an advanced alternative payment model, but what’s important is the bodies that are impacting how those models might be structured, and about how radiology refines itself within those future alternative patient models.

Elliot C. Dickerson, MD: We looked for cases where there were already the same readouts, so we got the institutional review board (IRB) approval to examine them. We did a formal data collection around 100 cases—basically how things changed before and after we had a meeting with the surgeon. For 43 of them, we found that there’s big change in how they reciprocate. There were big changes on how they managed the case. We were interested in if there was a discrepancy between ‘Was there an opinion for the radiologists?’ or ‘Was it that they just better understood what we were saying in our reports about the case?’ In a vast majority of cases, it was there understanding of reports and how we interpreted the case. It wasn’t that our interpretation of the case was changing, except for a small minority of cases.

Jiyon Lee, MD: This article specifically highlights how such direct and interactive public education can affect potential benefit in two ways. First, directly reduce one of the core criticisms about screening: The “anxiety” that women may experience, which is heavily weighed as a “harm” of screening. Most women do not experience high anxiety and are glad to have a test that may help them. Education can help demystify much of the process and protocol.

Two, education can directly increase one of the necessary components of shared decision making that is presumed in implementing breast screening: informing women.

The pre- and post-lecture questionnaire, along with fact-based quiz questions, provided insight (both to me and to attendee) and enabled a learning opportunity for the audience—these are not always measurable in community outreach efforts. Each attendee is her or his own control when reporting any benefit on educational empowerment and perceived anxiety. This education as I designed it will continue—and is shareable!– after the lecture is done. Many men attended too, happy to be learning and potentially supporting women in their lives. I always encouraged inclusive audiences. It was impressive to see the diversity, including young aged women who came to learn.

Rajini Natesan, MD: The success of a breast cancer screening program is based on patient participation, and so the key is getting access to many patients and involving those patients in their healthcare. It is important to reach out in a patient-centered way to drive engagement. I think this paper provides very tangible models of expansion, that set up the possibility of patient engagement, and the ability for academic institutions to provide the standard of care in breast health in the community.

How do you feel the information in your article will help radiologists? 

Ezequiel Silva III, MD: Anytime they’re talking about physician payment, it’s relative to payment for any professional services can be relevant to practices in that field. Payment, salary and technology drive us to do what we do. Understanding how that payment landscape is unfolding before us is relevant, so a big part of MACRA is ensuring quality metrics are satisfied for the betterment of patient care, for the betterment of patient experience and for the betterment of quality. That’s what we do: patient care and patient quality.

Elliot C. Dickerson, MD: This report is how radiologists can make themselves indispensable to their clinical services and their referring professions by being readily available for communication. In this study, we found that in-person communication was ideal. We had the opportunity to ask clarified questions ensuring that they can understand how the case matches and how we interpret the case. I think that’s going to be a value to both the radiologist and the referring clinician.

Jiyon Lee, MD: I’m thrilled at how this paper has galvanized the interest in this effort. I thank JACR for this. This paper is about using friendly, non-pressured talks to empower the attendees of all backgrounds. But it’s also about exhorting our collective compassionate pool of radiologists to step up, step out and be part of—in fact, enable—intelligent and thoughtful conversations. Be accessible. We cannot afford to assume anyone’s knowledge base on a topic. And in this wonderful country with its ethnic and cultural diversity, lack of awareness and lack of access can still undermine the work that all of us strive to do. Radiologists—we’re patients too!—can help with that, in any setting that can be considered community. 

May even the shy try, because sometimes the shyest radiologist among us may be the kindest voice and easiest on the ears. The direct, interactive, in-person experience is wonderful—and the only way to create nimble, flexible lectures that can flex with any recent lay press, address hot topics and embrace the people right before you. Hear their questions, welcome their curiosity, feel their perspective and help dispel fog—like a glorified, high-level show-and-tell. Explain why we screen ourselves and loved ones and not about why they must get screened. Rather, explain the process and the potential benefits and define “harms.” Or just talk about anything! It’s fun! I wish other health providers would do this for all health topics.

Rajini Natesan, MD: I think the key take away is that, given expansion is top of mind to most academic institutions, they should take advantage of the different approaches based on their specific situation and needs. Selecting the right strategy should then result in both improved sustainability for the institution, improved patient-centered care and increased value to the service. Achieving those improvements in care may require institutions to employ a combination or mix of the three strategies that we laid out. Each institution, based on its financial situation, brand risk appetite, expectations or operation success, may choose a different path with the same outcome in mind.