John A. Patti

Informed Decision Making Trumps Informed Consent for Medical Imaging with Ionizing Radiation

Until patient-specific radiation doses are measured routinely and reliably, and until the associated risk is known reliably, it is imprudent to require classic informed consent for medical imaging procedures that use ionizing radiation.

ACR White Paper: The Value Added That Radiologists Provide to the Health Care Enterprise

Radiologists represent arguably one of medicines least heralded but most important specialties. Although they carry sterling credentials as imaging and radiation safety experts, radiologists have lacked widespread public recognition. As public and private stakeholders cast an even more intense spotlight on imaging, the vital role of radiologists must be better understood. During the January 2008 ACR Forum on Future Practice Models for Radiology, participants and ACR leaders discussed the value added that radiologists bring to the health care enterprise and recommended that the ACR further study that topic. The ACR, dedicated to providing quality patient care since its inception in 1924, convened the Task Force on Value Added to address these issues. The task force determined the component stakeholders in the health care enterprise to whom value is added, defined the nature of the value for each constituent component, described the process of adding that value, and anticipated future trends that may affect the value proposition. Recommendations to the ACR for future action are offered.

Informed Consent for Radiologic Procedures

In Reply: We agree with Dr Mezrich that the precise nature of the relationship between x-ray radiation and cancer risk is incompletely understood and that maintaining patients’ radiation exposures “as low as reasonably achievable” is an important principle. The scientific community’s understanding of the relationship between radiation dose and cancer risk currently rests, for reasons of sample size and statistical power, primarily on data from nonimaging sources of radiation, and it is impossible to reconcile every study in the radiation epidemiology literature with every other study. Even so, as we have previously discussed, the major US (National Academies, National Council on Radiation Protection and Measurements) and international (International Commission on Radiological Protection, United Nations Scientific Committee on the Effects of Atomic Radiation) advisory organizations have reviewed this literature and supported the notions that radiation-associated cancer risks are cumulative and that the linear-no-threshold model best fits the available data for purposes of radiation protection. Although Howe’s work on a Canadian cohort of tuberculosis patients receiving fractionated moderate-dose radiation from fluoroscopy during pneumothorax therapy failed to demonstrate a positive association between lung cancer risk and dose, it did demonstrate a strong linear trend of increasing breast cancer risk with increasing dose (P .001). As suggested in the Biological Effects of Ionizing Radiation VII report, the presence of tuberculosis may modify radiation-attributable risk of cancer mortality. The breast cancer study cited by Mezrich, which was an earlier report on the Canadian tuberculosis cohort with 7 fewer years of follow-up, was not powered to find a statistically significant difference in breast cancer mortality when excluding patients with cumulative breast doses of 70 cGy or more, which included 41% of the breast cancer deaths. The authors’ main finding was that women “exposed to 10 cGy of radiation had a relative risk of death from breast cancer of 1.36, as compared with those exposed to less than 10 cGy (95% confidence interval, 1.11 to 1.67; P=.001). The data were most consistent with a linear doseresponse relation.” Dr Durand’s comments underscore the subtleties involved in balancing radiation’s benefits and risks, and his point regarding risk associated with future exposure being independent of past radiation burden is important yet often unappreciated. We do not regard efforts focusing on patient populations receiving high cumulative doses as conflicting with uncertainty regarding the net significance of disparities in imaging use. A priori, efforts to decrease radiation doses stand to benefit such populations the most in terms of absolute risk reduction. Although our study found high cumulative radiation doses in many patients undergoing MPI, another message was that much of this radiation is the result of medically indicated care. More than 80% of initial and 90% of repeat MPI examinations were performed in patients with established cardiac disease or symptoms consistent with cardiac disease. Radiation is one element of a thoughtful multifactorial, patient-centric consideration of all of the potential benefits, risks, and costs of diagnostic testing. Rather than alarmism, we advocate heightened efforts at all levels to ensure appropriate and optimized use of medical radiation.

Impact of Generational Differences on the Future of Radiology: Proceedings of the 11th Annual ACR Forum

The 2011 ACR Forum focused on the impact of generational differences on the future of radiology, seeking to inform ACR leadership and members on how best to address the influence of the new integrated workforce on the specialty of radiology and on individual practices.

The 2009 ACR Forum: Health Care Payment Models

The 2009 ACR Forum addressed health care payment models, the strengths and weaknesses of different models under consideration, their implications for radiology, and the role radiologists should play in the debate.

2013 ACR Presidential Address: A Personal View on the Future of Radiology

In this address, John A. Patti, MD, acknowledges the celebration and success that radiologists have experienced throughout their careers but also asks incisive questions about how they will face the future. Answers to those questions require an analysis of the past, an understanding of the present, serious and penetrating introspection, and engagement of a process for moving forward. An understanding of who we are and why we do what we do is essential to facilitate the changes that will be necessary if radiologists are to control the future, rather than having the future control radiologists.

The national radiology data registry: a necessary component of quality health care.

m t p l w p It has been 12 years since the Institute of Medicine released its landmark report To Err Is Human [1] and 10 years since the release of the equally paradigm-shifting Crossing the Quality Chasm [2]. It is important to look back at the recommendations of those reports in the current light of what medicine has or has not accomplished. Because the house of radiology now stands at the center of modern health care, it is evenmore important todetermine if radiology has met the expectations outlined in these reports. One of the main conclusions of To Err Is Human is that most errors are caused by faulty systems or processes that lead people to make mistakes, or fail to prevent them, and that mistakes are best prevented by designing a safer health system. In its second report, the Institute of Medicine focused on safety by outlining 10 “rules for redesign.” Three of these rules are particularly germane to this discussion [2]:

Radiology in 2022: Challenges and Opportunities in the Coming Decade—Proceedings of the 12th Annual ACR Forum

The 2012 ACR Forum focused on the anticipated challenges and opportunities facing radiology in the next 10 years, centered on the themes of health care reform, future payment models, research and innovation, patient-centered radiology, and information management. The recommendations generated from the forum seek to inform ACR leadership on the best strategies to pursue to ensure the continued success of the profession in the coming decade.

Managing Hospital-Radiologist Relationships: Proceedings of the Tenth Annual ACR Forum

The annual ACR Forum brings together a multidisciplinary group to discuss a topic of present and future importance to radiologists. The 2010 gathering was dedicated to radiologist-hospital relationships. This article summarizes the conversations and details the advice of attendees to the ACR as to what actions might best benefit radiologists and the specialty.

Is quality good enough

“Dear Dr. Patti, I read your comments in JACR every month and appreciate what you have to say. I strongly agree with any and all sentiments urging radiologists to rise to the highest level of quality possible. In our rapidly changing world, with rising health care costs and outsourcing potential, we see obvious threats in front of us. However, I’m here to tell you that demanding the best and achieving it is not enough. For the last two years my group was the #1 ranked department in the annual medical staff Press-Ganey surveys. To my knowledge, we have the universal support of the entire medical staff. Despite this highest quality ranking, our group fell under the eye of the administration and was recently unceremoniously discarded after 39 years of staffing.” [1]