I'm Rich Howlett, I'm a cardiovascular imaging specialist, Indianapolis primarily. I'm the medical imaging director for a freestanding heart center through Ascension, and then a clinical associate professor at Stanford when I'm really lucky. So I've got three things to discuss this morning. One, ways we can, you know, things we've learned in terms of protocols and value-added information we can provide in private practice. I think I'd be remiss if I didn't talk about turf a little bit and explain what our situation is and maybe ways to look at things. And then third, a little bit on mentorship, which I think in private practice may or may not get as much due as is needed. So I wanna talk about these things. It's gonna be reasonably non-didactic in terms of there's not a lot of stuff to memorize or whatever else, but send us in questions. Be happy to entertain them afterwards. My contact info is there. So first, protocols and value-added information. I think if you can set up a good cardiovascular protocol system, that's really gonna improve the consistency of your output across a wide spectrum of patients. Things that are complex will become less operator-dependent, and so we cover like 17 hospitals and clinics, and so it's really difficult to get something that's consistent throughout all those places. So we try to do that. I'll explain how we do it. My experience has been that vendor protocols and support are limited, especially after their first install time. So once they're done with the install and the techs say, oh yeah, we got this, it seems to vanish, unless you're willing to fork over a lot of money. So this is a way that we can improve patient care and really demonstrate some of our value. This is just an example here. It's gonna play or not. It might play. It might not play. This is a thoracic outlet syndrome case here. We have a very specific injection protocol for this. It's easy, but if you don't know what it is or the technologists don't know, then suddenly it's complex. So I can't show you the video, unfortunately. So here's your didactic part of this test, this whole, there will be no test this whole lecture. If you understand the rules of really contrast medium dynamics as a cardiovascular imager, you're gonna be way ahead of the ballgame in terms of being able to make a protocol. So this is work from Dominic Fleischman and others, and I think it's just brilliant work. Three things to remember. One, the arterial enhancement is proportional to the iodine flow rate or the iodine flux or the iodine delivery rate, depending on your nomenclature. So the faster you inject per milliliters per second of contrast or the higher concentration of contrast, the higher the enhancement you'll see. Two, the arterial enhancement increases over time as a cumulative effect, and that's because of recirculation of contrast back into the target area of interest. If you look at this graph on the left side, this is seconds over here on the x-axis and Hounsfield units on the right, on the y-axis. You look at continually going up, each one of these is kind of a little short segment bowl, as you could think of, but your density continues to go up until the end of the injection. And so we can leverage that in terms of being able to build a contrast protocol. And then third, realize that arterial enhancement is really variable between individuals. It's certainly inversely proportional to cardiac output and body weight, or BSA, which has a lot to do with how we will design our protocols. And then there's a patient factor. Some patients have a high attenuation response, some people have a low attenuation response. That's something we're still trying to figure out, and I hope that there's gonna be some machine learning slash AI initiative that'll maybe let us predict a little better beforehand who will have this higher or lower attenuation response. So that's how we'll do it. I realize that for all of your practices and mine as well, the scan time that you're looking at really is dependent on the scanner and the scan mode that you choose. So if you're doing a turbo flash mode, you can go with 700 millimeters per second or something. If you've got a four-slice scanner, maybe your scan is gonna take 12 or 14 or 15 seconds. You gotta factor that in. We use weight-based contrast dosing, and if you don't do it just by 1.3 milligrams of iodine per kilo or something, at least have a few buckets. So like small, medium, and large. We do it a lot of our places just so that we can get something that's a little bit more consistent. We certainly utilize low KBP imaging when we can, and iterative reconstruction techniques, certainly important. And the other thing to realize is that it takes about six seconds for images to get reconstructed. You see the bolus triggering, the table moves, and breath-hold instructions are given. So I add about two seconds to that because I like to be right usually. So here's your, really, the take-home message in terms of making a scan protocol. The injection duration for contrast in seconds is equal to the scan time in seconds, plus about eight, plus any additional delay you might have to add if, for example, you're injecting at a slower rate for a longer period of time in imaging later. So that really works, and if I just have to make a protocol off the cuff or something, this is what I'll use. And again, the references are down here. It's brilliant work. It's not my work, but I think this is really brilliant. From a cardiac MR perspective, in private practice, we like to make these protocols as quick as possible, mostly because a lot of times we don't have a dedicated cardiac magnet. Our heart center has a dedicated cardiac magnet and probably does eight or 10 cardiac MRs a day. Everyplace else, we may be doing one or two cardiac MRs a day out of 25 MRs. So really important that we don't slow down the chain of patient flow for the rest of the enterprise. So we like to make it 45 minutes or less. That's certainly doable, I think, in most places, but we also need to protocol these things beforehand. In some places, for example, Stanford's got a really great PAX Epic integration. Do all your protocols beforehand. It's fabulous. Our main hospital partner in Indianapolis does not have something that's wonderful, and so that involves a lot of emails. So I get emails when things are scheduled. Here are the clinical notes. How do you want to scan this? So we get this done beforehand, and then when the patient comes in, we're not trying to find somebody to get a protocol done or whatever else. So this really, I think, helps, but you have to address it beforehand. We do coordinate with nursing for a lot of different things, including the stress cardiac MRs, and we do a lot of device patients. And if you do device patients, either for cardiac or non-cardiac MR, I think it's important to have a really good protocol for these patients, too. For us, they get cleared by an EP guy. They come in to a short-stay area. The device rep is there, interrogates the device. They get the procedure done. We've set the procedure up beforehand so that we know what the SAR limitations are. And then they go back to the short-stay area. They get rechecked to make sure the settings are all appropriate. We do more than 300 a year, knock on plastic. We haven't had an issue. And patients are really happy because most of the places will just tell them, oh, we can't do your MRI. So important to have a good protocol for that. So moving on, then, on some value-added services. We find that, in our practice, 3D imaging is really important. And our referring clinicians love it. It's just like candy. If you can make 3D images, it's great. Mostly because it gives them pathology or anatomy information that they can see in an environment that they understand. So if you can give them something that is exactly what they're looking for, that really shows the value of what we do. We use this for everything from living renal donors, we're a renal transplant center, to cardiac MR, certainly with all the structural heart procedures, not just TAVR, but TMVR, tricuspid valve trials and things like that. We do quite a bit. We are in the infancy at our site of 3D printing for a couple of reasons. One is the barrier of just getting in and the knowledge base. And this is a good place to get that knowledge. RSNA has a lot of really nice opportunities to learn about 3D printing. But we're getting there. And the questions we still have for any of this 3D imaging is who provides it? Is it a technologist? Is it a 3D lab? Is it a radiologist? Is it the cardiologist? Is it somebody else? Is it an off-site company? And who pays for it? And these are the things that still, for us, aren't worked out fully. But we'll see going forward. Like I said, it's integral really to referring services and understanding of things. And it looks like we're gonna get movies that don't play, so I apologize for that. So this is a coronary CTA with an anomalous right coronary artery here. You can see that it comes off really close to where the left main is here. And so our surgeon's question was, is there a single osteum or are there two ostea here? And what does it look like? So this is just an endoluminal blood pool inversion image showing the two separate ostea. I just labeled them for him in nice garish colors so you can't miss them. And then emailed this to him and they found that very useful. This didn't take long to make once you get over the intro level learning of the system. But it's really, I think, very valuable to them. This is another case that's not gonna play, but this is a case of a patient who has HALT, hypoattenuated leaflet thickening with restriction of leaflet motion in a experimental aortic valve that was supposed to not have leaflet thrombosis and not have any leaflet thickening. The video certainly does it better justice. But in this situation, they found that very useful. And we've had a number of these cases where we followed them back on anticoagulation, back on antiplatelet therapy, and you can actually see a lot of the HALT decrease. We can compare it side by side, send the surgeon notes. They love this. I think this is something that if you're not doing it in your practice, even to do it a little bit is very beneficial. So we did set up a 3D lab a few years ago where we've used a thin-client, zero-footprint, cloud-based rendering system. We do tons of structural heart disease, so Watchman devices, pulmonary vein mapping, any kind of TMVR or TAVR studies. We do about 750 TAVR studies a year. We also process coronary CTA, cardiac MR, and do left atrial mapping cases. This is just some of the output that we would see from our 3D lab. We recruited and trained in-house, and if you wanna build a 3D lab, you won't have a shortage of people who wanna come and work for you. At least in our place, the CT techs and the MR techs would much rather be able to do something they think is really cool and useful than get thrown up on by patients all day and whatever else. So we got great people. Unfortunately, the pandemic took a couple of them away from us, and they moved to different areas, but we've been able to train them in-house, especially thanks to Shannon Walters, who's the Stanford 3D lab director. Fantastic training for these guys. And then we standardized the workflow here as well, and that's easy enough to do. This is an output from the system just for a TAVR case. You can see you got everything that our implanters want. They want coronary heights, they want annular size, they want valve calcium score, and access vessels. And so we can do all this with a reasonably good output same day, and I think that's been really well received. 3D printing, like I mentioned, we're kind of in the infancy of this. This is a case from our place. A lot of times these days, our referring clinicians let's just get on and use the 3D rendering system. We can dice that up however we want. We can show what's there, cut something out we don't want. That's usually sufficient for them, but there's been a few instances where a physical model really helps. Troubleshooting and spatial relationships for the pediatric cardiac surgeons is something, as well as this case, where it really was a discussion with a patient and a surgeon trying to figure out what was going on. Like I mentioned, the barrier to entry is training, and then also resources. It's getting cheaper to do 3D printing now, but we're still finding it very difficult to get paid for it. So that, from our main hospital system, has been a barrier to expanding this work. So this is a case here of a contracircumval end of the heart that's recurrent. It's growing into the interventricular septum here. You can see this frond-like lesion here, and we took this with the cardiac MR data, made a 3D print here showing the bulk of the actual enhancing tumor, and then the surgeon and the patient had a discussion about this in terms of what they would do. They decided there wasn't a way they thought they could do it safely because of the tricuspid annular involvement and the depth of the septal involvement, so this became something that was not a surgical case for us compared to the thoughts beforehand. So moving from 3D imaging to TIRF issues. I'm sure if you're here, you probably have understood there's more than one specialty that does cardiovascular imaging, but I think it's important to look at it head-on and realize where it came from and maybe how we can deal with it. Again, here's contact info if you need it. So historically, this was all siloed. Back in the day, everybody who was a urologist, they did kidney surgery, they did bladder surgery, they did prostate surgery and lymph node dissections, but maybe they didn't do anything else like that. Everybody who was a cardiologist did NUCs and EKGs and ECHOs. That's allowed them to kind of fully invest themselves and master a particular area, but there's been a lot of changes over the years, and one of them has been that the imaging has gotten so fantastic. As we've gotten better with imaging and as there have been cuts to reimbursement, that's really created a lot of pressure, both internally and externally within different specialties, and so that gives rise to TIRF battles, and that's where we're at, I think, for a number of reasons. Things we should realize as well is that the cardiologists, there's a large number of them, that are now trained and interested in cardiac as well as vascular imaging, and the cardiology practice, I think, really views some of what we do as some of cardiovascular imaging as an existential threat to their historical practice. The recent chest pain guideline changes have shifted away from NUCs, for example, and toward coronary CTA, and for our practice, that's very important. So I mean, obviously, it makes sense they'd want to be involved in these things. It makes sense we want to be involved in them as well because these are things we've developed. So also realize that the hospital systems may employ your cardiologists, and our biggest system employs more than 100 cardiologists and the cardiovascular surgeons, and so I'm sure it's in their best interest to want to keep the revenue internally. Third thing to consider is that we seem to be really popular at night and on weekends and less popular during the daytime hours, so that's something else. We have 24-7 in-house people, so that makes it, you know, it's a good thing to have, but the same token, you know, it doesn't seem really fair. So what are the negative things that can happen? So first and foremost, you're gonna duplicate services. If we've got three different services doing cardiovascular imaging, the vascular surgeons, cardiologists, and us, who knows how that works, but I do know that it duplicates both physician time, a lot of waste in terms of planning, it fragments patient care, and you can't really look at this if you're a data manager and get any useful information because who knows if the cardiologist did 500 CTs and we did 300 CTs and somebody else did a couple hundred, where is the data there to look at? So that makes it difficult. The diffusion for the responsibility of patient care is important. So if you're a vascular surgeon and you do a case at three o'clock on Friday afternoon and the patient comes back in at midnight with a cold leg, who's doing the thrombolysis? Is there somebody on call for that? Is it the IR guy? So again, it makes it difficult. Finally, then just lack of information sharing, problem solving and communication really hinders patient care in the long run. So these are the negative effects. We like to try to collaborate where I'm at and I'm really happy we do. So this allows us to reorganize how we do things by disease lines, not by specialties. So our IR service, for example, is shared between interventional radiologists and vascular surgeons. A lot of the cardiovascular imaging is shared between cardiovascular radiologists and cardiologists with imaging training. So we do a lot of multi-specialty meetings that I think is really helpful and I'll show you those in a second. But really the goal is to reduce errors and improve outcomes and to some degree develop new procedures or at least methods of looking at new procedures. This is our setup at the Heart Center of Indiana. There are three cardiology imagers. All of them have completed an additional year of dedicated imaging training. And so these are not guys who went to the weekend course to learn to do coronary CTA. These are people who spent the whole year doing cardiovascular imaging. And they're very good. I'd be happy to have any of them read my coronary CTA or my cardiac MR. There are two of us on the radiology side that are cardiovascular imaging and cardiothoracic imaging fellowship trained docs. For a long time, we were located in the same spot, which was great. It was like a little shack. And the little shack had space for both of us. Since the pandemic happened, that's changed things a little bit. And so we're more diffused. We still stay in pretty good collaboration and contact throughout the days. We've divided the labor across the sites. So at the Heart Center, for example, coronary CTA and cardiac MR get read by the cardiologist. We read the structural heart stuff. At the bigger level one trauma center, we read the cardiac MR and the coronary CTA. We also overread their imaging studies for extracardiac structures. And so that's something that I think is important. That's something that some people may have an issue with in the interest of getting along. It's certainly, I think, the best thing to do. So we do have close collaboration. We do a lot of stuff together and we have mutual respect, I think, at least I do. So these are our collaborative meetings that we do. So every two weeks, we do a structural heart valve conference with the more complex heart valve cases. Every two weeks, we do a heart failure conference with the more sick advanced heart failure patients. Vascular conference one to two times a month with the vascular surgeons. We have a weekly pediatric cardiovascular conference with the pediatric surgeon as well as the pediatric cardiologist. And then a monthly CV service line quality improvement committee where we look at one modality per month in terms of ways to measure quality and then try to improve that. So the goal here really is to get everybody on the same page. And finally, I just wanna talk just a little bit on mentorship and kind of how you can think about that, not just in cardiovascular imaging, but also with your practice. Important also that if you really wanna learn more on this, later today in S501 at 4.30, there's a whole hour on this, not just on cardiovascular imaging, but I recommend that if you wanna really learn, go see this because a lot of what I'm mentioning here, a lot of the papers that I've listed will be from these people. And so I'm only giving you the intro to this, but I think it's important for anybody's practice. So for all early career radiologists, there are a lot of challenges. Anybody who's been out for five years or less knows this. Suddenly, you're in an environment where you've got geographically separate sites. You're not just at the university or something, for example, the exam volumes have certainly not slowed down post-pandemic. They dipped during the pandemic, but since that time, our volumes are huge. There are performance benchmarks for promotion and partnership, no matter what kind of practice you have. You've got maintenance of certification issues that you have to remember. And then a lot of junior radiologists have administrative responsibilities that may be new to them, since leaving their residency and fellowship, depending on their particular expertise. Specifically a non-academic practice, there are other issues. The practice structure and leadership can be an issue. There can be unexpected contract changes. We know this for sure. Loss of partnership alliances, this can happen as well. Groups can sell to private equity. Groups can merge together, merge together and sell. So there've been a lot of consolidation within radiology in the non-academic space within the last few years. Some of that has involved a change from physician-led to more of a corporate practice management as well. And so I think there's a lot of flavors of this, but it behooves you, if you're in one of these situations or considering one of these situations, to understand the entirety of what that practice looks like. That's certainly a challenge. It can create anxiety, depending on what the situation is. Everybody wants to know, what do I need to do to advance? And what's the work-life balance that I can achieve in this job? And the ever-present threat of commoditization is the other thing to consider, where if I'm a nameless, faceless person spitting out reports, that certainly devalues, I think, our expertise, and it devalues people's understanding of what we do for patient care. So these are all challenges to consider. COVID-19 hasn't made it better. Obviously, we were physically distanced for a long time. We're kind of getting better at that. Remote work patterns happened. Both hospital systems and practices had a lot of financial loss. There were delays, as well as decreased quality of resident recruitment and training. That's been published. And the research opportunities were certainly not nearly as plentiful because of the way the pandemic changed everything. Important to know that disproportionately, women and underrepresented minorities were harder hit by this, women in particular, because they tended to assume more domestic responsibilities disproportionately, as well as other types of impacts, not just in the home. So, important to realize, and then figure out ways that we can improve this. So what does mentorship do for a private practice? This helps us foster strong relationships across the board, right? So not just with patients and colleagues, with our technologists, with our administration, which these days is even more important, and with the referring physicians, but I think it's very important. So if you can be affable, available, and able, that's perfect. And I think mentorship helps to set the bar to do that. We want to create an empowered workplace so that there's mutual trust and respect and everybody can work together well. An example of a good mentorship effect is in your practice, do you feel comfortable asking for a second opinion? And that's something we really try to stress, that if you're not comfortable, that maybe there's something that needs to be improved there because I want people to ask me, and I want to be able to ask people, hey, what do you think of this? It not just helps in terms of patient care, but it helps kind of bring everybody to a more cohesive alignment. So this, I think, is important. A bunch of barriers to this, time being probably first and foremost. We're all busier. They turn the treadmill up, you're reading more studies. It's difficult to want to take time to do these things. It can make it feel more like a corporate mentality, even where you feel like you have to churn out more work. So it's important to find a way to make the time to do it. Communication is more challenging now since we're not all in the same reading room, that my partner 50 miles away, it's a lot more difficult to get together with them than it would maybe have been beforehand. And then how to reward and recognize mentorship and mentee activities. Because without some kind of recognition or reward or something, then apathy tends to set in, which is exactly the opposite of what we want to do. So learn much more about this at the 4.30 thing today. How we've done it as a formal process. So everybody who we hire gets assigned, or I can't pick, a mentor in their subspecialty area that we really should be sounding boards for everything from how do you turn the packs on to what's this 3D workstation do to which clinicians want to have a 3D report or which ones want to have an email to what stuff to do in the local area. So we really hope that we can smooth the transition a little bit, allay a little anxiety. But informal approaches can be effective as well, especially if you're a smaller practice where you may not have a large diversity of subspecialty people or just not enough people to cover everything. Where you can do a situation where you have a peer-to-peer learning or a distance relationship with a specialist that might not even be at your same location. And you can have the mentee choose the mentor. We haven't done that, although we certainly, if somebody wants somebody, it's not a problem. So important to set it up and then this is what you get out of it. We have seen that it's improved our retention and productivity. Definitely has improved our morale. We tend to do a lot more stuff together now as a group. And really this has improved engagement as well. More people who have been through the program then want to either be a mentor, they want to take on additional clinical learning, or they want to provide leadership within our practice. So this is important. It also has allowed us to redeploy a little bit of our resources to quality metrics and practice growth rather than continuing to onboard, train, retrain people that we'd be doing otherwise. Which I think has made us more attractive overall. And with that, I just want to say thanks to four people that I think have really, I've tried to learn as much as possible for my mentors. Dominic Fleishman from Stanford. Jeff Rubin, who's the chairman at University of Arizona. Fran Dix Chan, who is the fellowship director at Stanford in the Pediatric Cardiovascular Guru. And Sue Meyer, who's a musculoskeletal radiologist with my practice in Indy. Who's really, all of these people have taught me kind of what it's been like to be a radiologist, to be a good radiologist, and to be a good human being. So I think, again, I'd like to thank them for sure. So to conclude, despite all the challenges in cardiac imaging, it's still rewarding. You can still get a lot out of it. We can still do a lot for other people. We can leverage our training to educate not just our practice, but our referring clinicians. I think collaboration's really important in cardiac imaging, and if you can do it in a manner that everybody benefits, then that's the best way to do it. And realize that mentorship is important. And not just for your practice, but also for eventual patient care. With that, I thank you very much for your attention.

cardiovascular imaging

protocol systems

turf issues

mentorship

contrast medium dynamics

multi-specialty collaboration