On behalf of the RS&A Educational Committee and our track chair Dr. Diane Strollo, we welcome you to the Essentials of Non-Interpretive Skills course MSES 31. We have an excellent series of speakers and thought-provoking topics for you today. I am Dr. Robert DeWitt and I will be giving you the first lecture of our series. My topic addresses the role of professional confidence and how that relates to accepting mistakes. I have no relevant financial disclosures and the thoughts in this lecture are my own, not necessarily those of the United States government. An ancient Roman poet once said, they are able who think they are able. By the end of this lecture you should better understand the relationship between confidence and achievement. Gain strategies to assess and build confidence. Recognize the value of mistakes as opportunities to learn. Consider utilizing peer learning as a safe environment for collective learning from errors. And lastly, appreciate how artificial intelligence may impact the identifications of errors in the future. Not surprisingly, studies show that in general having a slightly negative expectation of your personal ability increases effort, increases the attention to strategy, and increases performance over time relative to very low self-confidence or even positive expectations. So basically, having a small but healthy fear of failure is helpful in striving for perfection. However, having low self-confidence in general is maladaptive. We know that people who anticipate failure will accept failure and recalibrate their goals for lower levels of achievement. Anecdotally, in radiology, having low self-confidence may be projected by having vague overly broad differentials or non-committal diagnoses. If low self-confidence is a recurrent theme, ultimately your referring providers will shop for another radiologist that provides more clinical direction and helps remove uncertainty. My belief is that it's better to be helpful 95% of the time and assume the small risk of occasionally being wrong than be so non-committal that although you are never technically wrong, you are also rarely helpful. Being overconfident is equally maladaptive but in the other extreme. Complacency and decreased work ethic leads to degradation of skill and general incompetence over time. Anecdotally, in radiology, being overconfident is basically dangerous and being confident and wrong is probably the fastest way to lose the trust of your referring providers. So clearly, it behooves us to have an accurate self-assessment of our certainty for a diagnosis. In other words, know what you know and how well you know it. But how does one exactly calibrate confidence? Enter arguably the most famous living psychologist Dr. Albert Bandura and his work on social cognitive theory. Self-efficacy is a type of situationally specific self-confidence and it is immediately applicable to our professional confidence as radiologists. Self-efficacy is the extent to which an individual believes they can master a particular skill. Self-efficacy plays a major role in one's approach to goals, tasks, and challenges and is influenced by self-monitoring of one's own mastery experiences. Self-efficacy increases with perceived successes and decreases with perceived failures. Self-efficacy is not a personality trait but rather a teachable skill. We all have moments of daily high and low self-efficacy based upon our comfort zone. Dr. High self-efficacy is a thoracic radiologist who loves interstitial lung disease. If he encounters a high-resolution CT of the chest, he will approach it enthusiastically. However, the very next study could be a pediatric wrist MRI and because this study falls outside of his comfort zone, the same person is now in low self-efficacy mode. He's likely to throw up his arms and phone a friend and that's okay because nobody knows everything. Now there are several premises for understanding the construct of self-efficacy theory. First, personal ability is an acquirable skill as opposed to inherent aptitude. In other words, radiologists are made not born. Second, success and failure are attributable to behavior or modifiable variables. Getting sleep, studying hard equals success. For you psychology majors, we have an internal locus of control. Thirdly, we must regard errors as a natural part of the skill acquisition process. Simply put, mistakes are opportunities to learn. When attempting to build self-efficacy, it is important to focus on the positive aspects of performance. What are you doing well? While at the same time identifying areas for improvement, positive reinforcement is important. Secondly, when suffering a setback to self-efficacy by encountering a failure, it is important to focus on what exactly needs to be learned to surmount the failure in the future. It may be necessary to break skills into smaller parts and incrementally model or rehearse those skills to build mastery. We all do this in practice when we teach or learn a new skill. Now bigger steps forward in building self-efficacy can be accomplished with more difficult tasks, tasks that are attempted independently, and tasks that are accomplished early on in the learning process. So in other words, let's say that you have a new staff and you'd like to give them a confidence boost. Well, consider assigning them a really tough project, not giving them any help or guidance, and having them do it right out of the gate. Does that sound like a good idea? Probably not. The reason being is that the way that self-efficacy works is that you have to have a successful self-assessment and that scenario may just be a little too challenging to have a positive outcome. There are conundrums. Practically speaking, cultural and logistical obstacles interfere with our ability to achieve our desired levels of self-efficacy. Building self-efficacy requires both frequent focused feedback and perpetual recognition of our mistakes. Imagine, if you will, a reality reminiscent of a perpetual first year of residency. Our current workflow as attending radiologists does not provide frequent focused opportunities for feedback. Errors, when they are found, are most often dispositioned by a shameful wince and a subsequent cover-up operation. Typically, they are not benevolently collected anonymous shared learning opportunities. We need to aggressively pursue opportunities for continuous performance feedback. First and foremost, reviewing cases through direct participation in interdisciplinary conferences and Radbath correlation is by far the best feedback opportunity. However, that opportunity may not be available to all of us. The next couple of options allow you to be your own teacher through many small feedback opportunities over time. These opportunities are providing confidence indicators in your reports and reading the history after you have completed interpreting the exam. Lastly, the transition from peer review to peer learning initiatives shows a very promising role in providing opportunities for positive performance feedback. This is my own lexicon of confidence indicators to clarify communication with referring providers. Our job as radiologists is to reduce clinical uncertainty as much as possible and provide clear direction for or against a therapeutic action. Being as certain and confident as possible will be very much appreciated by your referring provider. I usually give a differential if my confidence falls below the 80% level and my differential will lead with my favorite diagnosis. There is no shame in admitting uncertainty. However, we should be able to acknowledge when it is appropriate to be vague and work hard to have noncommittal diagnosis increasingly be the exception, not the norm. Although I started using confidence indicators to have clear communication with a referring provider, I found an unexpected advantage was that it helped me retrospectively monitor my own performance over time. This helps me become more discerning with both my observations and reporting and I believe contributes to the development of self-efficacy. In general, much more work needs to be done so that the language I use and we all use for confidence indicators is universally defined and applied within radiology. I prefer to read the history after interpreting the report. Removing pretest bias is simply good science. However, this also has the unintended advantage of providing instantaneous feedback on occasion. My success in making the finding should mostly depend on the integrity of my search pattern. If I only make the finding on my second look after reading the history, I have to ask myself, is it my sensitivity or search pattern that needs to be adjusted? Occasionally, I can teach myself a blind spot. Also, I have found that if I read the history immediately prior to making my impression, I more often speak directly to their clinical question. In theory, this should encourage the providing of comprehensive histories over time. Most practices use score-based peer review to satisfy joint commission requirements, but frankly, many find little additional value in the time invested. Although peer review does have an important role in focused professional practice evaluation in certain situations, it has an absent or even negative role in building self-efficacy. That is because it was designed to identify incompetence by the random auditing of a minority of cases. Studies show that it is prone to sampling bias, subjective, inaccurate, and that it may foster defensiveness and undermine collegiality. Peer learning, on the other hand, actively identifies cases with learning potential and then reviews them in a collaborative conference setting. The interpreting radiologist and the patient in these cases are anonymous so that any error can be addressed without shaming or HIPAA concerns. This forum is distinct from monitoring for deficient performance and can be used to celebrate successful management of difficult cases. I am excited about the potential for peer learning. Some practices have adopted it to replace indiscriminate score-based peer review in the joint commission requirements for practitioner-specific performance data. In addition, I believe a well-run peer learning program can be fertile soil for the development of both self-efficacy and emotional intelligence. If given the time and the resources it deserves, peer learning programs have the potential to impact the cultural values and goals set forth in the Institute of Medicine's 2015 report on improving diagnosis. I believe that the future will have seamless radiology workflow with powerful artificial intelligence applying deep learning algorithms to the effect of drastically improving efficiency and accuracy in diagnosis. In practice, this will continuously augment our own performance through performing thorough peer review, identifying and prioritizing urgent findings, maybe in creating a CAD-STAT classification, and streamlining reporting potentially to the competency level of an upper-level resident. In effect, the omnipresent computer oversight means that acknowledging and identifying our mistakes will become routine. Processing those mistakes in a healthy way by incorporating them into an environment of continued learning will be necessary. The future reality of relative imperfection also increases the relative importance of skills that are unique to our humanity, such as good communication skills, emotional intelligence, tact, and affability. So in summary, high self-efficacy promotes high achievement and is a critical element in the strive for both individual and institutional perfection. In an effort to build self-efficacy, you need both continuous focus feedback and the ability to learn from our mistakes. Investing in peer learning should improve self-efficacy and create a healthy forum for community learning from our mistakes. I believe that the culture of medicine is still currently largely in denial of the fact that to err is human. I also believe that increasing the application of artificial intelligence will force this philosophy to change. Ironically, only by embracing our imperfections are we able to achieve high self-efficacy necessary to our continued relevance in the future. Thank you again Dr. Strollo and Dr. Barbosa for advising and assisting me in content. I am delighted to introduce our next speaker, Dr. Omar El Moussa. Hello everyone, my name is Omar El Moussa and I have no disclosures. My talk today is about physician burnout and substance use disorders. Part of my talk includes my personal journey overcoming these challenges. The death of one man, this is a catastrophe. Hundreds of thousands of deaths, that is a statistic. This quote has been falsely attributed to Stalin. So the question is, how do you convert a statistic into a tragedy? You tell a story and here is my story, a story of burnout, a substance use disorder, and now recovery. How do you meet an international arms trafficker, a dirty DA, a drug kingpin, a former Green Beret who forged credit cards, an on-the-take bail bondsman, and a physician who wrote scripts for himself? You're right, you get sent to prison. The old saw of any publicity is good publicity, I would argue is wrong. Top left is a snapshot of the article in the local newspaper with my mugshot. Below is an aerial view of the Federal Correctional Institute at Morgantown, West Virginia, where I was a guest of the federal government. Circled in red is Carlson Unit, which is where I was housed most of the time that I was there. My Yelp review still has not posted, but I can assure you it was not a five-star review. Before I get to my story, I want to discuss physician burnout. This is defined by the American Medical Association as long-term stress leading to depersonalization. The consequences can be quite severe and include lower quality patient satisfaction, high physician and staff turnover, alcohol and drug use disorders, and even suicide. The prevalence is surprisingly high and has gained a lot of attention in many journals. How high is the prevalence? Well, the average is 42% among all specialties. Radiology, unfortunately, is above average with a burnout rate of 46%. Substance use disorders are also unnervingly high and worth emphasizing. One out of five physicians has a substance use disorder. These numbers should worry you. This brings me to substance use disorders. Initially, I was asked to talk about opioid use disorders among physicians, but this can be extended to substance abuse disorders with the main difference between them being the substance that's used. The American Society of Addiction Medicine has outlined criteria to diagnose and assess the severity of these disorders, and that can be found in an 11-question inventory. In order to develop a substance use disorder, three components are usually found, but not always necessary. They include a genetic component, exposure to the substance, and the right environment that encourages or facilitates the use of the substance. These are managed haphazardly among physicians, and in some cases, these are still viewed as a moral failing rather than disease. I'm sure you want to know more about my story. It starts with circadian misalignment. For 10 years, I worked nights, and that paved the way for my burnout and the fatally flawed decisions that would follow. Let me take a minute to point out that the World Health Organization recognizes night shift work as a health hazard. In some Scandinavian countries, disability is paid to people who develop health complications from night shift work. Now back to my story. I was section chief of one of the largest sections in the Department of Radiology at a high-powered academic institution, managing the administrative and budgetary pressures of that section, and I'm sure many listeners are familiar with. I worked nights to help free up time to care for my elderly parents, whose health was progressively failing. Lastly, I was managing pain related to a chronic illness I suffer from. I share this with you to set the stage. It starts with rationalizations that are largely cloaked in truth, and they become so seductive that you believe them. You never really intend to do wrong. Instead, you listen to explanations inside yourself that sound reasonable. I'm sick. My doctor did not help me manage my pain. I am in pain. I am desperate. These explanations become more convincing. What I couldn't see was that I was a ticking time bomb. I was oblivious, and I was whistling past the graveyard. When you make a catastrophic mistake, it's not as if you suddenly wake up and think to yourself, hmm, I think I'll destroy my entire life today. It simply doesn't work like that. In my mind, at that time, I was managing my pain using doses which were within therapeutic limits. This seemed reasonable, but it was still illegal. Abraham Lincoln once said, if you are your own lawyer, you have a fool for a client. I would say, if you are your own physician, you have a fool for a patient. The cruel irony is that my GI doctor afterward would have legally prescribed me the same dosages I had acquired illegally. So, what does happen when you burn your house down? Up until March 1st, 2018, I thought I was managing my pain and helping myself sleep. However, the world was about to introduce me into a harsh new reality, one that involved handcuffs, hearings, judges, rehab, assistant US attorneys, and finally prison. This was life-altering, to say the least. It's hard to fully relate the intense isolation I experienced despite the efforts of my family and friends. The best I can do is share a saying that I was introduced to in prison, you go in alone and you leave alone. This isolation was magnified by my loss of voice, because during the legal process, you're strongly advised from speaking out. So, the media fills that void and your story comes out distorted, not intentionally, but because nobody knows the entire story but you and your attorney. By the time you can share it, the dust has settled, the party's over, and everyone's gone home. The process is just overwhelming, and then, as things start to slow down, you become gradually more aware of the downstream collateral consequences as the letters start rolling in from the Office of the Inspector General, from the State Boards of Medicine, from Health and Human Services, and from the National Practitioners Database. That is how I was introduced to the criminal justice system, and it was eye-opening. The first thing I realized was how procedural it is, or clinical, for lack of a better word. This could be seen with my charges. I was charged with distributing, rather than diverting, prescriptions, implying that I trafficked, even though my activity was for self-medication. By the letter of the law, I was charged with distribution, even though I never sold any prescriptions, nor did I trade them for any favors. Another example was my charge of health insurance fraud. It didn't matter that it was $728.13. It would not have mattered if it were $1. The law was broken. Because of this charge, I was legally not able to have an FDIC-insured bank account or credit card. At one point, all my liquid assets were in a cashier's check. I had money that I could not use. Timing also impacted my case. Jeff Sessions was newly appointed as the Attorney General of the United States, and he wanted to crack down on pill mills, as they're called. Opioid-related deaths were climbing, and the number of ER visits for overdoses was terrifyingly high, at 500,000 per year. Unfortunately for me, I got swept up in that net. The path to self-discovery only comes through adversity. In order to initiate movement, you need friction. To build muscles, you need to tear them. Life as a successful physician did not demand any self-examination. The process was a harsh, probing, inwardly-directed inquiry. Groping around in the darkness, I found the bad and the ugly. But I also found resiliency, humility, and gratitude. Ultimately, you bracket out the noise to find out what truly matters. No, for the MRI geeks out there, I'm not talking about signal. I'm referring to family, friends, and good food. I'd like to share some resources about recovery programs. They include Alcoholics Anonymous, Narcotics Anonymous, the Buddhist-themed program, which is Refuge Recovery, and Smart Recovery. These are available internationally. Evidence-based recovery programs are found at rehab centers. Recovery is a source of self-awareness and humility. It makes me a better person. I'm not there yet, but there is a light near the end of the tunnel. It's hard to describe prison as being valuable. Instead, I would say I made my time there valuable. I mentioned learning about who I am, but that's not an easy question to answer because our lives are dynamic. Permit me a controversial example. Who is Lance Armstrong, the competitive athlete who won seven tours while doping? Or is he the man who set up an incredible network to support families in their struggles against cancer through the Livestrong Foundation based on his own personal journey battling cancer? Sometimes good people do bad things. Sometimes bad people do good things. Some folks would take my charges and render judgment. That part of my story is very public. However, what is not public was the packed gallery of people who attended my sentencing on May 9th, 2019 at 10 a.m. More than 40 of those in attendance were, and I would argue are, my colleagues who needed to take time off and arrange with their colleagues to cover them in order for them to come and support me. Even today, I'm still humbled by this. So, if you needed that single most diagnostic image on a study, this is mine. I think it gives an accurate view of me through the eyes of those who know me well and have worked with me for nearly two decades. I want to say a few words about the different monitoring groups. Each state has a physician's health program with whom physicians may enroll voluntarily for monitoring in exchange for their advocacy with state boards of medicine. In addition, each state has a physician's health monitoring program, which is the regulatory enforcement arm of the state board of medicine to document sobriety. When I started thinking of what I wanted this talk to be about, I wanted to share what I learned personally, but I also wanted to share what I learned professionally and provide some practical suggestions I learned on this difficult journey. I thought to myself, if I were section chief again, what do I need to be aware of and how would I do this differently? Let me start by saying that these issues are common, even if we're not talking about them very often. Next, let me emphasize the attrition related to night shift work because this had a large impact on me and others. It's hard to ignore that in my former section, I saw 10 out of 28 people who cycled through it leave for either health or personal reasons. It's also worth mentioning that one of them died. It really emphasizes the importance of self-care. Finally, I want to make sure to pass along some concrete recommendations I have for night work as it relates to burnout. These focus on two things, load balancing and the need for recovery. I strongly urge you to consider limits on the RVUs per hour, the RVUs per shift, shifts per month, and shifts per year. Then, I would emphasize that time off is time off. Let me take a page from baseball where they monitor pitch counts so that players don't injure their shoulders. It comes down to monitoring the volume of work and number of shifts. I cannot emphasize this enough. Thank you for taking the time to hear my story. I hope you found it informative and uplifting. If you have questions, please feel free to email me at the address provided. Now, it's my pleasure to introduce the next speaker, a professor of pediatric radiology at Indiana University, Dr. Richard Gunderman. Hi, I'm Richard Gunderman from Indiana University, and I'm happy to be talking with you today about how generosity can enrich your career and life. And I really want to talk about four topics, the first being economics, the second generosity, the third AA, and the fourth Van Gogh. Kind of an eclectic group of topics, but I hope they'll make sense by the end. So I think many of us, if asked how successful we were, might be inclined to think, say, how much money we're making or how high we've risen in organizational hierarchy. Here you see a graph of median salaries for radiologists in the United States. Do we, in fact, have any idea how well we're doing by the amount of money we earn? I think what we think about enriching our careers and lives in those terms, we're often in a mentality of scarcity, thinking about, you know, how much am I capable of buying in a marketplace? Sometimes we think about exploitation, you know, I make a bargain, I strike a deal, am I getting the better side of the bargain? And very often in economic terms, the goal is to profit, right? I want to come out ahead from every exchange in which I engage. This, by the way, is a Van Gogh painting of a group of prisoners, basically moving within circles and high and thick walls. And that comports nicely with the sentiment expressed by the poet William Wordsworth, that in getting and spending, we can often lay waste our powers. So, you know, when you think in economic terms about our careers and our lives, sometimes we find ourselves thinking in pretty static terms. For one person to get a bigger piece of a pie, somebody else has to make do with a smaller piece or no piece at all. You know, there's very little transformative about it. You either end up more or end up with less, but you're fundamentally the same rational exchanger, not really changed as a human being. So I'd like to suggest an alternative for radiologists and other health professionals. That is what we think about enriching our careers and our lives. In fact, how successful we are, not in terms of how much we're getting, how much we've managed to accumulate for ourselves, but rather in terms of how much we're given. And I think when we do that, to some degree, the sky becomes the limit. So this brings me to the third topic I want to talk about today, which is AA, an organization some of you might know as Alcoholics Anonymous. There are, of course, many other 12-step groups, Narcotics Anonymous, for example. But if you've ever been to an AA meeting, you realize that that it's not an economic organization. For one thing, if you go to a meeting, nothing's being bought or sold. Now, some money does change hands. For example, people are asked to contribute to buy coffee. And any literature that's distributed to the organization is funded through contributions. But AA is a fundamentally different organization from most of the healthcare today, largely because there's no fee to participate. There's nobody at the door, no triage person who performs a wallet biopsy before they decide whether they let you in the door. And anybody who's there is there voluntarily. And I think that changes things. It becomes possible to be generous and to show real gratitude. We can replace the economic account of our work and our lives that has little or no place for generosity and gratitude with one that's all about gratitude. And this, by the way, is a photograph of Bill W., probably the founder of AA or the co-founder, along with another person known as Dr. Bob. And I just want to give you a sense of what AA could be like for people. This is the account of a woman named Kim. She said, I always carried a fifth of booze in my oversized purse. I made numerous trips to the ladies room to chug. I chewed lots of gum and breath mints. At first, it helped me with my insecurities. It was my best friend. But then it turned on me. I knew I was going to die an alcoholic. My husband took me to a meeting, an AA meeting. It was scary walking into a room of strangers. I did what they suggested, went to a meeting every day, studied the big book, made lots of friends. Eventually, I found myself not drinking. A week went by. Then a month. Before I knew it, an entire year had passed. So this is an organization making a difference in somebody's life over the course of actually not just one year, but many years, where the exchange of money wasn't what it was all about. Nobody was there to get money. They were there to support each other and contribute to each other. This raises a natural question for people who know about AA. Suppose you're involved in such a group. Suppose you have the sense that your participation in AA has made a difference in your life. You've benefited from your participation. Now what do you do? That, of course, is what the 12th step of the 12 steps is all about. Namely, turning your attention from yourself to other people. Thinking not so much about your own recovery, but being there to support other people. This is, of course, a painting by Vincent van Gogh called The Good Samaritan. The idea of the 12th step of 12-step programs is that recovering or recovered alcoholics help other alcoholics when called upon to do so. We help not because we hope to emerge enriched economically by the encounter, but because it's part of what it means to be recovered and recovering. It's part of what it means to have benefited so profoundly, to have experienced the transformation in life. The most natural thing in the world is to want to pass along that gift to others. There are multiple ways people in AA do that. One would be through what you might call testimony. Sharing the difference that the program, that the friends they made, made in their lives, and also sharing the kind of transformation. For the person who I quoted from earlier, Kim, her life was really profoundly transformed through AA. She, in fact, felt that she'd gotten her life back, that she'd lost it for a long time. Of course, she was still alive, had a pulse, and was moving air in and out of her lungs, but in a way didn't feel like she was living. Her experience in the community of an AA chapter had restored her life. The idea in the 12-step program is that you find yourself moved by the work you've done, the conversations you've had, the self-exploration, sometimes very painful encounters where you were forced to look yourself square in the eye. That makes you want to labor in service to that work, the work you've done through your own exploration, reaching out and helping others. It's through our sense of gratitude and the transformation that spawned it that we gain the ability to share our own gifts with others. Just imagine if that were what radiology, the practice of radiology were like for us, if when we came to work in the morning, we were thinking first and foremost about having an opportunity to share our gifts. So gratitude, in my view, doesn't follow generosity. Usually, we think somebody gives you a gift, you're grateful. I think here the suggestion is it's exactly the opposite. We need to be given a gift and we need that gift to work on of us before we can hope to share it. This is, of course, Van Gogh's Starry Night. And I want to turn briefly to Vincent Van Gogh and his life as an example of this. Some of you may know Van Gogh, a Dutchman, died at the age of 37 years. Most of us are well beyond that point. And in fact, he only painted for about 10 of those years. But in those 10 years, he created about 1200 works of art, including 860 oil paintings. So he was very prolific from the time he took up painting. And it's worth mentioning that during his entire career, he only sold one painting. In his lifetime, he sold exactly one painting. Why would somebody paint a thousand paintings if they only sold one? Well, presumably, they were painting for some other reason than as a means to make money. And here, of course, is Van Gogh's The Sower. So Van Gogh starts out in the family trade. He's an art dealer. Basically, all the men in Van Gogh's family were either what we might call clergymen or art dealers. And he started in one of the family trades as an art dealer at the age of 16 and spent six years as an art dealer. And initially, he was very successful. He was excited about the paintings, delighted to see such a variety of images. It really enhanced and refined his passion for art. But with time, he became increasingly uncomfortable with what you might call the commodification of art. He came to think that art wasn't primarily about the value a painting could bring in an auction, that we shouldn't think of art primarily as a commodity. And he would actually talk people out of buying works that he thought were of poor quality. Here's Van Gogh's irises sold for over a hundred million dollars. Van Gogh wrote to his brother that he was adopting a new path, that he and his brother and others should continue walking a lot and loving nature, that loving nature is the real way to learn and to understand art better and better. And in Van Gogh's mind, the purpose of paintings and painters was to help us understand nature and love it and to teach us to see it. Whether it's a flower garden or the starry night sky, painters teach us to see. And here's another Van Gogh, The Sower, that the best way to love God, the best way to care about what's most important in life, is to love many things. Van Gogh said, love a friend, a wife, something. It leads to God, to the highest reality. If a man loves Rembrandt, he will know that there is a God, he will surely believe it. The great masters tell us in our masterpieces. Van Gogh felt that he'd been given a gift by the masters in his craft, painters, and that his mission was to share that gift with other people through his paintings. He was a failure in the conventional economic terms, but of course he's now one of the most highly esteemed painters in European history, and many of us have learned to look at the world around us anew through the pigments and canvases of Van Gogh. So here's a detail of a Van Gogh self-portrait. What do you see in those eyes? What do you see through those eyes? The proposition of this presentation is that we can learn to see new things, or we can see things we've always seen anew, and that helping one another, our patients, their families, our colleagues, ourselves, helping us to see anew, is in fact one of the greatest gifts we can give each other. It doesn't cost anything in economic terms, but it can actually transform other people's lives. I think that's the difference between economics and generosity and experiences in communities like AA and learning more about the life of Vincent Van Gogh and his art can help us radiologists see our careers and our lives in new and transformed ways. So it's been a pleasure to speak with you. I want to conclude by introducing the next speaker, Dr. Eduardo Barbosa from Philadelphia, who will be speaking on maximizing reading efficiency and accurately through intelligent radiology reporting. Dr. Barbosa. Welcome to the last lecture on this essentials of radiology non-interpretative skills course, maximizing reading efficiency and accuracy through intelligent radiology reporting. My name is Eduardo Mortani Barbosa, Jr. I'm a radiologist at Penn. These are my disclosures. My lecture is organized into two parts. First, I'll emphasize what you can start using today. The second part, I will focus on what you'll be able to do in a few years. Part number one. Intelligent reporting today emphasizes actionable information and answers to clinical questions, uses structural templates and standard macros wisely. It is adaptive to clinical context, indication specific when appropriate. It is faster to dictate which should lead to improved efficiency done properly, should be concise, clear, accurate, efficient, and professional. The report is the center of the radiology universe. If you think about what a report accomplishes, the answer is a lot. It is essential for building compliance. It is the documentation of what was done to the patient. And as such, it provides the best medical legal defense. Above all, it's a communication tool to patients and referring providers in which the radiologist conveys the patient's likely diagnosis or differential diagnosis, offers information about the patient's prognosis, and guides management. There are several benefits to such reports. In education, it facilitates teaching of best practices in reporting. Quality, it reduces errors, especially voice recognition related, increases consistency, increases referring physician and patient satisfaction, optimizes coding and billing, leading to less denials of reimbursement, increases efficiency when used and implemented thoughtfully, facilitates research through analytics. There are several risks, such as depersonalization reports, they will all look the same, workflow and productivity, for example, a cumbersome interface, too many clicks, lack of flexibility in complex scenarios, it may limit radiologist freedom and these need to be addressed. How to do it? Adoption is key and relies on institutional and peer buy-in, as well as alignment of incentives. You must associate report template and the corresponding exam code, such that it automatically launches on dictation. Automation is critical, that's where most of the efficiency gains come from, you must auto-populate relevant information from the EMR and RIS. Embed the technique within the template by adding contrast volume and indication, when appropriate. Address complexity with what I call hybrid structure reports, these combine fill in fields and pick lists wisely. Anything you say often, let's say five times a day, make a macro for that, there's no need to repeat yourself. Standardized recommendations based on best evidence, those are best addressed by pick lists. Complex situations, nuances of interpretation and conclusions are best addressed by free dictation. On the left side, I'll give an example of a narrative report. It does not have an internal organization and it can be very hard to read and extract information from, as opposed to a well crafted structure report, in which the information is clearly presented and is divided into sections that can be filled with different strategies, as I will discuss in a moment. Report organization. It's important to remember that a report has a content that summarizes the thought process and assessment by the radiologist. It ranges from descriptive to interpretive. It also has a format, which contains a structure and a language or lexicon. It can range from fully narrative to fully structured. The template is very important, because it allows you to it can range from fully narrative to fully structured. The template is a document with consistent format used repetitively. A field is a report area filled by a particular type of information. That's where the macros will be added to. A macro is a trigger word replaced by a constant string of text when invoked. We can divide the report into three sections. Section number one is what I call billing and regulatory compliance. Technique, contrast, comparison and indication should be automated and auto-populated from the RIS and the EMR into the report. Section number two, that's where you present your findings, divided by anatomy and system. This should be a primarily descriptive section in which you provide measurements and elaborate complex reasoning, if needed. Section number three is the conclusion. The most important part of the report should be interpretive and actionable. In this section, you answer clinical questions, emphasize clinically relevant diagnosis and temporal changes and provide recommendations based on guidelines and available evidence. I will provide an example of an indication-specific structure report template, which we use for Lung Cancer Screening. The first section, which contains indication, comparison, smoking history and technique, should be completely auto-populated from the EMR and the RIS, which means there is nothing for us to dictate in this section. The second section, that's a description of findings containing measurements, its structure and organized by the type of finding. Each field can be either filled by free dictation or macros. We use macros very liberally, such that the process of filling those fields is very efficient. The final section, which is the conclusion, contains a combination of PICLIS, for example, for Lung Reds category, but also free dictation for significant incidental findings. This generates a structure report that automatically populates a recommendation, which in this case comes from ACR Lung Reds. In the second part of my lecture, I will focus on future directions in intelligent reporting. Future intelligent reports will incorporate artificial intelligence-driven quantification when meaningful, replacing text with images, graphs and tables, creating hypertext reports, will become an integral component of the image, what is called semantic tagging, will leverage computer programming logic as well as human reasoning in what I call conditional reporting. AI-driven quantification can generate imaging biomarkers through research studies, which can be incorporated into structure reports for clinical use. For example, in cardiothoracic imaging, the possibilities are endless. We can perform dynamic lung evaluation in inspiration and expiration. We can segment airways and vascular structures three-dimensionally, and we can compute lung parenchyma and air trapping volumes. All of that can be incorporated into clinical virology reports, either as images or as charts and tables. This type of information can be used to guide patient's management by representing physiologic and pathologic processes with a higher degree of accuracy. The combination of AI-driven quantification in hypertext reports can be very powerful. I'll illustrate with an example of a patient who has a metastatic malignancy, in which a lung nodule was automatically segmented and measured by an AI algorithm at two time points, for example, December 2019, March 2020. One can appreciate that the nodule has grown by an amount that would be difficult for a human reader to identify. That information can be plotted in a chart against time, in which case the nodule number one, which is the nodule that was measured by the AI algorithm, has grown from December 2019 to June 2020. When chemotherapy was instituted in August 2020, that nodule dramatically decreases in size. That tells different physicians that this nodule number one is a metastasis that has responded to therapy, whereas there's another nodule that I also added to the chart, nodule number two, that has not changed over the course of the four studies that we represented here. That nodule is benign. This is a much more compelling presentation of this information than just text descriptions in a regular standard radiology report. Semantic tagging allows us to create a report that is an image overlay and becomes part of the image. For example, this patient had two chest x-rays six months apart. The patient presented with positive PPG and weight loss. The first x-ray on the left, we can draw a region of interest that can be done by a human, but also by an AI algorithm. And we can also identify what we think this represents. In this case, a cavitary left triple lobe consolidation, likely reactivation tuberculosis. On the second image, we can draw additional regions of interest that demonstrate change. And we can annotate what they represent. For example, left chest wall emphysema, which is new. The same consolidation, now with a muscle flap, which is treatment related. And new areas of airspace disease in the left lower lobe and in the right lung that we are calling multifocal pneumonia. So that tells this patient probably has active reactivation tuberculosis. What I call conditional reporting is an exciting future direction. Dissects human thinking processes into computer programming logic that can be executed by an AI algorithm. I'll give an example of how we humans assess pulmonary nodules. We typically follow a logic sequence of steps. We start by identifying the largest nodule size and measuring it. We address whether the nodule is new or changing. And if such, we can potentially calculate a growth rate. We assess the nodule attenuation shape and margin. And finally, the patient risk factors. Each of the steps can be performed by a human, but it can also be implemented in an AI algorithm. Some steps can be extracted from the EMR, such as the patient risk factors. We then integrate clinical guidelines, for example, Fleischer Society, with quantitative prediction models, risk calculators, and AI-driven, with our radiologist expertise. This generates an optimal diagnosis with a level of certainty, as well as management recommendations that are evidence-based. In summary, modern medicine cannot exist without medical imaging. Yet, reporting has changed little, which offers us opportunity for improvement. Poor-quality reports add no value, and as such, are an existential threat to radiologists. What can you do today? Intelligent, adaptable stroke reports can be implemented right now. In the near future, I believe AI-driven quantification, feeding hypertext reports, semantic tagging, and condition reporting will revolutionize the way we create radiology reports. AI and stroke reports, when combined, are a disruptive technology that can substantially enhance radiologists' value and efficiency. The report is the face of radiology. As such, it should be accurate, scientifically sound, clear, produced efficiently, delivered timely, and communicated effectively. Better information communication may allow improved diagnosis and patient outcomes, which finally allows radiologists to deliver more value to patients and society at large. Here, I provide my email address, as well as some key references. This concludes the RSNA 2020 Essentials of Radiology course. Thank you very much for your participation.

non-interpretive skills

professional confidence

self-efficacy

peer learning

burnout

substance use disorder

support networks

intelligent radiology reporting

AI-driven analytics