We are going to start this afternoon with Dr. Rama Ayala from Cincinnati Children's Hospital. Dr. Ayala is Associate Professor of Radiology, Vice Chair for Culture, Quality, and Safety, and Division Chair of Abdominal Imaging, and will be talking to us about moral distress and its impact on burnout. But to start out my talk, since I'll be setting up this entire session, I'm going to start first with a story. So we're going to start with the story of a radiologist. So she works in a academic institution where she is in a group of four radiologists in the division. So they split all the clinical responsibilities. They take Q4 call, and they're also an academic institution where they are responsible for teaching trainees as well. She also took on an administrative role in the department. So she took a role in the residency program, and then also was overseeing some of the operational stuff in the department as well. She also is academically driven, and so she has a significant research interest. So she was publishing significantly on many things, speaking at national conferences, and also had a very vibrant life outside of work. So had significant family and friends and hobbies and things like that. However, over time, these things all became competing with each other. So the clinical responsibilities started going up as volumes went up, when they were short-staffed. She was working much more. She didn't get any dedicated time for her administrative and her academic roles, and that really, really put a strain on spending time outside of work. And so when you are pulled in all these different directions, that leads to burnout. And so she burnt out, and she had to leave her job, and she was able to find a different place to figure out how to deal with all the stresses and everything that was the repercussions of this story. And so I want to just kind of give this as a background for what we're going to be discussing. I also do want to say that this is an autobiographical story. So this was me at one time in my life, and this is the reason why I am interested in this, and right, I'm passionate about talking about it, as well as writing about it, because I do want to help others. So I think words really matter, and so there's a lot of different terms that are all thrown around. So I kind of want to go through this a little bit before the, as a beginning of this, this talk. So moral distress. Moral distress is defined as psychological unease generated where professionals identify an ethically correct action to take, but are constrained in their ability to take the action. And so I really also want to just mention ethically. So ethically means in this case where you feel like you are doing something that goes against what you believe is right. And so when we talk about moral distress in medicine, there's a lot of different implications. It can really affect patient care, and it can also affect how we work as teams, the relationships we have with our colleagues, as well as people outside of work, and also the biggest thing that really drives this is time, and the lack of time and the resources we could have to do our responsibilities. So then moral injury is sustained moral distress that leads to impaired function or longer-term psychological harm. It can produce profound guilt and shame and a sense of betrayal and profound moral disorientation. So when you look at these two, you can see that moral injury is due to multiple episodes or prolonged sustained moral distress. And then burnout. So burnout is something that I'm sure everybody in this room has heard about, read about, and it's prolonged stress related to emotional exhaustion, decreased accomplishment, and depersonalization. And there's many, many implications of what burnout does, and I'm not going to get too much into that, but one thing I will focus on, and I think that it's really important for this session, is it leads people to potentially leave their job, leave radiology, or even leave medicine altogether. And that's what we need to really focus on trying to mitigate. So based off of all the definitions I just gave here, this is something that I think is important to take away from this. So repetitive moral distress leads to moral injury, which causes burnout. So these are all not interchangeable terms. They all are separate different things, but when we talk about what we can do to mitigate burnout, we need to figure out how we can fix moral distress. So there's going to be a whole talk about the causes of moral distress, but I do want to just briefly highlight some things, just to put it into context of what we're talking about. So when we talk about moral distress in medicine, or in radiology, specifically, unattainable expectations. So having the feeling like you have to, you have a lot of studies to read, and you're not able to read them at the pace that you would like to, or you might be reading them too fast. Lack of knowledge. You might be having to read studies that you may not feel necessarily well trained to, or comfortable to do it, but it's part of your requirements. This can all lead to inadequate patient care. So one of the things is, if you're reading too fast, you may feel like you're missing things, and it might be causing you to think that you're giving inadequate patient care. And then we talk about, in academics, how important it is to, you know, spend time teaching our trainees. But when you have all this clinical expectations, it can be very challenging to really have focused time to spend with the trainees. I mentioned this also in my initial scenario. Lack of dedicated administrative academic time can really lead to creep of work in non-work related hours, and so blurring of boundaries. And then one thing that also I think is really unique for radiology is recurrent technological interruptions and issues. We are really, really focused and based on technology, and it's great for us, but unfortunately, if PACS crashes, or if we have some sort of workflow issue, that can really also cause issues for how we feel about our job. So ultimately, time is one of the most important factors that is really difficult, because you're being pulled into multiple directions, and you only have a finite amount of time to do all this work. And so what this leads to is burnout. It can lead to patient care errors, and obviously I mentioned leaving radiology and medicine. But on a personal level, it can also lead to mental health issues, substance abuse, depression, and even suicide. And so in the last part of my talk, I really want to also just focus on something that we need to think about as also another cause, or something that we need to think about in this setting of moral distress. So this was a great paper that came in a couple years ago discussing physician task load and the risk of burnout. And so overall in medicine, there's increased complexity of health care. There's a significant impact day-to-day for our workflow. And this not only is our increasing in our clinical volumes, but it's also increasing our administrative and our cognitive burden. So what this study did was they used a validated index survey, the NASA task load survey, and they did it by multiple different subspecialties. And you can see that there's four different areas within the... I don't know. Oh, here we go. There's four different areas here within the the survey. And I just want to highlight here that radiology has the highest mental demand out of any of the subspecialties. And we can all probably relate to that when we are reading on a day-to-day basis. We're not rounding. We're not in clinic. We're not writing EMR notes, but we are using our brain a lot to read studies. And so I just want to give an example what this means in real life. So you are on service and you open a complex MR with over 1,000 images to interpret. This is a common thing that many of us do. You get a phone call at that point to protocol another study. Then you get another phone call after you return back to that MR to check another MRI that's on the scanner and the technologist wants to make sure it's appropriately done. You go back to the original MR. A clinician finds you because you need to review a case that you read and they would like your opinion about an explanation of the findings. Then your fellow or resident has a question and you need to prioritize that. So while all of these things are going on, the list continues to grow while you're still on that one MRI. And if you are like me, you probably are still scrolling that single sequence that you started with in the beginning and you've forgotten your train of thought. And so you are, your brain is all over the place and it's really hard to focus because you've been interrupted so many times. So this is an example of cognitive overload where you're having so many different interruptions. You're task shifting so you're not able to focus and I will say that this is a significant cause of moral distress and this is something that we need to think about as we're trying to figure out what to do about moral distress. There have been multiple papers out there including some of the work that I've done in pediatric radiology looking at the drivers of burnout and this is across the board not just in pediatric radiology. But if you look at this list, some of the things that we have been talking about as a society as well as nationally in terms of how to fix burnout in terms of wellness is not going to target any of the things that are on this list. So I will say that one of the key things that I really also that I strive for everyone to be aware of is we cannot put the responsibility on the individual. It needs to be organizational and system-based initiatives for sustainable change. So in summary, we need to address the causes of moral distress to reduce burnout and ultimately system-level changes are necessary. Thank you. Thank you very much for this wonderful presentation. So I will be talking about common contributors to moral distress in radiology and we will briefly talk about how to measure moral distress. We'll discuss how frequently and severely moral distress is encountered in radiology, what the most common contributors are, and finally, which current challenges in our work environment add to moral distress and need to be addressed. Validated moral distress surveys have been established and measure moral distress by respondents grading frequency and severity of moral distress for 16 different scenarios on a five-point Likert scale. The measure of moral distress for healthcare professionals is calculated as the sum of frequency times severity for each scenario per individual to a maximum score of 256, and the moral distress index for scenarios is calculated as the sum of frequency times severity for each scenario divided by the number of participants to a maximum score of 16 per scenario. In a national survey of radiologists published earlier this year, participants evaluated 16 different clinical scenarios from witnessing poor clinical care due to lack of team communication to being pressured to carry out imaging that they consider unnecessary or inappropriate for the severity and frequency with which moral distress was experienced. Moral distress ranged from 0 to 220 with a mean of 59 plus minus 47. Only two respondents in the survey responded as not having experienced moral distress and this overall is in accordance with other studies on moral distress including in the ICU setting. To gain a better understanding about impact of moral distress, respondents were asked whether they had ever considered leaving a position or had left a position because of it. 46% of respondents had left or considered leaving a position. The answers were correlated with the MMDHP scores and showed the highest scores for those that had considered leaving a position but had not left. Interestingly, those that had left had lower scores. This may reflect that the new work environment was more aligned with the individual's purpose as stated in a respondent's free text comment listed here. This is similar to a national survey of neurosurgeons where 47% reported significant moral distress and 10% had left a position because of it. Again, scores were improved for those that had left a position. Interestingly, the more severe moral distress was experienced when surgeons were pressured to perform futile surgery. The three most common causes of moral distress in radiologists were being required to read a higher volume of cases than one can safely perform or that interfered with resident teaching and lack of leadership support. The highest scores in the survey was a mean MDI of 6.5, comparable to other studies in other specialties. Lumini et al. reported an MDI of 6.6 for ICU physicians for being forced to deliver futile care and Epstein et al. reported an MDI of 7.7. Let's look at these causes in more detail. Sacrificing patient care due to a high workload was reported by 53% often and always with a severity of high and very high in 50%. This issue was previously identified in a survey of neuroradiologists in 2018 where 80% of neuroradiologists reported encountering this problem sometimes, frequently, or always. The second most common cause was lack of leadership support for a problem that is compromising patient care with an MDI of 6.2. This was noted by 37% often and always and 43% with high or very high severity. The free text entries on the right highlight how radiologists experienced their leaders to be out of touch and feel abandoned by them. The third most common cause was not being able to fulfill the educational mission due to a high workload, likely identified because 75% of the study population were academic radiologists. This scenario was frequently encountered by 52% with a high severity by 30%. The free text entry comment displayed here expresses very well what most radiologists currently experience. Disregard for professional expertise was another comment for moral distress. This was experienced for diagnostic imaging for 52% with a high severity by 30%. In interventional radiology, the frequency was lower although the severity was not surprisingly higher. Free text entries listed here underscore the radiologists experienced particularly in the emergency room. As we heard earlier, disregard for professional expertise is the most common cause of moral distress for other specialties. Let's now look at the challenges in our current work environment that contribute to moral distress. Workload demands in radiology have increased substantially over the last three decades. While in 1996 annual RVUs per FTE were slightly below 4,000, this nearly doubled by 2006. I added more recent data from my own institution as current summary data from SCARD is not available. This shows that volumes continue to increase and have by now nearly tripled. Several studies have shown that radiologists' concerns about decreased quality of care with high workloads are justified. Hannah et al. showed in a 2018 study in radiology that errors increase with shift volumes. In reporting up to four errors for study volumes approaching 200 cases, errors peak after 10 hours, most commonly encountered at 10 to 12 hours. It is impossible to avoid these errors as we are all trying to do more work with less staff. Long hours and high volumes have become commonplace as radiologists are working double shifts and routinely moonlighting after hours to keep up with high volumes. A study in neuroradiology published earlier this year correlated error rates and shift volumes and showed a statistically significant difference between shifts with errors around 47 cases per shift and those without errors with a median case volume of 34. 91% of these errors were clinically significant and most were perceptual in nature. So what is a safe number of cases to read? A survey of section chiefs in neuroradiology published earlier this year with participants from 42 departments revealed a median of 32 cases when the attending radiologist was reading independently. This number is of course variable depending on individual practice parameters such as case and technical complexity, non-interpretive task expectations and teaching requirements. In the same survey, 22% of section chiefs reported that they were operating at capacity while 78% were already either above or well above capacity. Let's look at what has happened with the many responsibilities for an academic radiologist over the decades. While in 2000 a clinical day included teaching, administrative work and research, by 2010 the clinical workload had doubled and less time was available for non-clinical duties. Currently nearly all time is dedicated to clinical work leaving minimal amount to teaching responsibilities which can only be made up for by dedicating personal time to this mission. A survey of the ASNR confirms these observations reporting that radiologists are forced to cut back on non-clinical professional activities with most respondents cutting back on at least one of the activities listed here. 80% of those who teach reported cutting back on teaching times sometimes frequently or always. 88% of those performing research reported the same for their investigative pursuits and professional development, society volunteering and practice building activities are equally affected. A study from Thomas Jefferson University quantitatively confirms a decrease in academic productivity with increasing workload and clinical demands crowding out academic pursuits. The number of RVUs most conducive to research was between 3,500 and 5,000 RVUs, volumes that were common in the 90s. The impact of high workload on the educational mission is high. In addition to causing moral injury to trainees and faculty, it has negative impact on role modeling for academic medicine. There's decreased teaching at the workstation and increased remote signing of trainees report which limits the possibility of feedback. A decrease in real-time didactic lectures and increase in pre-recorded lectures again limiting the possibility of feedback and the overall effect on trainee competency is as of yet unclear. Lastly, a quick word on our second most severe scenario, the lack of leadership support. In a 2018 Gallup survey of 7,500 employees, 23% reported burnout often or always and described the causes listed here which are equivalent to the ones we have discussed today as causing moral distress in radiologists. Staff expects leaders to address unmanageable workload and find solutions to unreasonable time pressures. Staff expects to be treated fairly, to have role clarity so that they can be successful in their work and expects open communication and support. Leaders who can address these issues will be able to decrease moral distress for their staff. In conclusion, moral distress is an important issue with 98% of radiologists having experienced it to some degree and 46% having left or considered leaving a position. Moral distress is experienced as an internal conflict between a physician's purpose of providing high quality care and resident education and our current work environment making it impossible to do so. System level solutions are needed to balance workload with our missions, to apply our expertise to the benefit of the patient and to provide visible leadership for the radiology workforce. Thank you very much for your attention. Our next speaker is Dr. Frank Lexa from UPenn. He is Professor of Radiology, Vice Chair of Faculty Development and CMO of the Radiology Leadership Institute and he will be talking about the importance of leadership in countering moral distress. Thank you. Thank you. Okay. I want to thank Dr. Siebert very much for having me here and also it's an honor to be on the panel with these other great speakers and thank you all for coming today. And I'm going to be taking a focus on leadership. As you just heard, I'm the current CMO for the Radiology Leadership Institute at the ACR and I've also taught leadership at Wharton and some other business schools. And so I'm going to be focusing on this element of it in the next 11 minutes. Let me just... I guess we have to do our... I had to click on this. Okay, so I've got to click down here. Okay, thanks. And this is the only disclosure I have and it's not relevant but I'm required to mention it because I have done this in the last 12 months. My goals are again to discuss distress and why leadership matters for better or worse. As the two previous speakers have already said, these are usually system problems. Motor stress, burnout have been blamed on individuals. That's almost always wrong. It's almost always a system issue just like PTSD is not usually a problem with an individual soldier. It's not his or her problem. It's usually a system problem. And we're going to develop a strategic perspective to address these issues. I'm going to give you some personal advice. I want to acknowledge the roles of leadership in causing moral injury and distress and also in fixing it. I want to consider ways to change institutions, leaders and leadership in the face of a perfect storm at least in U.S. radiology where we have workforce shortages, rising workload and thank you government, decreased reimbursement. I also put up a definition of moral distress and you just can read through this but it's where you know the ethically appropriate thing to do but are either unable or prevented from being able to act on it or you decide this is contrary to your values. So a couple things about this. First of all, if you're a sociopath, you don't have moral distress because you have to have a conscience. The second thing that you notice here is that this is up to you and you need to decide how you handle this and no one should put you into this kind of situation and yet I want to thank Dr. Seward also for referencing the first version of this survey. I've done this survey twice. This is the follow-up with Jim Chen and Trini Van Vatham and myself and looking at burnout and work-work imbalance and this was a follow-up that we did again of U.S. neuroradiologists and what we found was that not only were people reading too fast, they knew that they're not interpreting well and they weren't calling in significant findings. This is bad. I don't need to tell you this. You all took a note. This is one of the more popular ones. Modern Hippocratic Oath. This is wrong. Now I hope that the pilot who flies me back to Philadelphia tomorrow morning is not cutting corners like this. These are people who are highly trained, who've done 10,000 hours of training or more and they're admitting that they are deliberately skating. It's like they're driving drunk. So this is bad. And does leadership matter? You bet. First of all, your leaders have to be leaders. If they're just shop floor managers telling you to read more, then they're probably going to burn you out, as you just heard. Do they focus on what matters most for radiologists in the near, mid and long term? The earlier survey you saw really shows that we're being told to focus on today to the detriment of the future. Any psychologist will tell you that one key issue to sanity is being able to simultaneously balance the past, the present and the future. People who live only in one of those are often mentally ill. If you ask what a successful CEO has to do, they have to balance the present and the future. If you're not teaching, you're not mentoring, then you're putting us in the position of training the last generation of radiologists, which is a horrifying thing to say, but it's something we have to say. And so leaders can be part of the problem and they can also be part of the solution. It's sort of like this philosopher. You've probably seen this, and that's, by the way, not true, obviously. It's a problem and then it's a problem. But we're going to be discussing the roles of leaders in causing but also ameliorating moral distress. But again, this has to be a departmental or institutional level as well as some national strategies for sustainability in radiology. I will also remind you that you need to take care of yourself if your leaders or institutions won't. What most people forget from that Geneva Declaration is that you not only promise to take care of your patients, you also promise to take care of yourself. If you don't believe me, look it up. It's like the third one from the bottom. So maybe by then, like me, it was 100 degrees the day I was doing it. I was going to pass out. It's also a reminder that all of you are knowledge workers and you all should have some kind of a leadership role, whether that's acknowledged or not, whether or not you get paid or get a title. We're knowledge workers. We should lead. This is something that somebody said I said. I don't remember saying it, but ever since I got credit for it, I said it's a great quote. It's actually an adaptation from this gentleman who was actually a physician but didn't really practice because he was too busy being the president of France, that's Georges Clemenceau, and he was referring to something else but the same notion that at times there are things that are too important to be left just for the people who are designated as the leaders. Why does leadership matter and how does it matter? Well, first of all, it's a role model. If your role model is a really unhappy person who's in the hospital 14 hours a day like the character in the book House of God, then that's probably not the right person to be leading you. I'm sorry, I know I'm describing some people you might work with, but we really need to figure out how to set boundaries. Also set appropriate expectations. You just heard this number four from Max Wintermark, which is interestingly related to a different study that came out about six years ago which showed the same thing, that neuroradiologists start to make mistakes at about five or six cases per hour. But even five or six years ago, how many places could you find that neuroradiologists are only reading four cases an hour? It's pretty hard to find those. So you have to act as an advocate in the larger institution. The institutions we work for, whether you're in academics or private practice, are addicted to the technology component of the imaging that we do, so they want you to read more and they will push you to read more. And we have to advocate in the House of Radiology for leadership at a national level to put brakes on some of this, because I've heard people in private practice brag about the number of cases they're reading per hour, but you've also started to see the lawsuits that occur. And if you claim you've read 700 images and you're reading really fast, and in a recent lawsuit, 700 images read in about two minutes. And when that miss occurs, the jury may not really understand why sometimes white is good on an MR and sometimes it's bad on an MR, but they can sort of look at this and say, how can you read 700 complex images and then miss something like this? And it's pretty straightforward, so be very careful. We need to be doing this. These things come from an article that I wrote looking at how leadership can also be used to cure burnout, which is one of the things we're talking about today, but it's also the same with moral distress. It's having smart people who know the right way to do this and then giving them an institutional framework so that they can actually be the radiologist that they need to be and not cut these corners. Because again, you will be held accountable if you cut corners and somebody gets hurt. And again, you can't really have moral distress if you're one of our potential competitors, at least in the United States, where we now have people who are not physicians who are talking about reading cases. And if somebody spends 10 hours learning to read a head CT and misses something, there isn't much moral distress because they don't know the right way to do this. They weren't trained properly. They don't know what they're missing. So these are big issues for us. If we take strategies for this, we need to define the goals and outcomes we want. And I just went through some of those, but it's the notion that we have to have national standards for this. I'm not a big fan of books that are in the self-help category, but if there was one that I would ever recommend you read, it would be this one, because it's where I'm taking this phrase from, which is begin with the end in mind. And I think you really need to envision a way to do a safe amount of work and know that you're not hurting anybody, because if you ever talk to somebody who's been in a lawsuit, it kind of drags on for years. It's a terrible thing, in addition to the fact that you just hurt somebody because you were cutting corners. So please start to think about ways that you would drive that strategy and get to the things that you want. And the nice thing about the labor shortage we have in the US is that we can start making demands on the institutions and talk to them about limits. If you like this philosopher, and one of my residents kept using this phrase, that's a problem for future me, it's not a problem for me, and I had to look it up and that's where it came from, you obviously wanna take care of your future self. And again, if your institution won't do that, you need to do that. And what do we want leaders to do in the face of moral distress? Well, one is lead by example, and that's value alignment. And we went into this in detail in the paper, but basically, again, if your leaders don't believe in this and I talked to the leader, this is not an academic person, but the leader of one of the top tele-radiology companies in the US over 10 years ago now, and they said, yes, our model is that we burn people out, but you'll just make more people for us to burn out. And that was their attitude, at least they're honest. It's nice to have somebody at least speaks honestly. That can't happen now as much because of the labor issues that we have, but again, there has to be value alignment. There has to be a consensus on moral and ethical issues, you wanna protect members from institutional, extra institutional drivers of moral distress, and leaders need to work continuously to become better leaders. And we need to help radiologists lead at all levels, and where necessary, have you push back on some of these things. With that, I'm out of time. That's me with one of the few people in the business world who I really respect and like. That's the person who invented my computer, that's Steve Wozniak. So anyway, I wanna thank you very much. Our next speaker is Dr. Michael Bruno from Penn State University. Dr. Bruno is Professor of Radiology and Medicine and Vice Chair for Quality and Safety, and will be speaking to us about managing the workload radiologists mismatch. Thanks for the invitation, it's great to be here. Subtitle is Solving the Retention Problem. So I come from Penn State, which is in Hershey, and this is what it looks like. There really is a corner of Cocoa and Chocolate Avenue, and that's Milton S. So as you've heard, and are undoubtedly experiencing, there's a horrible mismatch between the demand for imaging services and our capacity to deliver on that demand. The demand is increasing exponentially. Part of it is because of the aging population with a higher disease prevalence, but a lot of it is this sort of epidemic of over-testing and waste. And waste is sometimes called low-value imaging, and one of Dr. Seaworth's slides earlier, there's a quote from an ER doctor saying, well, we don't have time to do an H&P, so imaging is just what we do. There's a tremendous irrational component of that. Anyway, the supply of radiologists, which is our capacity, is in free fall. We have the great resignation, we have strong limitations on the training pipeline. We cannot make radiologists fast enough. We don't have enough residency slots, we don't have avenues to increase those. And what we're seeing is a move toward part-time and remote work, a greater concern for work-life balance, people experiencing burnout, withdrawing from the workforce. You may have heard the term quiet quitting, where people do the absolute minimum. At my institution, we've seen our outpatient elective study worklists grow and have backlogs that we've never seen before, and now we have days and days of backlogs. Other places have much more. The other thing that we've noticed is that the people who are leaving the workforce had a higher capacity than the people that are coming on. So we have dwindling capacity. But at the same time, there's an exploding demand. So our cup runneth over, and this is a radiologist. Starting his workday with his morning coffee and he's already underwater. So, there's a lot published on this. Rising use of diagnostic medical imaging. This is from Rebecca Smith-Binman, who's been studying this for a long time. Utilization of chest and abdominal pelvic CT for traumatic injury. I'm an emergency radiologist. What I've been seeing is patients who have very minor injuries, or maybe one obvious thing, like a broken ankle. Nevertheless, are getting a CT scan of the head, neck, chest, abdomen, pelvis, all four extremities, and at least 45 extremity x-rays. And then we find, of course, that they had an ankle fracture. And a lot of people, very, very minor injuries. No real complaints getting a scan like this. There's, Dr. Alexa alluded to, non-physician providers that are contributing to this. Really on both sides, because we have non-physician providers that want to do our work, but we also have a lot of non-physician providers in the emergency rooms and in the clinics. And we know that they order a lot more studies because they're less sure of their clinical abilities. The exploding volume of chest CT for suspected pulmonary embolism in emergency departments, it almost like goes without saying. There used to be a very common joke that started out, man walks into a bar with a parrot on his shoulder. There's about 60 different punchlines for that joke. You may remember some of them. If you change it to emergency department, the punchline is always, what kind of CT do I get for that, and does the parrot need contrast? Overuse of diagnostic testing in healthcare, it's been systematically reviewed. Benefits and harms of CT screening for lung cancer, we're doing a lot more screening exams. But effectively, when the emergency room has not done a history and physical, and they scan a person from top to bottom with the basic goal of see if you find anything for me, that's the same as doing a screening of an unselected population. We are not very good at that in radiology. And what we crank out is all false positives. Which brings us to this great paper from Matt Davenport from Michigan about incidental findings in low-value care. And if you haven't seen this paper, I highly recommend it. This was in the AJR very recently, where he talks about how most of the things we find in that scenario are of really no clinical consequence. And so we're doing a lot of low-value care. We heard that that's a substantial contributor to moral injury. Last, I want to just mention opportunistic screening. You'll hear a lot about that. It's a very hot topic in literature. I see a lot of breathless excitement for this. But what we're doing is generating lots of more data that no one ever asked for or wanted, and no one knows what to do with. So this is gonna lead to even more imaging, more demand, which we don't have capacity for. So I would urge caution on this. At least 30% of medical imaging, and possibly a lot more, and that's defined by adherence to evidence-based guidelines. EBG is not medically necessary. And a great deal of it happens in emergency departments. 85 million CT scans were ordered in EDs out of the 100 million total per year, and it's increasing by 11 million each year over the past decade. Particular areas of wasteful use, headache, minor trauma, which I mentioned, suspected pulmonary embolism, you know, miscellaneous sorts of things. I mean, we were taught in medical school that one of the functions of the lungs is to catch tiny clots so they didn't make it to the systemic circulation. Well, we can now detect those. So if you detect an asymptomatic, tiny peripheral pulmonary embolism that was never gonna harm the patient, what do you do? Well, you anticoagulate the patient, and then they lead to actual harm. So all these, this low-value care is actually harming patients. We're harming them financially, we're harming them with increased risk. What I call shotgun imaging, no clear aim, no diagnostic question, no diagnostic hypothesis. We are bad at this. And, you know, the great donut of truth. Sometimes our photons are the first thing to touch the patient, and our texts are the first people to talk to the patient. And I can't tell you how many times I've called to give a critical finding or an urgent finding to an ER doctor, and they don't know what patient I'm talking about, and they haven't seen that patient yet. You know, somebody just ordered a scan as a matter of routine. And this curve is a growth curve, similar to what Dr. Siebert was showing. It stops at 2007, but you could substitute almost any years for this, and you get the same curve. This curve, which was from a recent article in AJR, is just looking at minor trauma, CT use in minor trauma. So ED imaging overuse, more than 38% of patients with low-risk headache are subjected to unnecessary imaging, and they get no change in management compared to those who didn't have a CT scan. And we never even ask the question of whether it changes their outcome. So only 1% of scans for atraumatic headache actually yield an actionable finding. And ED imaging overuse, nice reference on that. Over 85% of ER physicians surveyed believed that too many diagnostic tests are ordered in their own emergency departments, and 97% said that at least some of the imaging they personally order they know are medically unnecessary. And there's a lot of reasons for this. We know they're uncomfortable with diagnostic uncertainty. We know that there's defensive medicine issues and time pressure and other things. Most inpatient morning portable chest X-rays are unnecessary. Almost all outpatient thyroid ultrasound, and almost all requests for outside overreads. We actually did a project on this some years ago with the morning portables. We did an evidence-based intervention and actually reduced them a little bit, which was very nice. I'm sure it didn't last. We haven't remeasured. So there's tremendous cost of this waste in the healthcare system. There was a 2019 JAMA article that estimated the spending on this kind of low-value care. That's a euphemism for waste, to be between 75 and 101 billion. This classic paper now from 1991 from Freyback and Thornbury. I highly recommend it. The first line, it's clear that the appraisal of outcomes of care will have a major impact in medicine in the 1990s. Well, guess what? That's like flying cars. It never happened. We do not look at the outcomes of care in imaging. And Frey and Thornbury gave us this great schema of six levels. And the level one was technical efficacy. Can you resolve your line pairs? Yep, we did that. Level two was diagnostic accuracy. What's the yield of abnormal-to-normal diagnoses of a study? Sort of the ROC curve. Check, we got that. Number three is diagnostic thinking efficacy. Does it help the clinician to narrow their differential diagnosis and move forward? Check, we got that. Level four was therapeutic efficiency. The percentage of times the images were judged as helpful in making diagnostic or treatment decisions. Check, we got that. All right, so we're up to level four. Level five is patient outcomes. How often do patients who get imaging end up with a better outcome than patients who don't? Well, we have no data on that. And level six is societal efficacy. You know, what are we doing for society? We have no data on that. And getting back to this paper from New England Journal, chest CT for suspected pulmonary embolism in emergency departments. Despite more use of computed tomography in emergency departments to evaluate patients for PE, the immortality has remained stagnant. So there's the answer. We are not doing anything for patient outcomes. So this is the Thornberry hierarchy. I highly recommend that paper. We have done a few things. We created the ACR appropriateness criteria, evidence-based guidelines. And right now there's like 227 scenarios in there. It's fantastic. But if you don't ever do a history and physical and you have no diagnostic hypothesis, then there's no way to map a patient to the ACR appropriateness criteria. And therefore, it's all inappropriate. So unless we have a diagnostic hypothesis that we're testing with imaging, the ACR appropriateness criteria don't work. And they have had very limited impact. Clinical decision support based on this has largely failed. It's very sad for me to say because something that I've worked very hard on as a quality and safety guy. The PAMA Act of 2014 will probably never be enforced. It's basically been deferred indefinitely. We did a study looking at why clinicians resist clinical decision support, why they try to circumvent it, game the system, and dodge it. And this is published in JACR. It was actually funded by the American College of Radiology Innovation Fund. And we found that the answer is very simple. They know they want imaging that's not indicated. And so they're going to resist clinical decision support. And we asked them, why do you want it if you know it's not indicated? I just need to be more sure. I need more certainty. This, of course, is the logo for californiasychics.com, the joy of certainty. So perhaps they should do that instead of a CT scan. Anyway, it's a multifactorial problem. But the number one driver seems to be a desire to reduce clinical uncertainty taken to the extreme. It is very psychologically distressful. And this high clinical volume now threatens to exceed the collective capacity of our entire specialty, as we've discussed. Patients are harmed in myriad ways by this indiscriminate use of imaging and leading to a lot of false positives and overtreatment. I think it could be an existential crisis for radiology, because if we can't keep up, someone else will sort of move in. And we're beginning to see this already with interpreting PAs. And there are scope of practice bills being introduced in multiple states to allow nurse practitioners and physician's assistants to do our job. So what can we do about this? Number one, we need better outcomes data to evaluate the value of imaging for specific clinical questions. I think this is our most urgent need. If we have this, we can really use it to push back on unnecessary volume. If we can get rid of the unnecessary volume, our supply-demand mismatch will, of course, be much, much better. Evidence-based guidelines need to expand to incorporate individual patient risk factors. This is basically Bayesian reasoning. Not just the efficacy of an MRI to diagnose a certain disease, but also what's the clinical question, and how do we get that, and what imaging is appropriate for the clinical question, based on pretest probability. We need to consider whether our role should include being a gatekeeper, as is done in other countries. And perhaps a radiology consult is requested by a clinician and not an imaging order. Radiologists would then determine whether imaging is needed, and if so, what. And then we'd have to take full responsibility for our decisions when we decide to withhold imaging. And that's kind of a brave new world for us. A lot of my colleagues have frankly told me they're not comfortable with that. Number four, some solutions will exceed our sole reach, but we can be a vital partner. Medical education, to include the fact that resources are limited, that diagnostic reasoning is necessary, and to give a tolerance for uncertainty and less reliance on testing. The psychologists tell us that being tolerant of uncertainty makes you more psychologically resilient. And we're seeing in our society a lot less psychological resilience, a lot less ability to deal with uncertainty, and a lot less risk tolerance. We need payment reforms that create disincentives to wasteful utilization. And this is a huge factor. We're basically rewarded for doing the wrong thing, and that probably should stop. But I have had recent conversations with colleagues in England where there is no reward, and they're having the same problem there. So we still have to deal with the human factors, the irrational components, the magical thinking about imaging. But payment reforms will really help. Obviously, we need tort reform to reduce defensive medicine, and we need to reform the process by which expert witnesses are policed. Because as it is now, you can be an expert witness, and you can say anything you want. And that is a real problem in terms of torts. We need to temper unrealistic expectations regarding the power of imaging to resolve all diagnostic questions and to replace clinical imaging. Go see if you find me something is actually not a valid approach. And of course, all this is much harder than it looks. So what can we do about this? Well, I think we should also try to find alternative funding streams to increase the number of radiology residency slots. And perhaps the payers could be tapped for this, not just CMS. We need to strike a better balance between the general radiologist and subspecialists. This is a particular problem in academic radiology where we need a lot more people because of our high level of subspecialization. With general radiologists, you have shorter training, greater versatility. Also, we talk about importing qualified radiologists from other countries and streamline the alternative pathways. And improve radiologist efficiency with better IT systems. Rama mentioned that. And integration of AI to augment human performance. And I think that we can partner with the LCGME and ACGME to reform medical education. Work with CMS and Congress to obtain payment reforms. All these things will help. And that's sort of a pitch to get involved with organized radiology. Otherwise, we end up like this poor guy. Thanks very much. Our next speaker is Dr. Marion Hughes from UPenn. Dr. Hughes is professor of radiology and otolaryngology and former program director of the Diagnostic Radiology Residency Program. And she will be speaking to us about maintaining the teaching mission to reduce moral distress in academic radiology. Thanks, everyone. I'm really honored to be here. And thanks, Patina, for the invitation. I've been asked to speak to you about how to teach effectively and efficiently during a hectic workday. I just want to take a moment to thank the academic radiologists or all the radiologists in the room. You've dedicated your careers to caring for patients and teaching the next generation to do the same thing. So it's a very noble purpose. So thank you. I think we can all agree that sometimes it seems like teaching and clinical efficiency are competing interests and that it's hard to do both. This is not a talk telling you additional things you need to be doing. This is a lecture about efficient and effective teaching strategies. So how do you maintain that noble purpose even during a crazy workday when your list is exploding? This isn't a metaphor that we see all the time. Put your own mask on first. It's the idea that you can't help others unless you help yourself. I actually think this is really too extreme. We need to practice self-care in non-emergent situations. But if you are killing yourself, you're not going to be able to help anyone. So it's important. So I want to be respectful of your time. So in the next seven or eight minutes, we're going to talk about effective teaching strategies. So what's out there in the evidence? Because if you have a limited amount of time, you want to do what works. And then we're going to talk about efficient strategies that are in the literature for teaching clinical medicine. About five years ago, I read this book. It's sort of an overview of cognitive science. And it really changed how I thought about the science of how we learn. And it also changed how I personally teach radiology residents. It reviews a ton of evidence-based teaching strategies. But really, the big three and really the big two are retrieval practice, which is just another word for testing, and spaced repetition. And spaced repetition is the idea that cramming pretty much guarantees rapid forgetting. And if you space out your study sessions, say at one day, one week, and one month, you're much, much more likely to create an enduring memory. The medical students are all over this. They all use electronic flash cards, Anki cards. And they learn giant amounts of information for learning a new language, for studying congenital hearing loss. This is really an awesome technique. And the final technique is something called interleaving. It works well for your more advanced learners. And it's the idea that you just don't want to show them, I'm a neuroimager, I just don't want to show them brain tumor after brain tumor after brain tumor. They can predict what's coming. But rather to mix up the cases that you're showing them so they need to distinguish between. So these are sort of the big three techniques. Not a ton is out there. I had a really awesome chief resident. And he and I did a systematic review. We found actually one randomized controlled trial that looked at these techniques to teach radiology to radiology residents. So for those of you thinking I need an area of expertise that I want to dedicate my academic career to, this is ripe for publication. But if you're more like me and you want to remember, tell me one thing I need to do. Like when I take ski lessons, I'm always like, just tell me one thing. I can't hear like nine different things. What I would say is talk less. You can actually be a more effective teacher if you don't spend so much time putting information into their heads but not enough time pulling it out of their heads. So ask more questions. Talk less, listen more. This is a very easy, well, it's sort of easy but it's actually really hard when you try to implement it. But it comes at no cost and you can implement this. So that's the evidence, the big evidence-based teaching techniques, testing and retrieval practice and then spaced repetition. If you have really limited time, how do you teach clinical medicine effectively? We are not the only ones thinking about this. Back in the 90s, Dr. Nayer, a family practice doc, came up with what he called the one minute preceptor model. And I never knew about it until a couple months ago when I started researching for this talk. And I sort of like it. Many of you are already doing much of this. But it's a five-step model for teaching efficiently. And the steps are, number one, get a commitment. I feel like we sometimes don't, we just immediately start telling the residents what the findings and the impression are. But really, you wanna get a commitment from them. What were the critical findings? What do you think is going on? The second step is probing for evidence. And that's like, how did you come to this? Did you consider anything else? What else did you consider? And between those two steps, you can really get a sense of their knowledge. And then you can tailor your teaching to those steps. The third step is to teach a general rule or a clinical pearl. And this is an opportunity for all of you to share your disease-specific knowledge. And ideally, keep it succinct. So those are, and then the, so those are the first three steps. And then steps four and five are providing feedback. So reinforce what was done well. And then correct mistakes. So again, this will be one of your multiple-choice questions but the five steps for the one-minute preceptorship model, which should be called a five-minute preceptorship model, it's hard to do in a minute, would be get a commitment, probe for evidence, teach a general rule, and provide feedback. I try to do this, I've been trying to do this once with each resident during a readout. And if I can get through this, I'm super satisfied with that for my teaching during a super busy, hectic clinical day. The steps four and five are very similar to a feedback mechanism that I learned from some business executives in a leadership course. And I actually find this to be very helpful for providing feedback. It's a little less clunky than the feedback sandwich, which they all know is coming. This is continue and consider. So continue with whatever it is you want them to keep doing and then consider whatever it is you'd like them to change. So you might say to them, you did a great job summarizing the clinical history, making the findings, continue doing that, but you gotta consider a shorter differential and make sure you let me know and the clinicians know what you favor as your impression. So I like continue and consider for feedback. As a former PD and looking at a lot of national ACGME surveys, lack of feedback is a huge resident complaint. They want more feedback. So if you can get your faculty to do continue and consider, and I actually say to the resident before I do this, I am going to give you some feedback right now. So they're aware that they're actually getting that feedback. So the one minute preceptorship model, similar to evidence-based techniques, there's nothing in the radiology literature, one paper in the radiology literature, a descriptive paper. So I think we can do, there's a lot of room for publication here. There is evidence in the greater literature that if you use this technique, there's improvement in the student's perception of your teaching and improvement in the quality and the quantity of feedback. All right, so that was a quick tour through evidence-based teaching techniques and a single efficient technique called the one minute preceptorship model. I really appreciated to talk to you about something that's really important to me, and that's how to maintain the teaching mission. It's why many of us stay in academics. We love it. It's important. So thanks a lot.

moral distress

burnout

radiology

leadership

systemic issues

teaching strategies

work environment

evidence-based methods

patient care