to do work from home radiology. Probably a topic that a lot of you have been thinking about or people have been discussing because it's been a definitely a hot topic post pandemic. Sorry, I am not here in person with everybody. This is the first RSNA I have missed in a decade. And I just had a knee replacement so I could not travel. Little bit about my background is that I actually started reading from home in 2008 after a four and a half years in private practice. I actually was one of the first US-based finals readers for Nighthawk Radiology. Nighthawk was subsequently acquired by VRAD. I was at VRAD for many years and currently am at Matrix Teleradiology where I've been for the last three and a half years. And that is a division of Radiology Partners, our internal teleradiology arm. And so hopefully I have about 13 years of experience to draw on in order to help everybody set up their home workstations. And as a note, I actually was one of the practicing teleradiologists on the ACR task force in teleradiology. So this is a part and something I want to talk to radiologists about. So first I'll start by telling a story about a kind of a famous figure in the lore of early days of teleradiology. Someone who decided to work from home and set up his workstation right in the middle of his living room. And his spouse was also at home caring for young children. And long story short, he basically would kind of lash out and argue with his spouse if he saw her ever taking a break from doing chores and doing the work of the household and the laundry and dishes and food prep and taking care of the kids. If he ever saw her taking a break, he'd be like, well, this place is a mess. Why don't you keep this place clean? Likewise, if she ever saw him taking a break between cases or something, she would say, can you help me with the kids? They're out of control. Can't you see? Kind of a dangerous scenario, as you can imagine. The urban legend is that teleradiology caused his divorce. So I had heard that story before setting up my own home office. So I definitely wanted to avoid that fate. So some of the tips I had received was first a set of stairs. For the physical layout of teleradiology, nothing beats isolating yourself than a set of stairs. Whether it's stairs to the attic or stairs to a basement, it definitely helps because it is a real barrier for our kids and it's from the main activities of the household. So I definitely am a big fan of doing it on a different floor. Definitely not in a bedroom or in a living room or any of those places where activities of daily life go on. Another barrier would be the presence of doors. And for example, in my setup, I have a door at the top of the stairs, a door as you enter the area for the home office, and then another set of double doors when you actually enter my home office. So three sets of physical barriers for any kind of kids. It's not gonna be perfect. I mean, my youngest is 12. So her whole life, I've been home reading and she couldn't care less about any barriers. She'll come down and find me if I'm working. And you deal with it, you live with it. Sometimes she likes to fall asleep to the sound of my voice dictating. So it all has its benefits and drawbacks. But as far as room shape and lighting, I do advise avoiding windows. If you can do a kind of a windowless room, it would be great. The shape of the room, smaller is actually better. Smaller is better for kind of reproducing the kind of cubicle kind of system that we have in a reading room. But it is kind of focuses your vision on the monitors. The monitors become kind of the most biggest focal point in the room. And certainly that will help keep your attention. As far as lighting is concerned, I have dimmable lights. Dimmer switch is very important for the light source because you want it to be as low as possible. You're looking for a low light. And that way you can kind of almost reproduce a backlighting. Some people only have backlighting in their home office because backlighting and LED lights behind the monitors was kind of developed after I started. And so you could do either of those things. But definitely if you're gonna have a light in the room, you should have it on a dimmer switch. Soundproofing, I think the presence of my video is overlapping that last little slide there. But soundproofing is important. The most important thing you can do is carpeting. And so carpeting with padding is going to serve as a dampener. I have seen people have kind of soundproofing on the walls. If you're building or framing out a room, you can certainly put soundproofing type of foam insulation in the framing. And I actually have ceiling tiles that are black. They're black for, again, for keeping the room dark and helping with lighting. But I have seen ceiling tiles that actually have insulation in the ceiling as well to increase soundproofing as well. But just all these are the main things you should think about when you're actually thinking about the room. Going, there are kinds of things to think about in your work area. We'll approach this slide from bottom to top as far as technical considerations. Desk type, when I was talking about a small room, I was also kind of talking about kind of a U-shaped or kind of an angular desk that has sides that you can actually put stuff on the sides. I actually like that because your peripheral vision goes around and you can have monitors around you and you can have a printer or other things to the side of you. So it can actually increase your workable area. As far as chair type, do not skimp on your chair. I have had the really, really good Steelcase brand chair. Herman Miller is another great chair. There are some equivalents of that level of chair, but those are the two most common that teleradiologists use. We've actually done a survey of over 500 teleradiologists and looked at the chair types and those were definitely the most common and they're important. My son had a desk in his bedroom and he actually developed some back pain. I changed his chair to the same one I use and his back pain went away. So he had a real flimsy chair and it's an important consideration. You're gonna be spending a lot of time with that chair. Windows, if you have a window in the room, definitely make sure you have room darkening shades. They should be pretty thick to prevent light from getting in and also increase soundproofing. The last word on that arrow is actually HVAC. So many times you should consider having controlled AC so that a room doesn't become too hot. You're gonna have a lot of monitors, a lot of printers, and maybe one or two workstations in that room. So you want it to be able to be cooled and same thing in the winter. You want it to be warm and you don't wanna be freezing. So definitely HVAC controls are important. Talking about peripherals that you need, I'm a big fan of the desktop mic over a headset or over a dictaphone. I've been using a desktop mic for a long time and it's definitely optimal for me. That's my advice. A mechanical keyboard, which is something that gamers use, a mechanical keyboard is a kind of a clickety-clack keyboard and the keys have a tactile sensation. But I like that because it actually gives you a clear tactile sensation and very good for keys that you're gonna be pressing. Maybe you have macros for the PAX programmed to your keyboard. I use a gaming mouse and almost all my macros are programmed on that because the gaming mouse has a lot of buttons. Mine has 13. So I have dictation on and off or next series, all of those functions, windows and even dictation functions are mapped to my mouse. So I don't need to use a keyboard or fumble for keys or look down. Many people use a left-hand mouse. It's a really great idea. V-Rad has its own patented V-Grip that is a left-handed mouse that controls multiple mouse functions. It's a way to really, really keep your eyes on the images without fumbling for keyboard or other tool functions on your screen. Moving up, talking about monitors. I actually use 4K monitors, which gives me a diagnostic image. You can use diagnostic medical grade monitors too, or commercially available, very high resolution monitors. The key part of it is gonna be calibration to keep the ACR guidelines. And many software programs, whoever is providing your system is going to have that calibration software. The key factor is luminance. The reason why radiologists can't read off laptops, those screens are not bright enough. I've actually discussed this with some of the folks at Double Black Imaging and their colleagues from Samsung, and you just can't get enough brightness from a laptop screen to actually have a totally telerad kind of system where you're reading off laptops. So as a result, you have to have a very high quality monitor that has the right minimum 350 candela luminance. And obviously the monitors today are very, very good. The last thing I'll talk about with monitors is you can actually have them set side by side like most reading rooms do. But another way to do it is actually stacked on top of each other. So if you have three monitors stacked on top of three monitors, your eyes are moving up and down, but you're actually have the space of six monitors in a combined area that is much smaller like a three monitor area. So what does that prevent? That prevents excessive motion of the neck, prevents neck pain, prevents neck strain, prevents eye strain. So it's something to consider if you're really setting up things from the beginning. Finally, internet. Your source, your internet source should not be wifi. It should be a wired modem in that room with a router. And certainly you'll get VPN software from whoever is providing the telerad software. But that wired connection is key to give you the most fidelity in your signal and the biggest bandwidth. Fiber, cable, DSL, all are good options. You really need a minimum of about 50 Mbps, which is easy to do. In fact, I would recommend business class, buying business class level of service. I think I pay $85 for my internet connection whole house, but it's business class. What that does is it kind of gives you a dedicated bandwidth. So when a lot of people are working from home, your business class is kind of upgraded and kind of kept solid at all times. If there's an outage, yours will be the first to return because they like to keep their business class customers happy. If you have the option of choosing, you should choose for a static IP address. You can get us backup modem, a DSL cheaper line or something else. If you want, but you may not need it if your interconnection and your internet provider is really, really solid. Moving on. Examples of things I've talked about. This is kind of the wide monitor, 4K monitor that I like to use. This is an example of the Blue Yeti desktop mic. They also make a Blue Snowflake, but Blue is a great company for really high quality desktop mics. This is the Steelcase Think. Also the Steelcase Leap chairs, I find very good for office. These are the kinds of download speeds and tests you're gonna be seeing. You're gonna be looking at something called a ping, which is gonna be how fast the connection is working. It's more important than just download speed, upload speed. There is something called jitter, which is how stable the connection is. There's other factors that affect your internet quality. And the technical folks who work with will help you with those things. Just wanted to briefly touch on communication when you're at home. Because some people are always wondering, they're like, how can I not be at the hospital? I'm part of the healthcare system there. What happens when I'm at home? Well, certainly, you're gonna be talking to dogs. I use my cell phone. I have good connection. If you don't have good reception where you're working, you can get a hardline phone. The picture on the right is actually a video phone that I had when I was at VRAD. And you could even video communicate with other RADs. Instant messaging is really the standard for teleradiology. And systems like Teams, et cetera, are really good ways to communicate with all the people in the teleradiology world. The people who are connecting your calls, the people who are the techs at the local sites, et cetera, et cetera. But also, most importantly, it works hand-in-hand with the consult system. It's another way to talk to your fellow colleagues and get consults, et cetera. Like I said, many teleradiology groups have call centers. Even academic teleradiologists are working with call centers now. Call centers are becoming common and they really make things easy, but that's how you communicate. They connect you to the doc. Typically, you will have an IT resource that's helping you out when you're at home. So somebody else to keep in mind that you'll wanna keep in touch with. There may also be a scheduler or a workflow manager that's helping you as well, that's available to figure out glitches in people's schedules or even how the cases are being delivered. Music in the background is not going to interrupt your dictation, just a note. Many, many rads have music playing and really like that. I just wanna talk a little bit about efficiency. So you are starting a shift and one of the key things is make sure you're showered, make sure you're dressed and ready to go to work. It's not something to do in jammies and underwear or whatever that people have this impression of. I think that being ready to work and presenting a good appearance gets you in the mood to be very efficient. Do take lots of breaks. Breaks are crucial. I started intermittent fasting and I took my first break at two hours, that's when I got my coffee. But you build in that break, it actually makes you more efficient when you come back. It can be short, 10 minute breaks, et cetera. Regarding cell phone and email when you're on shift, I put my cell phone on the couch in the next room. It's loud enough that I can hear it ring if somebody's calling me, it's loud enough that I can hear anything but it's not next to me so I can avoid it. And same thing with email, do not have your notifications on, just silence them so that you can focus on reading. RVU monitoring, hopefully you have a way of seeing how much you're doing. I don't think this is a punitive thing or kind of a big brother thing. I like to know what I'm progressing towards the day to reach my goal. Again, coffee, food is important. It's important to keep your body sustained on your shift. Don't skip lunch, don't skip breakfast and eat after shift. Spend 15 minutes, even if you wanna do some addenda or whatever during your lunch break, you can bring it down to your workstation. Speaking of which, admin tasks at the end of the day, I save all my addenda for the end of the shift. If you do it during your shift sometimes, it kind of breaks up the flow of reading and you kind of wanna do all those admin tasks at the end of the day. I save them for the end as much as possible. If somebody says, Dr. Shah, you gotta fill out this form right away, do it at the end of your shift. It's not gonna matter. Just a hint, obviously a lot of teleradiologists are at night, but no matter what your shift time, definitely have good sleep hygiene. One of the things I found really good for discipline and efficiency in teleradiology is you gotta have a good sleep program. Don't mess around with your sleep cycle too much. There's lots of things you can do for good sleep hygiene. And that's it. That's kind of all the tips I wanted to include today. Thank you very much for your time and the invitation to talk to you all today. So we're gonna talk today about remote education and the new normal. And what I hope to do today is I wanna discuss the landscape of how education has really changed, and it's changed significantly through the pandemic. And we were just talking before this session about how remote learning and remote reading was sort of seen almost as taboo 10, 20 years ago, but now we've all embraced it and adopted it as something that is very profound and something that can really be helpful and beneficial. I'm gonna talk a little bit about the pros and cons to remote education and offer a little bit of insights in future expectations for training programs in radiology. So if you take a look at this picture, now this is just 20 months ago. And if you look at how radiology was taught, it looks nothing like this now, right? And literally 20 months ago, this is exact. If you were to come into a radiology residency training program, this is literally what you would see. You would see somebody standing at a podium teaching, you'd have residents sitting there, very close next to each other, taking notes, et cetera. This is more of what modern radiology residency looks like. This is a really profound change in the way we're teaching and educating. You may have a resident learning from home, somewhere else in the hospital, they're on Zoom, they're multitasking, they may be sitting with their dog, they're a child, very different than what we saw just 20 months ago, which is amazing. It's fascinating that the pandemic has caused us to rethink everything that we're doing and what we're doing and how we're doing it, quite frankly. There was a major transformation that occurred. So this idea of video conferencing, whether it's through Zoom, Webex, Dr. Shah talked about Microsoft Teams, this has really come to the forefront, forcing us to use different mediums to educate effectively. Asynchronous models, meaning giving people videos to look at at their own time or at their own leisure has really been very popular during COVID-19. And the major thing that has occurred that is still occurring now are the idea of virtual readouts. That was unheard of. Remember, this is all normal for us now, but that was unheard of 20 months ago, right? Like we would always be in person, sitting next to each other. If you think about the time that you were a trainee, you were always sitting next to your attending. But now most of the trainees or the residents, fellows that exist now in modern radiology departments are reading out virtually, or at least part of the time they're reading out virtually. There are many benefits to remote education. I'm only going to cite some of them because we have only a certain amount of time, but one of the major things that's occurred is that global education has really thrived in this atmosphere. So we've been able to disseminate knowledge all throughout the world. And for example, things like MRI Online, the APDR noon conference lecture series, Health for the World, these were all platforms that allowed radiology to thrive and knowledge to be disseminated throughout the world, throughout hundreds of countries. And this free access of knowledge really decreased the disparities between different societies in terms of gaining access to high level education and training. Because of virtual readouts, a lot of new opportunities have occurred also in radiology that we never thought were even possible, quite frankly. So for example, if you were, you know, two years ago, if you were on an MSK radiology rotation, chances are you were only reading and learning about MSK. But now you can literally be at home, join a Zoom call for MSK, but then when that's done, you can join an abdominal Zoom call, or then you can join a nuclear medicine Zoom call. You know, so there's so many more opportunities for residents to learn, even on a daily basis, which I think is very important. Even if residents, for example, are on vacation, or if they're attending RSNA like today, they can literally go on Zoom and join a readout that's occurring right now at their home institution. So, you know, there are so many opportunities now to enhance education. And as we all know, you know, at least for me, you know, the saving commute time is a huge benefit to remote education. People are not wasting time, you know, traveling to, you know, for me, it's 30 minutes one way, 30 minutes, so it's an hour a day for me, traveling to University of Maryland. So, you know, that's a huge factor, even for quality of life standpoint, you know, to spend time with your kids, your family, all that stuff is very important and meaningful. There are also indirect benefits for the virtual readouts, one of which is, you know, programs can have more trainees in their departments because, you know, there's less space constraints. Now, because things are remote, people can be sitting in their homes, they can be sitting in other rooms in the hospital, and they don't need, you know, workstations for every resident. That can have profound implications for, you know, the amount of trainees that exist in a specific radiology residency program. Faculty have been more productive. We saw in the literature, if you ask any editor-in-chief, you know, they've seen exponential increase in manuscripts during the COVID-19 pandemic because people have more time to actually write about the things that are dear to them and are special to them. So all these things have occurred because of COVID-19. Now, there are obviously cons to remote education as well. And the question is, you know, can we ever really replace in-person learning? And, you know, my opinion is we obviously cannot, right? There's something very special, very dear about in-person, innate, you know, face-to-face education, that the idea of, you know, mentorship, seeing someone, seeing someone's humor, seeing their humanity when you're sitting right next to somebody, you know, that can never really be replaced, right? You know, those relationships that we make, if you think back to the time that, you know, the people that have had the most profound impact on you and your education, you know, that one-on-one teaching is very special. And I think that, you know, it's almost like something gets lost in translation, right, when you're reading remotely. So that, I think, can never be replaced, but, you know, remote education has had profound impact and implications on other things in the sense of education. So let's take a poll right here. So, you know, from the people that are sitting here, you know, what statement best represents your sentiments with respect to virtual readouts and radiology? Is it, who thinks that by a raise of hands that virtual readouts enhanced radiology education? How many people feel that that's your sentiment? Okay, so I would say about 15 to 20% of people think that's true. How about virtual readouts neither hindered nor enhanced radiology education? If you feel that that's true, raise your hand. Okay, that's another 20% of people, okay. And then how about virtual readouts hindered radiology education? Raise your hand. Okay, so that's about 30%. Okay, so 30% of people didn't vote, but that's good. 70% of people did, so I'm glad people are staying awake. That's excellent. All right, so we actually did this poll to our residents at University of Maryland, and we distributed this poll throughout the country through an APDR, AQCR Square survey. And the results at my institution and nationally were virtually literally identical within like one percentage points for each question that we asked for both faculty and trainees. And the majority of people want to have like about 51 to 52% of trainees want to have a hybrid system, which is a combination of in-person and virtual readouts. But I think it's interesting to note that 46% of trainees actually preferred strictly in-person readouts, which means that they did not want to have even any virtual readout. So I think that that's an important thing to remember. And 36% were opposed to even hybrid readouts, which were a combination of in-person and virtual readouts. And when we asked faculty, they had similar perceptions, but slightly less. So 38% of faculty preferred only in-person readouts and 29%, so almost a third of them were actually opposed to hybrid readouts. But again, the vast majority of faculty and residents preferred this hybrid model that already exists, you know, kind of moving forward. So there are some cons to virtual readouts and the major con seen on the survey was it was harder for trainees to ask questions during a virtual readout, that they had concerns about being able to ask their questions that, you know, when they were in person, they felt more comfortable doing that. And that's a real concern because when we're training residents, there should be a nice safe environment for people to ask questions. And if their questions aren't being answered, are we really doing our trainees a service? So the future is undoubtedly this hybrid model that already exists at major modern, you know, residency programs, fellowship programs, this hybrid model already exists. So whether it's in-person and virtual lectures or in-person and virtual readouts, they are occurring. This RSNA, it's in-person and virtual. We just had a virtual lecture, now I'm here in person, right? So even this model is already being perpetuated within our society meetings. And I think that's gonna continue, you know, indefinitely. So the future, our departments have to invest in these resources to sustain this type of model. And what do I mean by that? What I mean is that, you know, first of all, there has to be a culture where trainees are able to ask questions very safely. And that it's not an issue if trainees are asking questions and we have to sort of allow them to do so in a very safe manner. There needs to be more engagement when we do remote learning. So, you know, obviously, you know, they're not in front of us, so it's a little harder to engage trainees. So, you know, having things like audience response, asking questions, having the camera on so that we can see facial cues and facial gestures. Those things are all important. Those things all add and increase audience response and engagement. We also need to optimize the IT infrastructure when we do these type of things. So for example, I can't tell you how many times I see virtual readouts and only one screen is being seen. But in person, we see the current study and the prior. So there needs to be split screens for trainees to see both the current study and the prior for the session to be optimal. There also needs to be two-way share screen, right? So oftentimes, if I'm the attending, I'm sharing my screen, but my trainee can't share his or her screen, right? So that's a problem. So the trainee should also be able to share their screen in order to optimize search patterns and to go through a study. So all these things I think are very important for us to invest in to make the learning as optimal as possible. The bottom line is the future is bright. Let's embrace it. This is what's going to happen for the next years and decades to come. So I think it's great. And I think it's really revolutionized our practice here. Thank you so much for your attention. All right. So I'm going to be talking to you about the new normal homework stations from the private practice perspective. A little bit about me though, I'm not entirely private practice, although I absolutely love what I do in Radiology Partners. For Radiology Partners, I'm a member of our matrix teleradiology practice. And I'm one of our POD or regional presidents. I'm also the director of innovation engagement for our national practice focusing on AI implementation. But I actually share my practice with both academics and private practice. I'm also a clinical assistant professor for Stanford Nuclear Medicine and do my work for Stanford entirely remotely as well. All right, no disclosures, no perceived direct conflicts of interest, but I do conduct all of my work from home. Academic, private practice, and all of my research and industry consulting is all from my home office. So certainly I do have an interest in making sure all of this works. Just a little brief housekeeping slide. You absolutely have my permission to take pictures of any of the content of this lecture. I always put this in all of my presentations just to start a culture of continuing a conversation across our digital media platforms. So what are we going to cover over the course of the next less than 10 minutes? I'd like to talk a little bit about the variability of practice setups, review some of the pros and cons of practicing from home with a private practice lens, talk about equity, because I always like to bring diversity into the conversation, and then really briefly visit the impact on both clinical and business landscapes today. So variability of practice setups. We talk about shades of gray across CT scans at least, and it's not a binary type of practice. You're not all telerad or all in the hospital or in a private practice imaging center. There's really a wide range of options and it's a choose your own adventure type possibility. You can have 100% remote practice like we are with matrix teleradiology. You can be 100% onsite like some traditional practices still are. But really there's a middle ground with endless possibilities where a portion of your practice can be remote or a portion of your practice can be onsite. And there are so many different ways you can make up your team. And really that doesn't need to be a set percent setting throughout the course of the day. There are varying practice models that can work over the course of a workday. So some practices like to be all 100% boots on the ground during the day, but then they switch to a teleradiology or remote reading setting at night. Some practices have a general rad onsite during the day, but then they access subspecialty reads with remote readers for different types of subspecialty needs that the hospital or the client may have. So it's important to be flexible to really consider the possibilities and know that your practice can really fall during any of these shades of gray. It doesn't need to be binary at all. The question is, how do you build your team? So I love this breakdown of intramural and extramural. It's a nice definition to sort of give us language and tools to talk about what teleradiology teams may look like. You can have a teleradiology team that's intramural or intra-organizational, which means that the radiologist is associated with the organization that acquires the images and cares for the patient. Or you can have an extramural team where the teleradiologist is not directly working for the practice that's affiliated with actually acquiring the images. And really there's pros and cons to both and both work great. It just is a question of what's going to help you deliver the highest level of patient care and really serve the needs of the diverse patients that depend on us. So let's talk about pros and cons. I'm an optimist, so I like to start with the pros and then we'll kind of address the other side of things. The first thing I love is that you can work outside the box, right? Take someone like me, a totally non-traditional working in both academics and private practice and able to do it all entirely from home. I like to think of the box as that traditional reading room in the basement of the hospital. We don't need to be in that box anymore. We can really practice at a very high level of care from anywhere. Meeting the personal and professional needs of the team is another major pro. Many, many different radiologists have different needs that revolve around their life circumstance, their personal needs, their professional needs and allowing people to practice in a variety of different settings and environments will meet the more diverse needs of your team across a practice. Fostering diversity in radiology is huge. I actually gave an entire talk at this meeting about how flexible work arrangements help to really build the advancement of women in radiology. Diversity is still a big problem in radiology and a conversation that needs to be at the forefront and we found that having more flexible work arrangements such as remote reading or teleradiology really does help the advancement of women and underrepresented minorities across radiology. Building a culture of work-life balance is critical. As we just heard from the speaker before, cutting out that time gives you back hours in your day not only for educational activities but to do lots of fun and interesting things. Myself, I don't work at a hospital, I work at home so my lunch break every day is going to the dojo to practice martial arts. I would never ever be able to do that if I worked on-site at a hospital so it really has given me back my own work-life balance and made my life so much more rich. And I put this redefining excellence in patient-centered care because even though we're not at the hospital, we're still able to deliver very, very high level of care. It's just about embracing all the different ways of communication that we have. I have incredible, wonderful, rich conversations with my referring providers, with my patient's care team, all from my home office and because I'm able to focus in this wonderful environment, because I'm able to be myself, because I'm not stressed, I'm really having a very high-level discussion with my patient's care team and able to redefine excellence in the patient care center. So let's talk about the cons and actually you can take all the pros and just flip them. Nothing is totally perfect. There's always two sides to everything. So working outside the box, yes, we're no longer in the hospital in that nicely controlled reading room but as we saw from Samir's presentation, now we're navigating new and challenging spaces. Myself, I've got three little boys running around at home and I definitely understand the importance of having those barriers. Meeting personal and professional needs. Yes, you do meet new needs with the teleradiology or remote reading environment but now your team has different needs that need to be creatively addressed, right? Your radiologists may have different needs that are individual and depending on their unique circumstance for their home office and as a leader in that space, it's really your job to help them meet those needs and find an environment for them that can help them excel. Fostering diversity. Of course, we know that flexible work arrangements do help advance women and underrepresented minorities across radiology but we also need to make sure that as we're making a major change to our work environment, we're gonna ensure these new methods of connection don't contain things like unconscious bias that don't allow for microaggression to sort of leak into spaces and we really wanna protect our new digital forms of communication to make sure that we have advancement for all members of our practice. That takes a lot of awareness and actually formal education and training to make sure as we move into a digital and remote space, we continue to really support one another across the diversity of needs. Building a culture of balance. So like I said, I have wonderful work-life balance because of my work-from-home arrangement but you also need to learn to set healthy boundaries, right? A couple of our rads at first when they move to home can struggle with when do you stop? When are you off work? And how does it not sort of just continually leak into the hours of home because you're already home and you could do one more hour or two more hours. You really need to learn to set those healthy boundaries and not only work when you're at work but then learn to be home and learn to be off work when you're off work. And then redefining excellence in patient-centered care. We often talk classically about the radiologist as the doctor's doctor. We need to learn how to now become the doctor's doctor in the new era across new digital and technology spaces even though we're not physically sitting in that hospital anymore. And that's really about embracing new forms of communication and learning to be a very effective communicator when you're not face-to-face when you're using a different form of communication. So let's jump into equity which to me is at the heart of everything I do and such an important element to bring into this conversation. First, the dangers of disruption. So what is a disruptive technology and what is the potential for it in terms of how we practice medicine? I would argue that the COVID-19 pandemic was truly a disruptive event in all of our lives. An interesting thing about disruption is it forces change in people that were normally resistant to change. And we brought in new technology and new advancement in different ways of connecting digitally. And certainly there has been tremendous breakthrough in new technology that's enabled work from home faster and more efficiently. But the problem with disruption is it can do two things. It can either deepen healthcare inequities or lessen healthcare inequities. And I think as we learn to evolve in this new era and more and more of us take on flexible work arrangements, we need to make sure to lessen healthcare inequities in the process and not deepen them. So what is health equity? What does it mean to us and our patients? Certainly we're all familiar with the access to care issue and the benefits of remote reading in terms of access to care and providing care to underserved areas. But I'd like to flip the conversation just a second. A lot of people say that patients perceive health inequity as looking at their team of care providers and they want to see healthcare providers that they can identify with. And they wanna see a diverse team that reflects the diversity of their patient population. So taking it back to the conversation on how flexible work arrangements really can help the advancement of women and underrepresented minorities, we really need to make sure that we continue that advancement because then we create a diverse team that our patients see, that our patients identify with and that are better positioned to care for our diverse population in the years ahead. And this comes really out of the session that I gave before. This is actually a picture of me with my son that wasn't feeling so well and curled up in my lap while I was reading studies one night. Really, when you look at the COVID-19 pandemic and the impact particularly on women inside of radiology, there were new strains and new challenges to take on as a lot of kids were home from school. They had more work demands, they had more home demands. And there are new challenges to sort of address and have that conversation about. I think it really put the spotlight on all the challenges of balancing family and work when you work from home. And I think this is an important conversation for us to all continue to have because it really does play into our physician wellbeing, our sense of burnout and certainly our own professional advancements. So pivoting a little bit, impact on clinical and business landscapes. So I was doing a bunch of pre-reading for this presentation and I came across this paper from 1998. So that's quite some years ago. And you'll see the summary is really relevant to right now today. It says private practice deals with delivery of high quality timely service. In order to be successful, we must really clearly define our objectives and find solutions that are proven to meet these objectives. But there's one thing that's different in this and that is the focus is really all entirely on speed and efficiency. And I think we've grown a lot over the last 20 years. Certainly we've mastered the speed and efficiency piece but now when you look at papers published in 2021, they're a lot more focused on moving from volume to moving to value, right? The ACR imaging 3.0 conversation. We know we've got the speed and efficiency piece down. We know our tips and tricks but now we think about, okay, holistically, how is this impacting the art of delivering excellent patient care? How is this impacting our wellness inside of radiology? And how can we create a more holistic picture of what work from home is and how it's gonna really reshape the future of radiology moving forward? So what do we need to do and how do we need to continue to shepherd this movement from volume to value? We need to continue to sharpen the focus on quality patient care and physician wellbeing. Yes, metrics matter and speed matters and efficiency matters but we also need to make sure the quality of the care that we're delivering is truly excellent and that our physicians are healthy and happy in their work from home environment. And what do we do? This is a business conversation too. We need to understand the return on investment. We need to understand the value that happy, healthy physicians and excellent patient care brings to all of our health systems as we continue to build out these business models in the teleradiology setting. And then we can evolve the landscape really around what matters most because ultimately, healthy, happy physicians delivering excellent patient care is a great business model and really creates a wonderful and bright future for radiology for the generations to come. So in closing, practice radiology outside the box, right? We can move outside of the box of the basement of the hospital and consider a variety of endless opportunities of practice settings. We really can take our challenges and turn those into transformative growth and that's really what we try to do every single day in the teleradiology setting as leaders. We want to embrace positive disruption but we want to use it in a way that it lessens healthcare inequity and it builds a more diverse team. And how do we do that? We really focus on building value in line with patient-centered care and physician well-being. I have my references here and you can certainly access them online if you're interested in reading those papers. This is my reading room assistant, Quartz the Cat. And I thank you for your time and attention and I really look forward to our discussion. Thank you. Thank you, Dr. Hawk. Had a great statement of look at the past and build the future. So I'm really gonna be talking a little bit about that. Going to wrap up our session before we allow time for Qs and As. Going to briefly reflect on the changing landscape overall. We alluded to a lot of it in our prior presentations. So for today, I'm going to briefly take us through the past, present and future of teleradiology really marked by the COVID-19 pandemic which marked a major shift as we know in how teleradiology is viewed and performed. This timeline is going to highlight some of the major events and publications that came to effect teleradiology. As we said, really teleradiology had its origins prior even before the 1990s, but in the 1990s is really when it took root. ACR came out in 1994 with a resolution that state licensing boards should require licensure for out-of-state physicians for the state in which studies were physically being performed. In 2005, the ACR formed a task force on international teleradiology, studying legal, regulatory, reimbursement, insurance and so on. Issues associated really with the practice of international teleradiology. You know, at that time really interpretations were generally outsourced and really when we're talking about this, we're talking about external teleradiology. And so really different than what we're discussing today is teleradiology today no longer fits that sole definition. After this was published, you know, external teleradiology itself continued to grow for after hours interpretation predominantly and literature suggests that it really peaked for that purpose around 2010. In 2012, the ACR task force on teleradiology itself was formed with updated guidelines then published via a white paper in 2013, emphasizing really that patients are the primary focus, onsite coverage is preferred, high quality standards should be maintained of course and credentialing privileging should be performed in a uniform process. So since then there was slow evolution of teleradiology but as we know the COVID-19 pandemic truly hastened immediate workflow changes leading to many practices adopting or enhancing teleradiology of some sort in their own practice. As the pandemic continues now but has lessened somewhat in severity, the question really becomes what might your practice look like post peak COVID-19? What changes are here to stay and what are not? How might teleradiology really be incorporated into practices or not? These are all questions that many practices are facing now. So delving a little bit quickly into the details of the past, I'll start by again noting that teleradiology was performed predominantly for outsourcing after hours work originally, a so-called Nighthawk service as emphasized here by two different types of Nighthawks. Furthermore, the overall opinion really regarding teleradiology bluntly was quite negative with concerns honing in on commoditization of radiology, lower reimbursements, predatorial displacement of radiology practices, encroachment by other specialties, potentially lower quality reads, decreased face time with patients, lack of proximity to technologists leading to QA, QC issues and regulatory credentialing burdens. These are all important things that I think we should talk about and not really shove under the rug. But things have been changing, right? So leading up to the pandemic, there has been growing acceptance and penetrance of teleradiology. We can all know that there are several advantages that we've discussed today, covering volume demand, supporting staffing shortage, adding dedicated high quality subspecialty expertise for 24-7 coverage, improved access for rural, critical or other underserved populations and potentially improved turnaround time. So we've really seen a shift from these external utilizations to more of an internal utilization and therefore less outsourcing, which was one of the very concerns brought up previously. So leading up to the pandemic, teleradiology now in the last couple of years, even before the pandemic hit, teleradiology was shown to be everywhere in a variety of settings, a variety of subspecialties. We really have to face that this is true. Even back in a study in 2003, Ebert and all showed that about 15% of practices were using external teleradiology. Although 67% were using teleradiology, including internal and external overall. In a more recent study by Ebert and all, by ESR, there was general consensus of widespread adoption of internal and external teleradiology across practices in Europe. Finally, right before the pandemic, this study, which I've also previously referenced, it showed 77.7% of respondents in an ACR survey showed utilization of teleradiology. So you can see it's here. The most common perceived challenge to teleradiology implementation as seen in the survey was accessing patients' electronic health records. Furthermore, smaller practices overall were less favorable of teleradiology, mainly because they were less likely to agree with the advantages of teleradiology and certainly faced larger implementation challenges. So what happened then in really the present? So when COVID-19 hit, we all know the story by now, we've discussed this before, but there was really a rapid transition, right? There was a rapid transition and a rapid need for remote capabilities. So what really happened was suddenly all practices needed to consider remote usage, many of which had not even looked at this before. This was inclusive of academic and private practice and really led to increased internal teleradiology. So as alluded to before, this subsequent rapid impact really required acceptance by leadership, really buy-in by stakeholders, necessary IT infrastructure developments. This altered our educational approach, as Dr. Alwin said, altered our multidisciplinary approach to how we communicated with referrings at tumor boards, team meetings with each other and altered our workflows. During this time, multiple studies were also performed regarding the use of remote reading during the pandemic and one in particular by Kaurishi et al, although the sample size is a little bit on the smaller side, 174, they really showed that there were actually the following results. 65.2 respondents began installing new home workstations, 73.6% respondents switched normal daytime shifts to internal teleradiology. And there was really no increased dependence on external teleradiology seen. Furthermore, they found that 55.9% respondents perceived enough benefit to continue workflow after the pandemic. So they noted that there were decreased stress levels, improved or no change in turnaround time, no change in rapport with other physicians, although it is to be seen that there was a minority which perceived decreased rapport in hospital owned practices and academic institutions more so than private practices and community institutions. And they found that there were decreased interruptions. Overall, there were some other trends noted, private practices more than hospital owned practices were favored continuing teleradiology in the workflow post pandemic and community institutions over academic institutions also agreed with this. So what does this mean for us moving forward? There are really some big key points that we've all talked about today. Like it or not, radiology is changing. Although this may be up for debate, I do believe that adaptation is key to survival. We're already seeing adaptation out of necessity from market forces, generational gaps, culture change. We've seen that there's an increased number of job applicants and current radiologists really requesting to work from home. Additionally, as a result and in response, job offerings have been adjusted significantly really to attract candidates as volumes have returned and the job market has tightened. We're seeing this across the board. So I really agree with the rest of my speakers that we have the opportunity here as radiologists to really mold the path forward for teleradiology. This includes amplifying the advantages that we've already discussed, increasing access, but really this has to be a collaborative effort. We've already seen a lot of benefit in rural and underserved areas with teleradiology mobile imaging, but we need collaboration with urban centers, with academic hospitals to access specialist services. And with a coordinated effort, I think this could really improve our patient care. We've all discussed burnout. Burnout itself is so prevalent that we are all tired of hearing about burnout. I know a lot of people didn't even wanna give talks on burnout because they're burnt out of being burned out. So there's a reason for this though, right? And the way we have traditionally worked is not sustainable. We're facing continued demands, both externally and internally. And there are some real opportunities for us here to address them head on. We've already seen that teleradiology can help decrease onsite call burden, can decrease overall call burden, lead to scheduling flexibility as Dr. Hawk was just showing, family-friendly work environment, and decreased burden truly will lead to decreased errors and better patient care. However, again, like I said, we have to combat some of the known disadvantages. Social isolation more than ever has been exacerbated during the pandemic, which affects things that are possibly less tangible and perhaps less measurable. As Dr. Shah referenced earlier, now instant messaging is such a key part of most teleradiology practices already. Even within non-teleradiology practices, many PACs and the such have the ability to chat cases, other messaging systems. So there are built-in functions for many practices. However, this also is important to note that culture and morale of individual practices are super dependent on leadership. We still need team building, we still need team bonding, we still need career development. All those things must still exist. And this is not to say that everything should be remote. There still needs to be in-person contact. We've also talked about communication problems in the teleradiology world. Lack of face-to-face communication with certain patients and with consulting physicians. There are already many systems which have started using video-enhanced consultations. Furthermore, there have been models developed for discussions with patients. Today at all, this year have shown that point-of-care virtual radiology consultations are not only possible but successful and received well by patients. Patient empowerment and shared decision-making keeps growing and growing to the point that radiologists really need to learn that we need to take a vital role in this. So beyond just that, some practices have already incorporated video consultation for things such as remote breast imaging and also between radiologists with technologists for QA and QC issues. Unsurprisingly, technical implementation still remains a challenge, particularly in these days of short staffing. And this is something that we still need to face head on. So as we heard today overall, just to summarize, balancing the advantages and disadvantages, understanding how to best utilize teleradiology is really the crux of the problem as we go forward. There are several areas of impact by teleradiology which we need to continue considering and debating. What is the impact on education? As Dr. Alwyn mentioned, hybrid structures allowing for a mixed focus and a mixed approach may be in our future. What is the impact on the specialty and what is the value of the radiologist? This is something that comes hotly debated. Market forces continue to change, practice structures are changing, so what is the value of the radiologist? Are we not educators? Are we clinicians first? We all have different roles and more to that, there may be an opportunity for a more patient-facing role that we didn't have before or have lost over time. The impact on practice group structure, as Dr. Hawk was saying, equity and equity concerns are certainly something that we struggle with and continue to try to solve. And then finally, quality assurance and quality control. Not all teleradiology practices are equal, we all know this, but we must have a good grip on QA and QC. As time moves on, we'll have also the opportunity to integrate with more and more AI tools, improve integration with patient data, increase utilization of remote reading, which will draw a growing market as well for AI enhanced workflow. And as we know, remote communication tools are vital. And we cannot forget about cybersecurity. So the reading room of the future, how do we see this? Roles of radiologists are being reshaped both in the academic world and the more corporate world. There is an emerging role for radiologists to be patient-facing consultants and take back that value. In my opinion, one size does not fit all. All teleradiology is not created equal. And furthermore, I'd like to emphasize that I do not think teleradiology obviates the need for an onsite radiologist. So in conclusion, teleradiology, when appropriately delivered and supported, I believe can help improve much needed access to high quality patient-centered care, relieve physician burnout, and work synchronously with onsite radiologists to fulfill the diverse missions of the specialty in a new era. I have a lot of references here, which are happy. You can definitely take a look at after the presentation.

teleradiology

radiology

COVID-19 pandemic

remote work

global access

diversity

education

technology

patient interaction