Alarm bells ring louder over UK radiology capacity crisis

The UK media has published increasingly worrying details of the country’s radiology capacity crisis as the nation continues on its uncertain path towards Brexit.

Research released on the International Day of Radiology revealed certain shortages of imaging equipment and qualified radiologists had left an estimated 56,000 angina patients without access to potentially life threatening computer tomography (CT) scans in 2017.

The figures, from the Royal College of Radiologist and the British Society of Cardiovascular Imaging, showed at least 132,080 CT coronary angiography scans should have been performed in 2017 but in reality, just 75,791 tests were administered.

Meanwhile, the BBC claimed a study by Adrian Crompton, Auditor General for Wales, had found Welsh radiology services were “unsustainable despite being well managed and meeting waiting times.”

Wales is supposedly the only nation within the UK where imaging waiting times have improved, according to the British Government. Even so, there is a risk that progress could be undone because of ageing equipment and struggles to recruit and keep radiology staff, the BBC said.

Injecting innovation into everyday technology

Much is being said these days about the potential impact of artificial intelligence (AI) on our profession.

This is supposed to be one of those transformational technologies that will forever change the way we work, hitting radiology with all the force of the printing press bursting in on the 15th century publishing world.

Indeed, there is little doubt that AI could have a significant effect on our practice, although perhaps not in the ways we expect (see below). Is it really as important as today’s headlines make out, though?

Interestingly, recent research by Geoffrey Rubin of Duke University and Richard Abramson of Vanderbilt University School of Medicine suggests smaller-scale innovation may be just as critical to our work.

In an article published in Radiology, Rubin and Abramson say: “Incremental innovation remains an important tool for preserving and growing radiology practices within a dynamic marketplace.”

They define incremental innovation as “the process of making improvements or additions to an organisation while maintaining the organisation’s core product or service model.”

Examples might include incorporating new best practice methodologies into workflows or exploiting new teamworking tools.

Unlike the adoption of AI, which may only be appropriate to big-budget institutions in the early stages, this “is accessible to practices of all sizes and must not be overlooked if practices are to maintain their competitive advantage,” they say.

The study raises interesting questions for our profession. Few would argue that we need to move with the times, but at what pace? And with what size strides?

Put another way, a too-strong focus on big-bang innovation could compromise quality born of tried-and-tested procedures. Meanwhile, a failure to keep up with everyday advances could similarly hinder progress towards better patient outcomes. Striking the right balance is not easy.

The task is made harder by the fact that some barriers to innovation are cultural or social rather than technical or economic.

Take teleradiology, for example: it has been around for long enough to be considered just another item in the radiology toolkit and yet continues to be viewed with suspicion by some.

A more innovation-friendly approach would perhaps be to accept the reality of teleradiology and look at the best way of integrating it into current practice. In time, it may be that the same goes for AI.

When it comes to innovation, perhaps the question is not whether or not to adopt it, but how best to make use of the benefits it may offer, on a scale that is appropriate for each team and institution.

As Darwin noted, organisms that do not evolve tend to die out, but evolution proceeds in small steps, not giant leaps. What step would you take to keep your practice evolving today?

 

“Common sense is a superpower”

“Common sense is a superpower.”

This throwaway remark, by an Australian academic general practitioner during a seminar at the Preventing Overdiagnosis conference in Copenhagen in August this year, really got me thinking.

I’m sure he says it often at such meetings, and most listeners ignore it, but for me it was a light-bulb moment. To a proportion of my radiology colleagues, it is a good estimate that at least 50% of the imaging we do in the UK is unnecessary.

To a proportion of the clinicians who refer cases to us, meanwhile, it is clear that too many scans are being done.

So when I receive what I think is a dodgy referral and phone the clinician responsible, I appreciate that often, in the absence of any good evidence base for not doing a particular test, I am appealing to their common sense. I’ve been doing this for many years.

There are colleagues, senior and junior, who immediately get what I’m saying, agree with my point before I’ve even finished, and cancel the pointless test.

There are others who will justify their request based on some misguided notion that they must rule out the tiny possibility of some rare and life-threatening condition, with huge medicolegal ramifications if they get things wrong.

With these people, we might as well be speaking a different language. We are never going to agree, and they will forever view me as being unnecessarily difficult.

Similarly, there are radiologists who, as I do, despair about the 10% annual increase in scanning demand and the huge rise in out-of-hours scanning. Yet others seem not to question whether what we’re doing makes any sense.

They want to buy more scanners and employ more staff. Yet the most recent Royal College of Radiologists (RCR) census shows how workload has increased without a commensurate increase in staffing.

Dr Nicola Strickland, the president of the RCR, rightly bemoans the gap between the numbers of applicants and funding for radiology posts in the UK. There is an estimated £116m spent on outsourcing that could be diverted to training and employing more radiologists.

This is not to say outsourcing is bad. The position of medical leaders in UK teleradiology is and always has been that there is a demand for outsourcing, and we should try to meet that demand. However, it needs to be treated with common sense.

Some client departments know this: they have tight control of job plans, using their own radiologists and reporting radiographers flexibly to maximise productivity, and plan their outsourcing in advance.

The most sensible departments even have a radiologist whose role it is to guarantee value for money.

However, others will phone teleradiology providers the week they have a problem, wanting to throw work at us with a tight turnaround time when teleradiology capacity is also low.

Teleradiology providers have been accused of cherry picking when they turn down this unexpected workload. The truth is that the medical leadership of all teleradiology departments would welcome a common-sense approach to the use of their services.

Through the TMC Academy, Telemedicine Clinic has offered to work with the RCR to contribute to educating the radiologists of the future, helping to increase trainee numbers more cost-effectively.

With better-staffed departments, TMC would then provide strategies to balance any outsourcing against local demand and capacity, reducing dependence on its services to a responsible level and allowing it to support departments more effectively.

When I read the annual RCR census and the commentary on it which reaches the national press, I am proud of my college for collecting and publishing such robust data, but I am always disappointed that the appropriateness of this huge increase in imaging is no longer challenged.

The big message from the College is that more and more money is wasted on outsourcing, and that it could be better spent. The implication is that outsourcing companies are a financial drain preventing the appointment of local radiologists.

In contrast, I’m convinced that if client departments were encouraged by the College to work closely with teleradiology suppliers to better manage their own capacity and control demand, as we already do out-of-hours, we could reduce dependence on outsourcing reports.

If we can harness this superpower called common sense, and teleradiology companies’ wide-ranging expertise is exploited, we can reverse many of these worrying trends.

– George McInnes

Opinion: heeding the RCR’s capacity calls

By Dr. George McInnes, Consultant Radiologist at Poole Hospital

As we all know, capacity challenges seem to be an ongoing feature of the European radiology scene. Far from nearing a resolution, though, in some markets the situation appears to be getting worse.

Perhaps nowhere is this more the case than in the National Health Service (NHS) bodies of the UK.

The main UK organisation tasked with sounding the alarm over radiologist shortages is the Royal College of Radiologists (RCR), and it is hard not to miss the sense of growing panic accompanying many of its recent announcements.

In December, for example, the RCR blasted a cancer workforce plan published by Health Education England, an executive non-departmental public body of the Department of Health. The trainee doctor numbers envisaged in the plan were “a drop in the ocean,” said the RCR.

The College’s president, Dr Nicola Strickland, said the RCR was grateful of a commitment to fund 35 new clinical radiologist training posts per year, but pointed out that imaging departments across England already had more than 300 vacant radiology jobs.

The extra trainee posts “will only scratch the surface,” she said.

Against this backdrop, the RCR was understandably supportive last month of a plan by NHS Scotland to go on an international recruitment campaign with the aim of boosting Scottish radiologist numbers by 10%.

NHS Scotland was looking to fill 32 vacancies with candidates from as far afield as Western Europe, India, Australia, the USA and Canada.

For people coming from Europe, though, the matter is complicated by seemingly interminable doubts over what will happen to foreigners working in the UK after Brexit.

In another alarming development last December, it emerged that UK lawmakers might junk Europe’s Working Time Regulations, which protect radiologists and others from working excessive hours and thus potentially increasing work-related risks.

The RCR joined the British Medical Association and other medical organisations in decrying the move.

“With health and care services under more pressure than ever before, and staff being called upon to work ever-longer hours, what is needed is proper resourcing and investment to increase our workforce, not the removal of safeguards,” said the bodies in a strongly-worded letter.

Are these messages getting through, though? While the Scottish recruitment campaign is a welcome sign, I fear policymakers in the UK are far too worried about navigating the stormy waters of Brexit to spend much time on radiology’s capacity problem.

This is leaving the NHS to muddle through as best it can. Private-sector services are helping to bridge the gap, but unless they can help train more radiologists their impact can only be short-lived. Luckily, some have taken up the training imperative.

Fans of the NHS may claim it is not right to use public money to pay for private services. Increasingly, though, there is little option: scans have to be read in a timely way or lives could be at risk.

At this rate, we may have to stop worrying about public-private distinctions and start thinking in new ways about how we deal with the capacity crisis. After all, bodies such as the RCR can only cry for help for so long before it’s too late.

George McInnes has been a consultant radiologist at Poole Hospital since February 2009 and has worked as a consultant in Glasgow, Edinburgh, Bermuda and Barcelona. His interests include interventional radiology,  and musculoskeletal MRI and his radiology experience includes plain-film reporting, CT and ultrasound. He is a clinical advisor to Telemedicine Clinic in the UK

For more insights into radiology career and life success with Dr. George McInnes, click on the box to the right to subscribe to The Bigger Image, his bi-monthly newsletter, packed with his regular insights into radiology career and life success.

                    

27% improvement in radiology reporting efficiency: sound good?

At the end of last year, we reported on a trial of TMC’s Collaborative Diagnostic Network (CDxN) in Sweden. It resulted in five hospitals in the Västra Götaland Region (VGR) improving radiology reporting efficiency by 27% after setting up an IT network to share magnetic resonance (MR) body cases across all the subspecialists. Discrepancy levels also fell by 42%, according to a recently published a case study of the initiative. The network helped VGR subspecialists who had not previously worked together to communicate and collaborate

Five subspecialists from across the hospital group were selected to carry out all first readings and then the cases were handed over to TMC for a second reading.

“VGR radiologists also received interactive, online case-based training to build up further crucial skills within MR body reporting,” said TMC’s Claudio Silvestrin, who wrote the report.

“Collaboration brought about by the network helped individual practitioners to improve their subspecialist skills in an area that until then had not yielded enough cases per hospital to allow experts to gain much experience. The VGR radiology community was comprised mostly of generalists who found themselves covering all subspecialty areas and radiologists with 300 or more reported cases achieved the highest reporting efficiencies,” Claudio continued.

What is important about this experience is that it could be replicated anywhere. The hospitals were networked via CDxN, which is available to any hospital group that wants it.

CDxN was bundled with a standard Sectra IDS7 picture archiving and communication system and Nuance Speechmagic voice recognition software. In other words, all the elements needed to achieve a double-digit reporting efficiency improvement are there for the taking.

Reporting quality: how to stay on top as you get older

Traditional lore says we get wiser as we get older. In a clinical setting, that means you would expect older doctors to make smarter decisions. So it is surprising that research published in the Harvard Business Review seems to show the opposite.

A team led by Yusuke Tsugawa, research associate at the Harvard TH Chan School of Public Health, found patients treated by older physicians “experienced statistically significantly higher mortality rates” than those cared for by younger doctors.

The finding conjures up images of creaky old medics dithering over their diagnoses, but a closer look at the data reveals a different picture. Among doctors who get to see more than 200 patients a year, there is no age difference in patient outcomes.

In other words, if a doctor has a low patient load then a younger medic, fresh out of residency training and with up-to-date knowledge of the latest techniques and technologies, may deliver better care than an older professional whose training is far behind them.

However, with a healthy workload this is no longer the case: ongoing experience, not age, is the critical factor for patient outcomes. This idea is backed up by a study from 2003 that shows surgeon patient volumes are inversely related to operative mortality.

The finding is important for radiology because it implies that being exposed to a higher volume of similar cases, for example through sub-specialisation, could help maintain reporting quality as the average age of radiologists increases.

Plus it dispels the idea that older professionals will automatically lose their touch. With access to a steady stream of sub-specialist cases, there may be no reason why the old guard shouldn’t continue to perform just as well as the best of the profession’s new entrants.

o How are reporting volumes helping you keep your skills up as an older radiologist? Let us know.

This one doesn’t seem very healthy…

We recently reported on a Spanish radiology team working with cetaceans. The patients may have been non-human, but at least they were alive… which is more than can be said for the subjects presented by a Peruvian team at the European Congress of Radiology earlier this year.

The show paper ECR Today reported how the Peruvian Society of Radiology former president Prof Jorge Luis Guerrero Gil and his colleagues had carried out extensive archaeological investigations of mummies from the pre-Incan Paracas culture.

The research demonstrated how members of the culture practiced cranial trepanation, with some even surviving to tell the tale. Medical treatment in the country has clearly advanced a lot since then, even if radiology services are still patchy, according to Guerrero.

At least, he said: “Every radiology modality is available in Lima and in large cities, especially on the coast.”

  • What’s the most bizarre application of radiology that you’ve come across in your work? Email us or leave a reply in the comment section below

The profession: are foreign experts better?

Determining whether foreign-trained doctors yield better patient outcomes is a thorny issue. You could argue that having an international background exposes medical experts to a wider range of circumstances and helps with decision making

Alternatively, you might say outsiders would be prone to miss local cultural nuances and thus might not spot vital clues for treatment. In the US, though, a recent paper in The BMJ has come down on the side of the foreigners.

The study compared patient outcomes between general internists who graduated in the US and those with degrees from abroad.

“Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates,” it concluded.

Why is this so? The authors speculate that foreign grads face a higher bar for finding work in the US, so only the best get to practice. “The fact that the international graduates outperform the US graduates in test scores in the US lends some credence to this hypothesis,” they said.

“In addition, many of the international graduates who are currently practicing in the US likely underwent residency training twice, once in their home country and once in the US.”

A further point may be that foreign medics may feel they have more to prove. Whatever the reasons, for now it looks like an influx of foreign expertise is likely to be a good thing.

  • What’s your view? How do foreign radiologists measure up to those in your country? Let us know

Radiology lives: beware of burnout

 The hectic pace of this year’s European Congress of Radiology (ECR) may have led many delegates to experience an increasingly common feeling among radiologists: burnout

“We’re working longer hours, doing more imaging studies, and because of this we feel burnout and we are losing the purpose of what we do,” warned Dr Mauricio Castillo in a video for AuntMinnieEurope.com after taking the stage to talk about the problem at ECR.

Castillo, who is professor of radiology and chief and program director of neuroradiology at the University of North Carolina at Chapel Hill in the US, noted that the American radiology workforce will be 20% less than what is needed by 2025.

Part of the industry response to this should be to attract more women into the radiology workforce, Castillo said. At an individual level, he recommended exercise and learning to say ‘no’.

Castillo himself recognised this was easier said than done: “I’m a person who has never learned to say no to anything,” he said.

The good news is that technology is coming to the rescue, with innovations ranging from reporting platforms to artificial intelligence helping to make radiology more efficient. In the long term, “the machine will help you,” promised Castillo.

o   Are growing workloads affecting your ability to deliver quality results? If so, let us know.

Radiology insight: a combination of quantity and quality

Being a medical professional in the UK is a bit like being a Manchester United player: your team is in the news every day. Unfortunately, though, with the UK’s National Health Service (NHS) we always seem to be on the losing side. Every story seems to be about a failure in our game.

This January alone, for example, we have heard more than 7,000 nurses could face the axe under secret NHS plans, the service no longer has the resources to care for our sick population and it will need £88 billion extra by 2067.

Most of this is about numbers: the NHS Confederation says expenditure has increased over the last decade, yet investment has failed to keep pace with the UK’s growing need for healthcare. This has led to a deficit of more than £2.45 billion in English hospitals alone.

Clearly, the NHS needs more money, for more staff and more resources. However, money alone won’t solve the problem. Healthcare isn’t just a numbers game. Quality counts, too. That’s a problem for the NHS, because quality comes at a price.

If the service is already struggling to recruit the number of people it needs, how is it going to make sure it gets the very best at the same time? The answer, when it comes to radiology, clearly is to get more inventive with the resources we have to hand.

According to TMC’s George McInnes, some of the measures that need to be considered in our profession, at least in the UK, include:

  • Understanding the role private firms should play. There are rightly concerns about privatising parts of the NHS, but some teleradiology players can offer a valuable service in plugging the capacity gap. Furthermore, the quality I saw at TMC’s on-call service last year was impressive.
  • Giving due consideration to radiologists’ work-life balance. Sure, everyone is under stress, but being overly stretched can lead to poor professional judgement. Furthermore, if you are under too much pressure at work then the chances are you’ll end up moving elsewhere.
  • Making it easier for professionals to gain training. Continuous learning is a cornerstone of quality in our profession, so it makes sense to give people as wide a range of training opportunities as possible, from residential courses to interactive webinars.
  • Encouraging more people to join and stay in the profession. Semi-retired radiologists, for example, have a wealth of skills… so why are we not making it easier for them to work part-time from home or otherwise continue contributing to the talent pool?

Whose responsibility is it to take these steps? It’s easy to point the finger at government, but that has hardly been a useful solution in the past and now, thanks to Brexit, it’s even less likely the plight of the UK radiology profession will be given much airtime by our leaders.

Instead, we need to take some responsibility for our own future, and begin thinking imaginatively about how we can achieve some of the goals I mentioned above. It’s not easy, but solving the quantity and quality issues in radiology won’t happen at all unless we try.

– George McInnes