ACR BUlletIn - American College of Radiology

June 2009 Volume 64, Issue 6

ACR Bulletin Bigger, Better, Stronger ACR and ARRS Unite

THE RACE FOR INFORMATION Solutions to IT hacking



TURNING THE CORNER ON CANCER

Opening new frontiers for treatment and research

BUILDING A STRONGER SPECIALTY The future beckons at AMCLC 2009

Words that deserve celebration:

You’re correct!

With the ACR’s online educational tools, you can hone your radiology interpretation skills to help you make correct decisions on real-life patients. Programs like Doctor Challenger pit you head-to-head against a fictional opponent in diagnosing tough cases in chest radiology. Plus, you can earn CME and SAM credits. How do you match up? Log on to http://campus.acr.org today and discover the online programs designed to enhance your skills.

The American College of Radiology (ACR) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ACR designates this educational activity for AMA PRA Category 1 Credits™ and SAM credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. MKT CODE: CAMPUS0609BUL 7385.3 06.09

ACR BULLETIN

bulletin

Staff

Executive Editor Lynn King Managing Editor Betsy Colgan Writers Leslie Miller Raina Keefer Design Anne Mitchell Contact Us To contact a member of the ACR Bulletin staff, e-mail [email protected]. ACR Bulletin (ISSN 0098-6070) is published 10 times a year by the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4326. The subscription price for nonmembers is $80. Single copies are available on request. Printed in USA. Copyright ©2009. American College of Radiology. All rights reserved. Opinions expressed in the ACR Bulletin are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher. No information contained in this issue should be construed as medical or legal advice or as an endorsement of a particular product or service.

www.acr.org

TABLE of CONTENTS

June 2009 Volume 64 Issue 6

Features

10 An Epic Moment

After a unanimous vote by the ARRS membership, the oldest radiological society in the United States and the College join forces to provide members more value and better services.

14 You’ve Been Hacked Viruses, worms, spam, and more! With front door and back door intruders, is it possible to stay safe in today’s cyberworld?

16 Healing Rays

Powerful technological advances enable radiation oncologists to move beyond merely controlling growth of cancer cells and relieving the symptoms of cancer to the goals of curing cancer and preserving organs.

20 Special Section: AMCLC 2009 Buzz

Excitement from the ACR’s annual meeting lingers with news about the ACR-ARRS integration, financial updates, expanding clinical research, and legislative victories.



Also Inside 5 6 8 27

Combining Forces Staging Prostate Cancer Once Upon a Podium Radiology on Location



Departments

Postmaster: Send address changes to ACR Bulletin, Attn: Membership Services, American College of Radiology, 1891 Preston White Drive, Reston, VA 201914397. Change of address may be made by sending the old address (as it appears on the ACR Bulletin) and the new address with ZIP code number. You may also e-mail address changes to [email protected]. Remember to include your new telephone number(s), fax number(s), and e-mail address(es).

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From the Chair: Playing to Our Combined Strengths ACR Headlines Advocate: Congress Considers Health Care Reform RADLAW: Protect Your Rights Job Listings

The ACR logo is a registered trademark and service mark of the American College of Radiology.

For information on how to join the College, visit www.acr.org, or contact staff in membership services at [email protected] or 800-347-7748. For comments, suggestions, or to order reprints of the ACR Bulletin, contact Managing Editor Betsy Colgan at [email protected].

ACR Bulletin ACR Bulletin is published 10 times a year to keep radiologists informed on current research, advocacy efforts, the latest technology, relevant education courses and programs, and ACR products and services. It provides a forum for members to share lessons learned, news and events, and achievements.

From the Chair

Playing to Our Combined Strengths On July 1, 2009, the American College of Radiology (ACR) and the American Roentgen Ray Society (ARRS) will undertake a James H. Thrall, M.D., smart new FACR, BOC Chair initiative together by forming a partnership to strategically integrate their activities. This initiative is fundamentally aimed at providing more value to members of both organizations by working together than can be achieved working separately. The strategic integration initiative was approved by each organization at its respective annual meeting, culminating in a formal signing ceremony on Sunday, May 3, at the AMCLC. The initiative is also described in more detail in this issue of the ACR Bulletin. The basic structures and missions of the two organizations will not change. Both will retain their independent identities and continue to engage in the activities that make them unique. In the case of the ARRS, this will mean, among other things, continuing to publish the American Journal of Roentgenology (AJR) and the AJR Integrative Imaging supplements and holding the ARRS annual meeting. For the College, it will mean continuing to be active in government relations in Washington, D.C., in carrying the message from the radiology community to members of Congress and leaders in the federal bureaucracy. The ACR will also continue its important work in economics, quality and safety, and management of

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research programs through the Radiation Therapy Oncology Group and American College of Radiology Imaging Network. Both organizations do a terrific job within these parts of their respective missions, and I hope and expect that to continue. One of the biggest areas of opportunity to break new ground by taking advantage of the combined talents of the ACR and ARRS is in continuing education. With the prospect of maintenance of certification already here for subspecialty areas and looming for basic board certification, education has never been more important to practicing radiologists. Coupled with a steady onslaught of new methods, such as breast MRI, PET/ CT, CT colonography, and coronary

exploit the major investment the College has made in the ACR Education Center. More than 700 radiologists have already enrolled in programs at the Center. The feedback has been spectacular on all accounts, but the most important observation is that the basic premise underlying the design of Education Center courses has turned out to be correct — radiologists learn most efficiently and retain knowledge the best when they are actively, rather than passively, engaged in the educational process. Immersive, hands-on learning allows radiologists to acquire and “own” new knowledge. By combining the creative abilities of those involved with education within the ACR and the ARRS, we

Leaders from both the ACR and ARRS share a vision of working together to develop cutting-edge educational programs that address these needs and do so in ways that are more efficient and powerful than in the past. CTA, the challenge of remaining up-todate has steadily increased over the years. Additionally, radiologists are being held more accountable to provide contemporaneous evidence of their proficiency, especially for procedures that may not have even existed during their own residency training years. Leaders from both the ACR and ARRS share a vision of working together to develop cutting-edge educational programs that address these needs and do so in ways that are more efficient and powerful than in the past. The ARRS will take the lead position in developing educational programs and overseeing their execution. One especially exciting prospect is the opportunity to work together to fully

should see a steady stream of new course offerings. One factor that bodes especially well for undertaking such a fundamental change, as is implied for both organizations by strategic integration, is the large number of people who belong to both societies and have played leadership roles in both and share a pride and affection for both. Discussions between the organizations leading to this point have involved many, almost invariably members of both. I am fortunate to count myself among those, and we have four people who are either current or former ARRS board members currently serving on the ACR Board of Chancellors. Please join me in celebrating the beginning of a bold new chapter in the history of radiology in the United States.3

June 2009 Volume 64, Issue 6

ACR Headlines Update on “Red Flag Rules” The Federal Trade Commission (FTC) again has delayed implementing the controversial “Red Flag Rules.” FTC has announced it will push back for three months, or until August 1, 2009, the Rules’ enforcement date. As ACR previously reported in the May issue of the ACR Bulletin, the Red Flag Rules will require ACR members and other physicians deemed as “creditors” of patients who have “covered accounts” with them to develop and implement an identity theft prevention program. FTC plans to apply the Rules to any radiologist or radiation oncologist who

renders care and bills a patient’s insurer for reimbursement or otherwise accepts payment from the patient at a later time, such as with a credit card or from a checking or savings account. However, the American Medical Association has indicated that it will try to persuade FTC that physicians should not be treated as “creditors” under the Rules. To read the news release announcing the additional delay, visit www.ftc.gov/opa/ 2009/04/redflagsrule.shtm. For more information about the Rules and how your practice should deal with them, please contact the ACR Legal Department at [email protected] or 800-227-5463, ext. 4044.

Tools to Guide Radiologists A new study, co-authored by ACR Board of Chancellors Chair James H. Thrall, M.D., FACR, found that radiology order-entry (ROE) and decision-support (DS) tools (both developed at Massachusetts General Hospital) can act to curtail inappropriate use of advanced imaging. The study is being highlighted as proof that a White House proposal to deploy radiology benefit managers (RBMs) as Medicare gatekeepers is unnecessary and ill conceived. Study results showed that using computerized DS tools to guide referring physicians on the appropriateness of ordering certain imaging studies for identified conditions reduced use of computerized tomography (CT). The DS system is built around the ACR Appropriateness Criteria® but is structured differently and is much more detailed. When ROE and DS systems were used, the CT trend line flattened out, and declines in use of magnetic resonance

Imaging Management Strategies The ACR and the Radiology Business Management Association (RBMA) have developed best-practice guidelines for third-party payers, managed-care organizations (MCOs), radiology benefit management companies (RBMs), and imaging providers for use in implementing or evaluating a Radiology Benefits Management Program (RBMP). The College does not endorse RBMs or their approach to the marketplace, as there are better alternatives. However, the College recognizes the current role of RBMs in managing use of imaging and seeks to improve the strategies used in RBMPs. The ACR is confident that, if implemented, the guidelines will result in a uniform process that would ease the administrative burden on payers, MCOs, ordering physicians, and imaging providers. These guidelines could function as benchmarks for RBM performance.

imaging and ultrasound, although not as dramatic, were still evident.

For more information, please contact Kathryn Keysor at [email protected]. To read the ACR-RBMA guidelines for RBMPs, visit www.acr.org/rbmp.

This study is must reading for anyone interested in reducing health care costs and eliminating unnecessary procedures. It could be the ammunition to counter a proposal by the Obama administration to use RBMs to preauthorize and oversee advanced imaging exams for Medicare patients. Read about the entire study in the April 2009 issue of Radiology.

Brain for Sale Remind your patients that radiologists are physicians, highlight the training of radiologists, and explain why your skills are critical elements in high-quality patient care — all with the “Face of

The American College of Radiology

Radiology” branding campaign poster. This 24-by-36-inch poster is perfect for your office or waiting room. Order yours today by calling 800-227-7762 or e-mailing [email protected].

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ACR Headlines Is Radiology Slipping?

Planning to Retire?

Although radiology is still among the top 10 most popular medical specialties, it has fallen three positions since 2007. According to an April 14 article in Diagnostic Imaging, results reported by the National Residency Matching Program (NRMP) indicate that radiology has fallen to eighth place.

A survey conducted by The Physicians’ Foundation in October 20081 provides a snapshot of physicians’ strategies for retirement. A severe stock market slide has many physicians rethinking their plans. As yet, no survey has captured how these numbers might have changed.

Top 10 Results 1. Neurological surgery 2. Dermatology 3. Orthopedic surgery 4. Emergency medicine

The breakdown of responses from 2008 follows: • 45.5 percent of physicians older than 50 years would retire if they had the financial means. • 44.5 percent of physicians 50 years old and younger would retire if they were financially able. • 20.3 percent plan to cut back in the next three years.

5. Obstetrics/gynecology

8. Radiology 9. Internal medicine 10. Neurology

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1. Merritt Hawkins & Associates for The Physicians’ Foundation. The Physicians’ Perspective: Medical Practice in 2008. October 2008. Available at: www.physiciansfoun dations.org/usr_doc/PF_Survey_Report.pdf. Accessed April 24, 2009.

1. Go to www.acr.org. 2. Click on “My Profile” (located on the top blue bar). 3. Log in using your user name and password. Your 2009 dues order information will appear (for reinstatement or payment of past dues, please contact ACR Membership [see below]). 4. Follow the prompts to complete your renewal and submit payment.

7. Otolaryngology

According to NRMP officials, more than half of all U.S. medical school seniors applied for this year’s residency program (nearly 30,000 applicants). This number may be attributable to the expansion of medical schools across the nation in anticipation of a future physician shortage.

ENDNOTE

Simply follow these steps:

6. Surgery

Applications from U.S.-based and foreign medical students and physicians for radiology residency and internship slots increased slightly more than 2 percent this year, with nearly 99 percent (1,085) of the positions being filled. Despite this growth, the annual increases have become progressively smaller in the last five years, says Howard P. Forman, M.D., FACR, chair of the ACR’s Committee on Radiologist Resources.

• 11 percent plan to retire in the next three years. • 10.2 percent plan to work part time in the next three years. • 7.5 percent plan to do locum tenens work in the next three years.

No-Hassle Renewal Renewing your membership is easier than ever with the new online renewal system.

For login assistance or dues questions, contact the ACR Membership Department at [email protected] or 800-347-7748.

Gold Medal Material The ACR Committee on Awards and Honors is seeking nominations for 2010 awards. The deadline for submitting nominations and supporting materials for candidates is July 1, 2009. Awards will be presented at the College’s annual meeting scheduled for May 2010 in Washington, D.C. Any member or fellow of the ACR may submit a nomination for gold medalist; any fellow of the ACR may submit a nomination for honorary fellow. For more information, e-mail [email protected] June 2009 Volume 64, Issue 6

Patient Safety

Combining Forces In a historic first, the ACR and the American College of Cardiology develop appropriateness criteria for cardiac imaging. By Matthew Robb

W

ith health care costs spiraling and federal regulators zeroing in on medical imaging, the ACR and the American College of Cardiology (ACC) began highlevel talks in fall 2007 to identify ways of working together. The result, a historic first, finds the two colleges developing evidencebased joint criteria to guide the use of cardiac imaging. The ongoing discussions reflect the position outlined by James H. Thrall, M.D., FACR, chair of the ACR’s Board of Chancellors. “If we don’t speak with the same voice,” he cautions, “[the federal government will] ignore us completely and regulators will do anything they want.” The ACR-ACC strategic partnership emboldened the two organizations to work toward a common cause: enhanced patient safety in cardiac imaging. Citing excessive medical imaging and federal efforts to contain costs — often with unintended adverse consequences for patient care — the ACR’s Director of Appropriateness Criteria® David Kurth says the ACR-ACC initiative seeks to “ensure that the patient gets the right test at the right time for the right reasons.” For more than 15 years, medical professionals have relied on the ACR’s Appropriateness Criteria, evidence-based guidelines that assist referring physicians and other providers in making the most appropriate imaging or treatment decision. These guidelines help providers enhance the quality of care and contribute to the most efficacious use of radiology. To date, the ACR has developed Appropriateness Criteria for 159 topics with more than 800 clinical variants. The ACR initially contacted ACC officials in 2007 about a collaborative effort on appropriateness criteria, but the work began in earnest in spring 2008. In weekly meetings, representatives from both colleges — which each had separately established protocols based on peer-reviewed, evidence-based research using a modified Delphi methodology — commenced a highly detailed deliberation on joint guidance. The ACR’s leadership is confident that the resulting joint guidelines will yield “a very strong document that will inform the government on what should be done in cardiac imaging,” Kurth says. The American College of Radiology

The ACR leadership remains aware of member sensitivities about this historic strategic initiative. Early in the process, some members questioned the College’s decision to start with cardiology, but the evolution of cardiology — and mounting pressure from federal regulators — made the ACC a logical starting point, Kurth explains. “Cardiologists are more and more involved in imaging to the point that observers often ask, ‘Where does imaging end and cardiology begin?’” The ACR has been, currently is, and will always remain “an equal partner in this process,” he says. “We are making sure radiology’s voice in cardiac imaging is as strong as that of cardiologists and cardiac subspecialty organizations.” At present, the ACR-ACC team is forming writing panels and expects to finalize the joint guidelines in January 2010. Looking ahead, Kurth says that the ACR may engage in initiatives with other professional medical specialty organizations, possibly to include programs in primary care, emergency departments, and radiology residency. “The ACR-ACC joint initiative is good for radiology,” Kurth says. “It’s a win-win for both colleges and certainly for patient safety. It is time both colleges speak with one voice, or we will surely be drowned out by a sea of very vocal regulators.”3 Matthew Robb ([email protected]) is a freelance writer.

To the Point

4For the first time, the ACR and the ACC are developing

evidence-based joint criteria to guide the use of cardiac imaging; the first document on heart failure is scheduled to be complete January 2010.

4Through this initiative, the two colleges will speak with one voice in terms of patient safety in cardiac imaging.

4The joint guidelines will inform the government about evidence-based cardiac imaging.

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Clinical Research Center

Staging Prostate Cancer An ACRIN® trial assesses a novel application of a new technology.

R

Photos courtesy ACRIN

esults of the ACRIN 6659 clinical trial (“MR Imaging and MR Spectroscopic Imaging of Prostate Cancer Prior to Radical Prostatectomy: A Prospective Multi-Institutional Clinicopathological Study”), conducted by the American College of Radiology Imaging Network® (ACRIN®), indicate that for patients who undergo radical prostatectomy, the accuracy of combined 1.5-T endorectal magnetic resonance imaging (MRI) and magnetic spectroscopic imaging (MRSI) is equal to that of MRI alone. Investigators reported in the April 2009 issue of Radiology many of the technical challenges and several of the unforeseen limitations of the trial.

ACRIN 6659 principal investigator (left) Jeffrey Weinreb, M.D., FACR, and trial central pathology reviewer Thomas Wheeler, M.D., correlate pathology with MRSI data.

Prostate cancer is the second leading cause of cancer death in American men. The American Cancer Society estimates that 186,320 new cases of prostate cancer were diagnosed in the United States in 2008 and that 28,660 men died from the disease.

Participating Sites Brigham & Women’s Hospital Johns Hopkins Medical Institutions Mayo Clinic Memorial Sloan-Kettering Cancer Center University of California, San Francisco University of Pennsylvania Medical Center University of Texas M.D. Anderson Cancer Center

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Despite prostate cancer’s prevalence, techniques for precisely staging the disease, which are critical for predicting prognosis and planning therapy, are lacking. With the advent of new and minimally invasive treatments, such as implant radiation therapy, cryosurgery, and high-frequency focused ultrasound, as well as active surveillance, more precise information about tumor location and volume and the local extent of disease is needed to improve patient care. As a result, imaging investigators have a heightened interest in identifying new prostate cancer imaging modalities and techniques to guide treatment decisions.

Image of a prostate MRI with MRSI spectrum data.

Preliminary single-institution studies have suggested that MRSI might provide useful information for increasing staging accuracy. As the trial’s principal investigator, Jeffrey Weinreb, M.D., FACR, professor of diagnostic imaging and director of medical imaging at Yale University School of Medicine, brought together an imaging research team to explore whether combined MRI and MRSI could provide treating physicians with superior information about tumor stage than MRI alone. MRSI is a multivolume technique that provides spectra from a two-dimensional or three-dimensional grid of contiguous volumes, allowing metabolic information to be obtained from a given voxel or anatomic area. “This was the first ACRIN trial that studied ‘functional’ information as well as images,” says Weinreb, “and the first to assess the new application of a new technology.”

Validating the Technique Although this combined-imaging technique showed significant promise, only a few academic medical centers worldwide had carried out studies with prostate MRSI. The next step was to validate the technique across multiple sites through an ACRIN trial. Seven academic institutions participated in the trial (see sidebar), June 2009 Volume 64, Issue 6

and researchers met rigorous qualifications before trial activation. These qualifications included participation in an intensive training workshop and demonstration of their ability to acquire acceptablequality prostate images and spectra from a phantom and three test subjects. From February 2004 to June 2005, 134 participants who had biopsy-proven prostate cancer and were scheduled to undergo radical prostatectomy were enrolled; data that were complete and that could be evaluated were available for 110 participants. After the study was completed, an expert panel convened at the ACRIN core laboratory to correlate the MRI and MRSI data with histopathologic specimen data, which served as the reference standard. Although the data analysis did not confirm the trial’s primary hypothesis, Fergus Coakley, M.D., a trial site investigator at the University of California, San Francisco, and chair of ACRIN’s Abdominal Committee, comments, “A critical trial limitation was selection bias. Because we only included patients who were suitable for surgery (in order to get pathological correlation), we were inevitably studying a population skewed to those with low risk and small tumors.” Many of the tumors detected were at or below the current spatial resolution of MRSI. Mark Rosen, M.D., Ph.D., director of the ACRIN MRI/CT core laboratory and a trial site investigator at the University of Pennsylvania Medical Center, points out that even though the expected results were not realized, “the trial demonstrates the importance of centralized evaluation of imaging data in multiinstitutional studies, especially those that involve complex correlations among anatomic, functional, and pathologic data. The ACRIN 6659 trial demonstrates the successful integration of these aspects of trial data analysis through the use of specialized imaging core

laboratory facilities.” Centralized evaluation is increasingly important as clinicians demand more precise and more detailed evaluation of cancers that are often small and subtle at both imaging and pathology. As Coakley notes, “ACRIN 6659 should not be regarded as the ‘death knell’ for prostate MRI but rather as an indicator that we still need better imaging of prostate cancer, whatever the technology or modality might be.” Adds Weinreb, “It shows that negative results, though rarely popular, are just as important as positive ones.”3

RTOG® Develops Treatment Strategies For decades, the Radiation Therapy Oncology Group® (RTOG®) has been an international leader in prostate cancer clinical research. The group’s research addresses key issues in delivery of radiation dose, combined-modality treatments for selected patient populations, and the timing and duration of hormonal therapy. RTOG investigators recently completed accrual to the largest phase III radiation dose escalation trial for prostate cancer, enrolling more than 1,500 men (RTOG 0126). RTOG members are currently enrolling patients into four phase III trials:

1 RTOG 0232 is exploring the benefit of combining externalbeam radiation with brachytherapy versus brachytherapy alone for men with intermediate risk of prostate cancer.

2 RTOG 0415 is investigating hypofractionation therapy with three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) for early prostate cancer.

3 RTOG 0521 is examining the role of adjuvant chemotherapy combined with 3D-CRT or IMRT and androgen suppression for localized, high-risk disease.

4 A three-arm trial, RTOG 0534, is comparing prostate bed radiation therapy (PBRT) alone, PBRT combined with neoadjuvant and concurrent short-term androgen deprivation (NC-STAD), and PBRT plus pelvic lymph node radiation and NC-STAD. In addition to developing new treatment strategies for men with prostate cancer, RTOG investigators, in collaboration with the American Society for Therapeutic Radiology and Oncology, held a multidisciplinary symposium on the use of prostate-specific antigen as a marker of treatment success. All of RTOG’s research efforts are helping lead the way to better treatment strategies for prostate cancer patients. Screen shot of the GE Functool application for acquiring MRSI data. The American College of Radiology

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Communication Skills

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o matter what you tell yourself, the facts you’re going to present to a room full of people don’t speak for themselves. As a presenter, you breathe life into your painstakingly prepared data and give them purpose, relevance, and direction. Your audience needs you to tell them why they should care about results, numbers, percentages, and other data.

“A classic mistake I see novices make is to read from the PowerPoint presentation, which can put an audience to sleep,” says Dilts. “But once they start telling the story, the audience starts listening.”

—Bruce Hillman, M.D., FACR

“There are some people who find it impossible not to read every word on their slides,” says James H. Thrall, M.D., FACR, chair of the ACR’s Board of Chancellors. “This drives people in the audience a little mad because they can read faster than the presenter can speak.” For Thrall, an ideal presentation matches the presenter and the audience. “The presenter has to understand the level at which an audience is prepared to listen to a topic,” he says.

“Many presenters just present the facts,” says David Dilts, Ph.D., M.B.A., director of clinical research for the Knight Cancer Institute at the Oregon Health & Science University in Portland. “You have to remember that you’re telling a story, and you need to be aware that there’s a certain pace and flow.” Dilts has given hundreds of talks around the world on topics from cancer research to strategic planning.

“For example,” Thrall adds, “most radiologists know quite a bit about the physics of radiation, but very few radiologists are experts in the kinds of differential equations and so-called higherlevel mathematics used to derive the equations that are so important in radiology. We might be interested in hearing someone tell us how to use the equations, but we would be less interested in hearing how they’re derived.”

“If you could have just two skills to make yourself successful, it would be to write well and talk well.”

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June 2009 Volume 64, Issue 6

Base of Operations Especially in scientific presentations, it’s important to be aware of your audience’s knowledge base. Because it’s not about your work; it’s about how your work relates to the work of your audience, says Scott Morgan, co-author of Speaking About Science: A Manual for Creating Clear Presentations.1 Morgan recently spoke with a physicist who was about to present his research and asked him how many other people had known about his research. The physicist’s response? Three people … in the world. “I next asked how he explains the research when he’s not talking to those three people,” says Morgan. “A great deal of preparation is in how to adjust your presentation for the knowledge base of the audience.”

“A classic mistake I see novices make is to read from the PowerPoint presentation.” —David Dilts, Ph.D., M.B.A.

a great presentation ends early and there’s food.” So if your presentation is going poorly, end early and “dismiss the class.”3 ENDNOTE 1. Morgan S., Whitener B. Speaking About Science: A Manual for Creating Clear Presentations. Cambridge University Press, 2006.

Structure Your Story Follow these steps, courtesy of Scott Morgan, co-author of Speaking About Science: A Manual for Creating Clear Presentations, to create a stellar presentation:

1. Create an 8- to 10-word presentation title.

It’s not as long as the title of an academic research paper. “I’m a big fan of colons,” says Morgan.

2. Develop a single theme. What is the key thought you want your audience to remember?

Morgan, who has been teaching presentation skills at the National Institutes of Health in Bethesda, Md., for 14 years, says, “My job boils down to teaching smart people to be clear no matter who they’re talking to.” He is also co-owner of Premiere Public Speaking, which offers one-on-one coaching sessions for a variety of presentation types.

3. Have your talk answer a single question. What

An Essential Skill

6. Prepare the introduction. Your short, tailored

In the field of medicine, it’s often impossible to go through an entire career without presenting something to someone. Even a simple departmental meeting can benefit from some presentation skills. According to Bruce Hillman, M.D., FACR, editor in chief of the Journal of the American College of Radiology and experienced presenter, “if you could have just two skills to make yourself successful, it would be to write well and talk well.”

7. End strongly and early. Consider touching on the

specific question drove your studies?

4. Include a “money” slide. This slide really brings it

home. Build the remainder of your slides around this one.

5. Adhere to the two-minutes-per-slide rule. 20 minutes equals 10 slides.

introduction should be about concepts, rationale, and logic. Ask yourself, “What are we [the audience and I] working on collectively, and how does my work relate to the audience’s work?” future direction of your research to signal your talk’s conclusion.

And nervousness? That comes with the territory. There’s no surefire way to tame nerves except to begin talking. “For confidence, I imagine I know more about my subject than the audience does,” says Hillman. Another aspect of presenting that can weigh on a speaker’s mind is how to keep the audience interested. Dilts uses an old teacher’s trick. He chooses not to use a podium and opts to move around in the crowd. “The ‘students’ have to pay attention because they never know when I’ll be standing next to them,” he says.

Coming to a Close A strong ending is another key facet of a good presentation. Keep this tip from Hillman in mind: “A good presentation ends on time; The American College of Radiology

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Participating in the historic signing ceremony integrating the ACR and the ARRS are (left to right) Anton N. Hasso, M.D., FACR, ARRS president 2007–2008; Arl Van Moore Jr., M.D., FACR, ACR president 2008–2009; Ella A. Kazerooni, M.D., FACR, ARRS president; James H. Thrall, M.D., FACR, ACR BOC chair; John (Jack) K. Crowe, M.D., FACR, ARRS president 2008-2009.

An

Epic Moment

Steps to integrate the ACR and ARRS began long ago. By Raina Keefer

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n April 29, 2009, members of the oldest radiological society in the United States, the American Roentgen Ray Society (ARRS), voted at its annual meeting to approve a strategic integration merger with the American College of Radiology (ACR). “I was thrilled,” says ACR Executive Director Harvey L. Neiman, M.D., FACR, of the vote. “It was a voice vote, and it was unanimous.” The strategic integration became official after a formal signing ceremony on Sunday, May 3, at the ACR Annual Meeting and Chapter Leadership Conference and will take effect on July 1, 2009. (See AMCLC Special Section on page 20.)

A Long Engagement The courtship between the two organizations lasted a remarkable six years and included dozens of meetings to discuss the union. The subsequent proposal period was quite long and required 10

revisions and even a change in bylaws — it can be difficult for organizations attempting a strategic integration to get it exactly right on the first try. “In 2003, [the integration] seemed like a good idea, but neither society was quite ready for the compromises that need to take place when you do something like this,” says Neiman. “Initially, it was just a dream, but as we [leadership of the ACR and ARRS] continued to talk, we solved the various issues that came up and quickly realized that this is a perfect match.” There are many other radiological societies, but the ACR and ARRS indeed seemed to be an attractive combination. Each organization does things uniquely well — ARRS is widely known for its educational offerings, and while the ACR has an impressive line of educational products, which includes the ACR Education Center, it has other core pillars that potentially may siphon resources away June 2009 Volume 64, Issue 6

from education. The combination of the ACR and ARRS will serve to enhance educational offerings for members of both organizations. “[The ACR] doesn’t have a scientific/clinical journal or a scientific educational meeting; they do,” says Neiman. “We have this void, and they have a wonderful way of filling that void. Meanwhile, the ACR is bigger and can give them financial muscle that they don’t have on their own.”

“In 2003, [the integration] seemed like a good idea, but neither society was quite ready for the compromises that need to take place when you do something like this.”

—Harvey L. Neiman, M.D., FACR

Mutual Benefits Both organizations will also continue to have their own names, identities, and brands. This move is characterized as a “strategic integration,” as opposed to a “classic merger.” “In a classic merger, one entity disappears,” says Neiman. “The ARRS and its Executive Council will continue to exist and have autonomy in the area of education; it’ll put together its own agenda and program development, and the ACR will take its educational endeavors and fold them into ARRS.” “What’s important to remember,” says ARRS Executive Director Susan Brown Cappitelli, M.B.A., C.A.E., “is that there are still ACR and ARRS members, and each group will continue to get The American College of Radiology

the same products and services they’re used to. We will see the potential for value as our two organizations come together in the elimination of redundancies, the realization of efficiencies, and the identification of obvious synergies and opportunities that will strengthen and broaden the educational program available to both memberships.” The strategic integration officially took effect on July 1, and both organizations have only begun to look at how to integrate the two organizations’ substantial program areas. “The goal is to create very tangible benefits that add value for members, whether that is a discount on dues, programs, or products,” adds Cappitelli.

Talented Support Because of the massive number of tasks required to pull off the integration, Neiman and other ACR and ARRS leaders interviewed several management and consulting firms to manage the process. Ultimately, “we came to the realization that not only was it quite expensive, but it was difficult to see the value [the firms] would bring to our organizations,” says Neiman. “And when I looked around at the staff, it was quickly apparent that there are extremely talented people who may not have gone through a merger but who have experience in human resources, IT, or legal, and there was no reason to bring in someone from outside.” Mitchell Lee Marks, Ph.D., who owns Joining Forces, a mergers and acquisitions consulting firm, often hears Neiman’s opinion. “Most organizational leaders think they can do it themselves, but they often underestimate the sheer amount of activity it takes to 11

integrate operations,” Marks says. He has written several books and papers on the subject of mergers and acquisitions, including Joining Forces: Making One Plus One Equal Three in Mergers, Acquisitions, and Alliances.1 Marks has also noticed a recent increase in the number of nonprofit mergers and acquisitions. “In nonprofits, [merging] is becoming an essential step just for economic viability.”

“This is really a culmination of two years of discussions and, along the way, it [the decision to integrate] could have gone in either direction.”

—Susan Brown Cappitelli, M.B.A., C.A.E.

Economy Not a Factor However, Neiman insists that the economic downturn was not the catalyst for the strategic integration, and that both organizations are financially strong. Though he does point out that the economy certainly “drives home the point that we need to be cost-effective and realize that to carry out this undertaking, we need to make sure our members get value out of their membership and be as fiscally responsible as possible. Daily news headlines remind us of this,” he adds. But Marks is quick to add a news bite of his own: “Seventy-five percent of all deals are failures,” he says. This doesn’t mean that three of four mergers don’t happen, but that the outcome of the mergers doesn’t meet the goals and objectives set out in the original agreements. “Organizations with successful mergers don’t slap things together,” Marks adds. “They take their time during integration and think.” Neiman adds, “that is exactly the approach we have taken — thoughtful and with attention to detail.”

“While ARRS and the ACR will have distinctly different roles, we’ll approach the measurement of success as a unified organization pursuing a common vision,” says Cappitelli. “From the standpoint of education, we’ll be looking for evidence of expanded reach of current ARRS programs and content and increased scope of ARRS’s activities to meet the diverse educational needs and learning preferences of the entire radiology community.”

News Flash Any updates on the integration process will be communicated to members in a timely fashion, using all available communication tools, including each organization’s Web site and publications. If you have any questions, “Members are always welcome to call or e-mail me anytime,” says Neiman, who can be reached at 800-227-5463, ext. 4901, or by e-mail at [email protected]. “There will certainly be a lot of questions as we go along,” says Cappitelli. “Members want to know where the value is that we promised,” she adds. “We plan to be vigilant about this substantial undertaking, and everyone should know that a strong team of professionals is working on their behalf.” Cappitelli is available to answer questions, and you may contact her at [email protected] if you have any concerns. After all the questions and trepidation, what remains is true excitement. “This is really a culmination of two years of discussions and, along the way, it [the decision to integrate] could have gone in either direction,” says Cappitelli. “So, to have the ARRS membership vote unanimously in favor of the integration plan was very satisfying. It says we struck the right balance.” For additional ARRS coverage of the ACR and ARRS strategic integration, including ARRS members’ perspectives and on-the-spot video interviews, please visit InPractice at www.arrs.org; click on “Publications.”3 ENDNOTE

Measuring Success Also, this is a different kind of merger, and both organizations are committed to success. In fact, they have been meeting almost daily for several weeks to ensure a smooth transition that includes a renewed commitment to excellence. “We’ll determine success [of the integration] several ways,” says Neiman. “First, a qualitative response of members that leadership has contact with at various meetings — how they feel about the strategic integration, but quantitatively, the financial position of the combined organizations, membership growth, satisfaction surveys, etc. There will be synergies that allow us to be more cost-effective and successful from a financial standpoint. I would love to see membership in the ACR and ARRS increase.”

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1. Marks, Mitchell Lee and Mirvis, Philip. Joining Forces: Making One Plus One Equal Three in Mergers, Acquisitions, and Alliances. Jossey-Bass Publishers, 1998.

To the Point

4The membership of the American Roentgen Ray Society (ARRS) voted unanimously to approve the strategic integration with the ACR.

4Talks of the integration began in 2003. At that time, neither society was ready to make the necessary compromises.

4As the two organizations are integrated, future benefits to members may include discounts on dues, products, and services.

June 2009 Volume 64, Issue 6

Reproduced with permission from ARRS

From the Pages of History

The 18th ARRS Annual Meeting was held in 1919 in Sarasota Springs, N.Y.

ACR Founder Albert Soiland presents second gold medal to Mme. Marie Curie in 1931.

Early Beginnings The storied past of the ARRS, the oldest radiological society, began in 1896, shortly after Wilhelm Konrad Roentgen discovered the X-ray. Scientists in that period attempted to start an X-ray society but did not succeed until March 1900, when they held the first meeting of the Roentgen Society of the United States. This early incarnation of ARRS boasted fewer than 1,000 members.1

The American College of Radiology

However, the ARRS paved the way for future radiological societies, including the Radiological Society of North America, as well as the ACR. Today, the ARRS serves a membership of more than 20,000, with a staff of fewer than 40 talented individuals. The ARRS has the third largest membership of all radiological societies, following behind RSNA and the ACR. It wasn’t until 23 years after the inception of the ARRS that the ACR began to take shape, courtesy of Albert Soiland,

M.D., and Benjamin H. Orndoff, M.D. “The ACR as an organized entity took form after many months, even years of travail,” said Orndoff, 1936 ACR president. “The deep desire to elevate the standards or radiologic practice, to create a new division in the medical science, to keep it in close step with ethical medicine, to overcome growing pains, jealousy, and to promote the joy and advantages of good fellowship all preceded the inception of our College.”2 Now, the ACR serves more than 30,000 members with an intense commitment to its members through its four pillars of service: advocacy, clinical research, quality and safety, and education. ENDNOTES 1. Gagliardi, Raymond A. Recollections and Reflections: The American Roentgen Ray Society, 1900–2000. American Roentgen Ray Society, 1999. 2. Orndoff, Benjamin H. B.H. Orndoff, letter to E.E. Barth, March 10, 1959, ACR Files. In: Linton, Otha W. The American College of Radiology: The First 75 Years. The American College of Radiology, 1997.

13

You’ve Been

Hacked

It’s not easy to stay safe in a hostile cyberworld.

Zombie computers, trojan horses, keyloggers, worms, botnets, back doors, smurf and fraggle attacks, click fraud, spoofing scams, list poisoning, scrumping, grayware, crimeware, NTP vandalism, SYN floods, DDoS mechanisms, and script kiddies.

By Matthew Robb

T

he arcane, often bizarre vernacular of the information technology (IT) professional reflects the constantly evolving threat to computer systems everywhere. Day and night, from within organizations or thousands of miles away, hackers target computers using a ninja’s arsenal of tricks, tools, and stealth. Commented one observer to InformationWeek, “It’s an arms race. They try something. We block it. They try something else. We block it. It goes on and on. Sometimes it’s fine, and sometimes we spend hours a day on this.”

Dutch authorities discovered an illegal worm (botnet) powered by 1.4 million hijacked computers.

What’s further troubling is that sometimes hackers successfully break through — and few targets are as tempting as the massive computing power that propels the world of medical imaging. “You can’t rest on your laurels,” says Michael S. Tilkin, ACR’s chief information officer. “You need to make sure you’re doing all the right things.”

Hacks staged by outsiders tend to dominate headlines. These malicious acts range from virulent viruses to invisible keylogger programs designed to purloin passwords. Although some “malware” manages to crash operating systems, most seek to steal “CPU cycles,” turning high-end computers into anemic laggards, says Keith J. Dreyer, M.D., Ph.D., vice chair of informatics at the Department of Radiology at Massachusetts General Hospital.

How widespread is the threat? Computerworld estimates that fully one million viruses have circulated since the dawn of computing, with 25 percent having been created in just the last six months. Among the worst offenders: MSblaster, Storm, Slammer, and the infamous MyDoom. But viruses aren’t the only threat. In 2004, 14

The implications are clear: All medical settings are potentially vulnerable. With new threats materializing every day — and the consequences of infiltration being so serious — the ACR Bulletin sought recommendations from several experts in the world of radiology.

Threats of Every Kind

And the menace is growing. Today’s IT expert must contend with Web 2.0 threats arriving via spam, instant messaging, vulnerabilities in Windows Vista, online social networking, gaming, and pornography. Phishing — a scam that uses copycat Web sites to lure Internet June 2009 Volume 64, Issue 6

users into disclosing sensitive information — is growing at an alarming rate. Internal threats abound as well. One of the worst-case scenarios is a disgruntled employee surreptitiously installing a Trojan horse that creates a computer “back door” for subsequent exploitation. “An upset employee can erase records, disturb the normal flow of information, and wreak wholesale havoc,” Dreyer says. “Even if the data are stored at multiple sites, and even if the system is off-line, it could still be problematic.”

“Prevention

is all important.

If hackers get in, they can install a bot that sends out data and is very difficult to detect.”



—Khan M. Siddiqui, M.D.

Sometimes hackers just waltz right in through the cyber “front door.” Despite the unambiguous decree of the Health Insurance Portability and Accountability Act (HIPAA), which mandated that ACR members and other physicians and health care providers adopt safeguards to secure patient-identifiable information, health care professionals continue to post user names and passwords next to computers, choose and share easily cracked passwords, visit questionable Web sites swarming with self-replicating worms, and commit unforgivable blunders. In early 2009, an orthopedics practice accidentally posted 1,000 patient records online. And some gaffes, if decidedly low tech, are equally problematic. In 2007 and 2008 alone, hundreds of thousands of nonshredded medical records were discovered inside dumpsters in more than a dozen U.S. states. In 2008, thousands of medical records fell off a pickup truck in California. The list goes on and on.

Protective Measures “Prevention is all important,” counsels Khan M. Siddiqui, M.D., principal manager of Microsoft’s Health Solutions Group and chair of the ACR’s IT Committee. “If hackers get in, they can install a bot that sends out data and is very difficult to detect.” Among the growing menaces he sees are employees falling prey to “social hacking” on popular sites, such as Gmail, Yahoo, Facebook, and dozens of others. You can start protecting your organization by assessing its vulnerability and defenses. Conduct periodic, probing audits to ensure that your defenses are robust and that your organization is compliant with the HIPAA requirement to “implement measures for controlling access to confidential medical information and protecting it against compromise and misuse.” For more information on the HIPAA security regulation and how to integrate its requirements into your practice, visit www.cms.hhs.gov/ SecurityStandard. The American College of Radiology

Settling for a “good enough” defense may be inviting trouble in today’s heavily regulated, highly litigious environment, Siddiqui says. In 2007, the U.S. Department of Health and Human Services unintentionally made headlines when reports leaked that it was requiring an Atlanta hospital to detail its “policies and procedures, physical and logical access to systems and data, Internet usage, violations of security rules by employees, and logging and recording of system activities.” Such audits are a massive headache to conduct and can result in stinging sanctions and sullied reputations that can affect contract renewal. Dreyer, whose doctorate is in computer science, notes that IT officers must balance computer security with ease of access, performance, and affordability. Beefing up an enterprise system to handle the drain of 24/7 malware-detection scanners can be costly. Similarly, radiologists bristle at the notion of 15-digit alphanumeric passwords, sluggish workstations, and maddening 30-second timeouts. The foundations of computer security rest on well-established principles. “Remember to maintain your firewalls, stay current with AV [anti-virus] updates and system patches, enforce complex passwords that change periodically, and manage backups in the event you need to isolate, clean, and restore compromised systems,” Tilkin says. All computers and workstations should have updated AV software, scanning engines, and patches. This isn’t always easy. “Some vendors don’t allow you to run AV software with their applications because they’re trying to maximize performance to meet specifications,” Dryer notes. It’s also important to encrypt portable devices, be mindful of Web 2.0 vulnerabilities, and safeguard passwords. Do not post or share passwords, Siddiqui says. Shared common passwords and user names make it impossible to audit who did what and when. Longer, more complex passwords are more secure. As one possibility, Siddiqui suggests using a favorite phrase and substituting numerals for vowels, such as “F2rstD2N4H4rm.” Follow your vendor’s best practices and avoid the painful lessons learned by others. Dreyer also recommends appointing a security officer. “Make sure that person is involved in the overall process, helps set policies that employees will conform to, and performs regular audits,” he says. Dreyer also points out that smaller, rural practices may falsely believe that they are too small or isolated to be targeted, but a three-person practice in Wyoming is as tempting a target to a hacker as a major group practice in Chicago. And remember that many records are compromised the easy way, through theft or loss of desktop computers, laptops, or flash drives. Dreyer offers a parting thought: “With the stringency of HIPAA policies, it would be a foolish person who wouldn’t come forward and disclose a hack. It may be tempting but don’t try to cover it up. It’s the wrong thing to do.”3 Matthew Robb ([email protected]) is a freelance writer. 15

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June 2009 Volume 64, Issue 6

Healing Rays Sophisticated technological advancements lead the way for a new era in radiation oncology. By Matthew Robb

W

hen Congresswoman Sue Myrick was diagnosed with breast cancer in late 1999, she joined some 183,000 American women that year in dealing with the frightening news. Just a generation earlier, her diagnosis typically entailed mastectomy and possibly an eclipsed life span. However, major advances in radiation oncology allowed the North Carolina mother of two to undergo a breast-sparing lumpectomy. Today, Myrick, 67, has been in remission for 10 years. Says Myrick, “The fact that radiation oncologists are able to localize tumors and target only cancerous cells … [meant] I was able to get treated in Charlotte in the morning, fly to Washington for votes, and fly back for treatment the next day. I credit my speedy recovery in large part to radiation therapy and the caring expertise of my doctors.” Her colleague on Capitol Hill, Rep. Parker Griffith, M.D., sings the praises of radiation oncology at every turn, chronicling its breathtaking tools, techniques, and dedicated corps of practitioners. Griffith should know. In January 2009, the genial Alabamian became the first radiation oncologist elected to Congress. Today, he notes that radiation oncology “has improved life expectancy and cure rates and enhanced the quality of life for many, many patients. The technical advances over the last three decades have been phenomenal.”

Opening New Frontiers “Radiation therapy is one of the most utilized and fastest growing cancer therapies available today,” notes prominent radiation oncologist Louis B. Harrison, M.D., chair of radiation oncology at Beth Israel Medical Center in New York City. In 2004, nearly one million American patients received treatment with radiation therapy for a broad spectrum of cancers, including breast, head and neck, brain, gastrointestinal, gynecological, lung, prostate, and pediatric cancers. Three cancers — breast cancer, prostate cancer, and lung cancer — account for more than one-half of all radiation therapy patients. The American College of Radiology

17

At least 75 percent of patients in 2004 received treatment with the goal of curing the cancer rather than controlling growth or relieving symptoms. Major breakthroughs have opened new frontiers in cancer research and treatment, says C. Norman Coleman, M.D., associate director of radiation research at the National Cancer Institute. These advances include insight into the interaction of radiation with cells and tissues, cell-cell contact communication, normal tissue injury pathways, pathways that make cells more resistant to cell killing, and the complex microenvironment of tumors. “We’ve made big advances in the knowledge of cancer biology and normal tissue injury pathways,” says Coleman, who holds three board certifications.

minimally invasive,” Harrison says. “We’re treating cancer patients to both cure them and leave them intact.” Using powerful imaging technologies, radiation oncologists can create and shape radiation beams to target tumors in highly sophisticated and precise ways that were not available even 10 years ago, he notes. “Today, oncologists can deliver very high doses of radiation directly into the tumor and relatively spare from radiation the surrounding normal organs,” Harrison adds. Such diagnostic and treatment sophistication allowed Myrick to keep her breast and look ahead to “a very high cure rate,” Harrison continues. For a man with prostate cancer, one of many available radiation therapies can give him “a much higher rate of preserving continence, maintaining sexual potency, and avoiding anesthesia

“Normal tissue injury is so much more complicated than just killing local tissues. We must consider everything from the inflammatory response to stem cell recruitment as we develop ways of mitigating damage from treatment.” “Normal tissue injury is so much more complicated than just killing local tissues,” he continues. “We must consider everything from the inflammatory response to stem cell recruitment as we develop ways of mitigating damage from treatment.”

— C. Norman Coleman, M.D.

and surgery.” Radiation oncologists can often treat patients with larynx cancer without removing their voice box, treat patients with low-lying rectal cancer without resorting to colostomy, and treat patients with sarcoma of a limb without having to amputate. This is more than good news, Harrison notes. These are stunning advances.

Two Options Treatment options are divided into two therapies. External-beam radiation therapy includes intensity-modulated radiation therapy and stereotactic radiation therapy, both of which modulate the intensity and shape of the radiation beam in multiple planes and multiple dimensions for optimal targeting of the cancer while sparing most normal tissue. Stereotactic technologies such as linear accelerator-based stereotactic radiation therapy allow many patients to avoid “major surgery — but with the same good results,” Harrison notes.

Betsy Ullrich (left) and Christopher G. Ullrich, M.D., FACR, attend fundraiser for Rep. Sue Myrick (R-N.C.).

Curing cancer is one thing, but radiation oncologists also seek to preserve organs and functioning. “What makes radiation therapy today so interesting and important … is it’s noninvasive or 18

On average, patients undergoing external-beam radiation therapy receive about 30 treatments. In contrast, in internal radiation therapies, such as breast brachytherapy and prostate seed implantation, radiation oncologists precisely insert radioactive seeds at the site of the cancer, again sparing normal tissue. In 2004, more than 81,000 patients received brachytherapy treatments. A radiation oncologist exemplifies the hands-on specialized physician who maintains close patient contact throughout treatment. “They see the patient, do the history and examination, get the appropriate imaging studies, and then determine the correct June 2009 Volume 64, Issue 6

treatment plan and perform the treatment with the help of a skilled team of professionals,” Harrison notes. This multidisciplinary team includes surgeons and medical oncologists, who work together to optimize patient care.

Parker Griffith: Radiation Oncologist and Congressman

“Radiation therapy is one of the most utilized and fastest growing cancer therapies available today.”

Q:

As the first radiation oncologist in Congress, what’s your message to Capitol Hill?

— Louis B. Harrison, M.D.

“Most cancer patients get a couple of treatment modalities, such as radiation and chemotherapy or surgery and radiation, so it’s very important that treatment be done in a highly organized and sequenced manner by the entire team to give the patient the best chance for recovery,” Harrison says. “I cannot emphasize enough the importance of a multidisciplinary team in the treatment of cancer.”3 Matthew Robb ([email protected]) is a freelance writer.

A:

The message I am taking to Congress is that radiation oncology is essential and a major treatment modality for cancer that has improved life expectancy and cure rates and has enhanced the quality of life for many patients. The technical advances over the last three decades have been phenomenal, and radiation oncology should be supported as a major specialty in medicine and a major treatment of malignant disease. … As a radiation oncologist, I also stress the need for Congress to invest in preventative research and care … to prevent diseases, catch diseases earlier, and increase a person’s chance of surviving. Rep. Parker Griffith, M.D. (D-Ala.)

Q:

What aspect of being a radiation oncologist did you find most gratifying?

A: At the end of the day, I personally found it most

gratifying to help those in need. As a radiation oncologist, people come to you with a need for care and comfort, and many times, you are their last source. Whether there was a happy ending or not, it was rewarding to help ease the pain of the patient and their families. … In addition to caring for my patients, I found the combination of the clinical medicine part of our specialty and the science part of our specialty, which is cell biology and physics, to be very satisfying.

Engaging with patients is an important aspect of a radiation oncologist’s treatment plan.

Q:

What do you see as the key challenges to radiation oncology today?

A: The challenges facing radiation oncologists are To the Point

4Radiation oncologists provide state-of-the-art care to cancer patients with technologies unavailable even 10 years ago.

4Radiation oncologists not only focus on curing cancer but also preserving patients’ organs.

4Two treatment options are available for patients: external-beam therapy and stereotactic radiation therapy.

the same challenges facing all medical fields. … We must improve outcomes while facing the tremendous challenge of lowering health [care] costs. We must also continue to find ways of improving quality of care in the beginning so that we can catch a stage 1 lung cancer before it becomes a stage 4. It is also important that our profession stays involved with issues on Capitol Hill. For too many years, we, as a profession, have stayed on the sidelines. The more physicians are involved in shaping public policy, the better the results will be for patients and the medical profession as a whole.

4A radiation oncologist exemplifies the hands-on specialized physician who maintains close patient contact throughout treatment.

The American College of Radiology

19

AMCLC 2009

The Evolution of Radiology The ACR’s Annual Meeting and Chapter Leadership Conference focused on change.

A

CR leaders discussed their vision for the future of radiology at the 86th Annual Meeting and Chapter Leadership Conference (AMCLC) that began on Sunday, May 3, at the Hilton Washington, Washington, D.C., and continued through May 6.

Transitions Executive Director Harvey L. Neiman, M.D., FACR, acknowledged the effects of the recent stock market collapse, as well as flat revenues, increasing expenses, and other financial matters. He noted that the ACR will meet economic challenges head-on by continuing to carefully monitor the budget and enact policies and procedures as necessary. Despite the challenging year, the College experienced numerous successes in 2008. Neiman added that the ACR Education Center has demonstrated the success of a learning model based on total immersion and active learning that emulates students’ practice environments. By offering Certificates of Proficiency, the Education Center provides radiologists with the credentials needed in hospital environments and for third-party payers.

Left to right, participating in the historic signing ceremony are Anton N. Hasso, M.D., FACR, ARRS president 2007–2008; Arl Van Moore Jr., M.D., FACR, ACR president 2008–2009; Ella A. Kazerooni, M.D., FACR, ARRS president; James H. Thrall, M.D., FACR, ACR BOC chair; John (Jack) K. Crowe, M.D., FACR, ARRS president 2008–2009.

Noting the approval of the strategic integration merger of the ACR and the American Roentgen Ray Society (ARRS), Neiman indicated that the College has been meeting almost daily for several weeks to ensure a smooth transition that includes a renewed commitment to excellence. He reassured members that they would continue to receive the same services they currently receive and urged those who were not members of the ARRS to look into membership.

to seeing all of radiology in one place, all in one organization,” Thrall stated.

Bigger, Better, and Stronger Together

No Dues Increase This Year

Before the signing ceremony joining two of the most prestigious radiology organizations in the world, the ACR and the ARRS, ACR Board of Chancellors Chair James H. Thrall, M.D., FACR, said, “There’s an old saying in the world of commerce that the best time to negotiate is when you can negotiate from strength.” By joining the two organizations, radiology is poised to receive a dose of highquality education products and services.

Secretary Treasurer Paul H. Ellenbogen, M.D., FACR, reported that ACR assets improved in April when the stock market rebounded. Long-term investments have declined, but other investments have held steady. This is due in part to a conservative, well-diversified portfolio.

Each organization will continue to do what it does uniquely well and will share reciprocal board seats. “You can look forward

20

He indicated that the strategic integration will result in new methods and tools for demonstrating evidence that will assist members of both organizations with privileging and reimbursement issues. “This integration will take us to a level of excellence beyond what either organization could achieve on its own,” he concluded.

In a discussion of dues, Ellenbogen stated, “Read my lips. No dues increase. This year.” Noting that the strategic integration merger agreement stipulated that neither organization would increase dues this year, Ellenbogen added, “but we have to look at where we are.

June 2009 Volume 64, Issue 6

“We’re presented with both an opportunity and a problem. There are 3,200 ARRS-only members and 11,950 ACR-only members. ACR has not raised dues since 2001.” One possible future scenario for increasing dues is to index increases to the Continuous Professional Improvement program, which would allow for gradual, incremental increases annually.

be on the right side of the issues when they happen and better positioned to adapt to our landscape.”

Gold Medalists ACR Gold Medals are awarded by the Board of Chancellors to select individuals for distinguished and extraordinary service to the ACR or to the discipline of radiology.

Success Is in the Air ACR economic and health policy work is expanding as the College collaborates with other medical specialties, especially in the area of appropriateness criteria. Thrall stated that “the rest of the world has caught on to appropriateness criteria, which we’ve developed for 15 years.” He noted, “We’ve learned that if we can harmonize our point of view with other important professional organizations and we go together to CMS [Centers for Medicare & Medicaid Services], what can CMS say when we agree? Otherwise, CMS gets a free pass.” On the subject of legislative activities, Thrall predicted that this year, legislation will be passed on payment reform, Medicare, and reform of the overall health care system. Most likely to pass, Thrall predicted, is Medicare legislation. Thrall indicated that it is unlikely that any new procedure will be reimbursed by CMS without clinical trial data. He said that the American College of Radiology Imaging Network® is “the only permanent clinical trial center capable of generating the data we will need.”

Just Change It As humans, our natural tendency is to maintain the status quo, to stay in our comfort zone, 2008–2009 President Arl Van Moore Jr., M.D., FACR, stated. During his presidential address, Moore pointed to the wisdom of Charles Darwin, whose theory of survival of the species — only those who are adept at adapting to change will survive — continues to affect us today.

2009 ACR Gold Medalists include (left to right) James P. Borgstede, M.D., FACR, University of Colorado; William J. Casarella, M.D., FACR, University of Kentucky; and Robert R. Hattery Jr., M.D., FACR, American Board of Radiology.

Honorary Fellows Honorary Fellows are elected by the Board of Chancellors in recognition of contibutions to the science or practice of radiology by individuals who are ineligible for admission as members of the College.3

“The imaging field will most certainly evolve,” he stated. “If we don’t adapt to change, we could become extinct.” Moore added that we are witnessing a world that is evolving across continents, creating hyper-subspecialization that provides high-quality radiology services anywhere in the world at any time. The competition is fierce, and we are at an important crossroads. “The answer is, as it will always be — put patients first,” Moore stated. “It is our solemn duty,” he continued. “If we do, we will

The American College of Radiology

2009 Honorary Fellows include (left to right) Maximilian F. Reiser, M.D., Munich, Germany; Carl-Gustaf Standertskjöld-Nordenstam, M.D., Ph.D., Helsinki, Finland; and Adrian K. Dixon, M.D., Cambridge, England.

21

Quality & Safety AMCLC 2009

Building a Stronger Specialty Leaders look beyond the health care horizon to future opportunities and challenges. personal CME database. By activating ABR in your organizational profile, your MOC-fulfilling CME and SAM credits can be transferred to your database on the ABR Web site. You can then log on to the CME Gateway at www.cmegateway.org to start managing your credits. ABR intends to increase the required number of SAM credits so they become 30 percent of the total CME credit necessary for the MOC program. It also plans to tailor cognitive exams to individual practice settings. “We will create an exam that looks like what you do,” Dunnick said. “Send us your exam material, such as cases, and we will integrate them into the exam.”

Beyond Cancer Research State representatives from various ACR chapters attend a session at AMCLC 2009.

O

n Day Two of the AMCLC, Charles W. Bowkley III, M.D., Executive Committee chair of the ACR Resident and Fellow Section (RFS), said the Radiology Career Handbook is an excellent resource on the RFS Web site to help residents define and secure their desired jobs. Residents can also improve their interpretation skills using the site’s MRI Teaching File, which includes more than 200 cases in body MR, breast MR, cardiac MR, and MSK MR. Bowkley mentioned that the RFS Toolkit can also be found online. The Toolkit provides an overview of the benefits of joining the ACR and RFS, details about the Deficit Reduction Act of 2005, information on reimbursement, and thoughts on the future of the specialty. Additionally, the RFS has created its own Facebook group, RFS of the ACR, which includes a discussion board, wall, and real-time posts. Be sure to access these resources at http://rfs.acr.org and search “RFS of the ACR” on Facebook to join the discussion.

Fine-Tuning the Core Exam The American Board of Radiology (ABR) sets the standard for the practice of medicine and has been serving the public trust for 75 years. N. Reed Dunnick, M.D., FACR, reminded the audience to use the ABR’s CME Gateway, which links the ABR to your own 22

Since its beginnings in 1999, the American College of Radiology Imaging Network® (ACRIN®) has developed and validated imaging approaches to surveillance and early detection of cancer. It has worked to characterize and monitor responses to treatment of cancer and other diseases that have important public health impacts. Network Chair Mitchell D. Schnall, M.D., Ph.D., noted that ACRIN has developed a cardiovascular committee and neuroscience committee that will help move the organization beyond cancer research and into other health care areas. Schnall also pointed out that ACRIN faces many challenges, which include developing new molecular imaging tracers and personalized screening for breast cancer, exploring optimized imaging of Alzheimer’s disease, and formalizing screening for colon cancer with CT colonography.

Tomorrow’s Patient Care Sharing good news, Mitchell Machtay, M.D., Radiation Therapy Oncology Group® (RTOG®) deputy chair, informed attendees that RTOG, a national clinical trials group, recently received another five years of funding from the National Cancer Institute following a competitive renewal process. In describing some of the organization’s international initiatives, Machtay revealed that RTOG is mentoring and recruiting institutions throughout the world. Its work has been outstanding in Israel and Korea, he said, and it now seeks membership from every continent. “This will help us to complete studies more quickly and allow us to do studies on diseases that are less common in the United States,” Machtay noted. June 2009 Volume 64, Issue 6

it’s already probably chronic,” he explained. “We’re intervening too late, when the costs are highest, and the treatment is least effective.” Noting that biomarkers will be critical, Zerhouni asked the audience, “What better biomarker than imaging?” He added, “Biomarkers are key for predicting and seeing patients earlier. Imaging as the ultimate biomarker is the direction we need to move in.”

States: Establish Relationships, Find Lobbyists

Elias A. Zerhouni, M.D., presents the Moreton Lecture on changing paradigms in health care delivery.

New Paradigms in an Evolving World The highly anticipated Moreton Lecture was presented by Elias A. Zerhouni, M.D., senior advisor, Johns Hopkins School of Medicine; senior fellow, Bill and Melinda Gates Foundation; and former director, National Institutes of Health. Zerhouni discussed how scientific advances and changing paradigms in health care delivery will influence radiologists’ role and how to prepare for these changes. “The next 30 years will be even more evolutionary for imaging,” he said. The future paradigm, Zerhouni said, will be to transform medicine from curative to pre-emptive. Imaging will need to play a role earlier in the disease process, he suggested. “When a patient suffers,

Alan D. Kaye, M.D., FACR, hosted the open microphone session on ACR state government relations examining the importance of having an effective presence in state capitols. Chapters were encouraged to invest resources in a lobbyist who specializes in health care to represent their cause. One audience member indicated that a lobbyist facilitates a focus on radiology issues, as opposed to medical issues, which is important because there are often conflicts between medical and radiology issues. All participants stressed the importance of developing relationships with politicians early in their careers. Establishing a continuity of relationships while politicians remain in the state legislature ensures a consistency of dialogue, develops a measure of trust, and establishes confidence for the future. It was also noted that radiologists must also use the multipronged approach of building relationships with politicians, health care lobbyists, state medical associations, and regulatory bodies.3

Predicting the Future and Dealing With the Present Annual meeting attendees receive practical advice for practicing in the specialty’s new era.

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n his keynote speech, to AMCLC attendees on Day Three, Donald H. Romano, former division director for the Centers for Medicare & Medicaid Services (CMS), cited a McKinsey Institute report stating that today’s skyrocketing health care expenditures are not due to a sicker U.S. population or the expensive malpractice system. Rather, it is because the U.S. health care system is intrinsically more expensive. Romano used the McKinsey report to back up his claim that the United States has approximately 54 percent more CT scanners and 40 percent more MRI machines (per million people) than other developed countries. He noted that the excess capacity results in an additional cost of $40 billion to the U.S. health care system. The American College of Radiology

The continued move toward requiring accreditation in order to ensure quality and the use of evidence-based guidelines for ordering imaging services might assuage the situation, Romano indicated. With such guidelines, “some profit-influenced self-referral will diminish because physicians will have to look the guidelines square in the face and decide to order the services anyway,” he noted.

Rising Demand and Cost During his overview of the ACR Commission on Economics, Bibb Allen Jr., M.D., FACR, said that increased Medicare spending, higher insurance payments, and changes to the private payer fee schedule are due to the increasing demand for imaging over the 23

AMCLC 2009

last 10 years. “It’s no wonder other specialties advocate for a conversion factor that doesn’t penalize them when their share of the pie is decreasing,” Allen said. Some members of the commission met with CMS during the AMCLC, and an update will follow in July. Meanwhile, the ACR Future Trends Committee plans to look at how payment systems affect radiologists, and the 2009 ACR Forum in June will be on physician payment models and future implications for radiology.

Self-Referral: Topic of Great Interest Discussion at an open microphone session, hosted by Alan D. Kaye, M.D., FACR, centered on the various positions on self-referral. As the volume of imaging services has escalated, the associated high costs have captured the attention of CMS, private payers, and other government officials. The bottom line is that nonradiologist self-referral for imaging procedures is a major driver behind the increased volume and costs.

Face the Music — Coding and Compliance Richard Duszak Jr., M.D., FACR, and Allen hosted the interactive session on coding and compliance, offering some practical advice. Select the name of the procedure or service that accurately identifies the service performed, they advised. Don’t select a Current Procedural Terminology® (CPT®) code that merely approximates the service provided, they added, indicating that if no such procedure or service exists, you should report the service using the appropriate unlisted procedure or service code. CPT coding is the national standard code set for billing of procedures and services to Medicare and other third-party payers.

RUC and Valuation Geraldine B. McGinty, M.D., M.B.A., and James V. Rawson, M.D., shared the podium to discuss valuation of imaging procedures. Explaining the process, they said the AMA CPT Editorial Panel reviews applications for new codes and code changes and sends new Category I codes to the Relative Value Update Committee (RUC) for valuation. The RUC uses the Medicare Resource-Based Relative Value Scale (RBRVS) to assign relative values to codes and makes recommendations to CMS. Existing codes, other specialties’ interests, and data from radiology literature are among the factors most likely to impact valuation at the RUC. Congress, CMS, cognitive specialties, and MedPAC are all critical of the RUC process and radiology. “It’s a feeling of the fox is guarding the chicken coop,” McGinty said. 24

Attendees enjoy enhanced technology, including individual USB drives, increased WiFi and cell phone access, and the AMCLC Web portal.

Coverage Issues for New Technology Robert K. Zeman, M.D., FACR, and Christopher G. Ullrich, M.D., FACR, moderated the AMCLC session on CMS coverage issues for new technology. They advised, “The ACR is representing your interests in advancing reimbursement for new technologies.” When code requests are submitted to the AMA’s CPT Editorial Panel, a Category I or III CPT code is created based on the information provided. If Category I requirements are not met, a Category III code may be established. Category III codes are often perceived as experimental, they reported. In the private sector, the creation of a CPT code is all that needs to occur for reimbursement, and both Category I or Category III codes could be potentially paid. According to Zeman and Ullrich, privatepayer coverage often mirrors Medicare coverage. The ACR worked with the American College of Cardiology (ACC) to create a model coverage policy that could be presented in the private sector to make decisions about coronary CTA coverage. In October 2006, the ACC met with the Blue Cross Blue Shield medical director group and presented the joint policy. To date, most private payers provide at least some coverage of coronary CTA as a result of these meetings.

Radiologist as Value Innovator At the Tuesday luncheon, Paul J. Chang, M.D., FSIIM, presented a lively talk titled, “Re-engineering Radiology in an Electronic and Flattened World: Radiologist as Value Innovator.” Chang is professor and vice chair at Radiology Informatics, and Medical Director of Pathology Informatics, University of Chicago School of Medicine. “Unless we are willing and able to dramatically change the way we practice, we will fail to successfully leverage and exploit the June 2009 Volume 64, Issue 6

benefits of optimized workflow integration,” Chang stated. “The danger is complacency,” he continued. “Software is the easy part; the hard part is changing ourselves, the way we practice. “Modern health consumers want realtime delivery of service and product, but your technology fails you,” he explained. “They say, ‘You don’t have PET-CT? You don’t have same-day service and results? Then I’ll go somewhere else.’”

material into reports so clinicians can understand their recommendations. Chang asserted that if radiologists provide value that cannot be commoditized, consumers will say, “These guys really add service; they are the doctor’s doctor.”

Surprise Honor Bestowed

To maximize value and quality, Chang suggests optimizing electronic workflow integration and maximizing information throughput. For example, he advised: use technology to improve efficiency in the scanning area, revisit your PACs workstations, and provide patients same-day service. “Vendors don’t do it unless you ask for it,” he said.

Allen presented the William T. Thorwarth Jr., M.D., Award to John A. Patti, M.D., FACR, who was both surprised and honored. Allen explained that Patti “is a leader and a mentor who challenges our professional ability. He always does his homework and is very precise, prepared, and articulate. He gives careful thought to how issues will affect radiologists and how they will affect the profession in the long term. He knows how to foster teamwork among volunteers. And he looks at challenges in a whole new way.”3

He also suggested radiologists try inserting hyperlinks to explanatory

AMCLC coverage provided by Leslie Miller.

Left to right, new officers to begin their service to the ACR include Paul H. Ellenbogen, M.D., FACR; Howard B. Fleishon, M.D., FACR; Carol M. Rumack, M.D., FACR; John A. Patti, M.D., FACR; James H. Thrall, M.D., FACR; R. Terrell Frey, M.D., FACR; and Alan D. Kaye, M.D., FACR.

ACR 2009–2010 Election Results President Carol M. Rumack, M.D., FACR Vice President R. Terrell Frey, M.D., FACR Council Speaker Alan D. Kaye, M.D., FACR Council Vice Speaker Howard B. Fleishon, M.D., FACR Board of Chancellors James H. Thrall, M.D., FACR, Chair John A. Patti, M.D., FACR, Vice Chair Paul H. Ellenbogen, M.D., FACR, Secretary Treasurer Bibb Allen Jr., M.D., FACR (first term) Cassandra S. Foens, M.D., FACR (second term) Donald P. Frush, M.D., FACR (second term) James M. Hevezi, Ph.D., FACR (second term) David C. Kushner, M.D., FACR (first term) Council Steering Committee Kimberly E. Applegate, M.D., M.S., FACR Philip S. Cook, M.D., FACR Jay A. Harolds, M.D., FACR Richard N. Taxin, M.D., FACR College Nominating Committee Laurie L. Fajardo, M.D., M.B.A., FACR Susan D. John, M.D., FACR Seth A. Rosenthal, M.D., FACR

John A. Patti, M.D., FACR, Massachusetts General Hospital, receives the William T. Thorwarth Jr., M.D., Award from Bibb Allen Jr., M.D., FACR, Birmingham Radiological Group. The American College of Radiology

Members-in-Training Marion Brody, M.D. Stephanie K. Burns, M.D. 25

ADVOCATE AMCLC 2009

Surpassing Expectations RADPAC® celebrates contributions and participation during the ACR Association annual meeting. By Ted Burnes

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oth RADPAC® and Capitol Hill Day participants have much to celebrate after AMCLC 2009. Successes included record-breaking fund-raising numbers and a tremendous amount of participation from residents.

In fact, 438 ACRA™ members — including 118 residents — contributed more than $127,000 to RADPAC during the AMCLC. And this year, 32 states reached 100 percent RADPAC participation with help from their state councilors; last year, only 21 states met this participation goal. Residents strongly supported RADPAC during the conference, with more than 65 percent who attended the meeting contributing to RADPAC. In addition, 13 states achieved 100 percent participation from their residents. The sixth annual RADPAC gala was a great success as well. Congressman Xavier Becerra of California’s 31st District, member of the Ways and Means Health Subcommittee and vice chair of the Democratic Caucus, received the Congressional Award for Radiological Excellence. Becerra provided gala attendees with a congressional perspective on the immediate and long-term future of health care reform. The evening concluded with entertainment provided by the nationally renowned comedy satire group, The Capitol Steps. On the last day of the AMCLC, more than 415 radiologists visited nearly 300 congressional offices on Capitol Hill. Of the 415 radiologists, 145 were first-time Capitol Hill attendees. Hill attendees focused their messaging on three points: Medicare reimbursement reform for physician services; stopping any proposed imaging cuts; and supporting electronic ordering with decision support as an alternative to radiology benefit managers to ensure appropriate quality imaging.3 Ted Burnes is the director of RADPAC. He can be reached at [email protected]. Top: Left to right, Michigan Radiological Society representatives Gary S. Gustafson, M.D.; Kurt E. Tech, M.D., FACR; and Stephen Kilanowski, M.D., were among more than 415 radiologists who visited congressional offices during the AMCLC. Center: Rep. John Larson (D-Conn.) (left) meets with ACR members from Connecticut. Bottom: J. Daniel Hanks Jr, M.D., FACR, (left) and Rep. Tom Price, M.D. (D-Ga.), discuss legislative matters pertaining to radiology. 26

June 2009 Volume 64, Issue 6

Technology

Radiology on Location With new mobile imaging applications, you can practice anywhere. By Raina Keefer

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any people in the late 20th century imagined we’d be driving hover cars by the year 2000. Nine years later, we’re not quite there. However, advancements in technology, specifically those designed for portable devices, have made it remarkably easier to do what we need to do, wherever we want to do it. “Physicians, and particularly service providers such as radiologists, are confronted with increasing demand for high efficiency and mobility,” says Osman Ratib, M.D., Ph.D., FAHA, professor and chair of radiology at the University Hospital of Geneva in Geneva, Switzerland. Ratib worked with hospital colleague and fellow radiologist Antoine Rosset, M.D., to develop OsiriX open-source software, and they have recently created the OsiriX Medical Imaging Viewer, available as an application for the Apple® iPhone™.

There’s an App for That

Photo courtesy of Osman Ratib

Ratib and Rosset distributed OsiriX open-source software free to more than 40,000 users, and the complementary OsiriX iPhone application is available for a small fee. The money earned from application sales helps support the OsiriX foundation, a nonprofit organization supporting open-source developments in medical imaging. However, the OsiriX application is only one of several imaging viewer applications designed for the multipurpose iPhone. MIMvista Corp., a provider of imaging software, released the first iPhone and iPod® touch imaging application, Mobile MIM™, in June 2008. The newest version, Mobile MIM Pro™, is currently pending clearance by the U.S. Food and Drug Administration.

Meanwhile, another organization, Merge Healthcare, which offers radi- ology and workflow technology solutions, also has developed a free imaging viewer applica- tion, Merge Mobile™. These applications give radiologists access to a variety of radiological images The OsiriX imaging viewer application is one of several programs available for the iPhone.

The American College of Radiology

on a mobile device as if they were at their own workstations. Ratib designed the OsiriX application for use as a mobile companion to the OsiriX computer software program — an interactive program designed for display and analysis of medical images. “The fact that [portable devices] are now capable of handling and displaying larger volumes of image data is certainly a key factor [in the technology’s adoption],” says Ratib. “Accessing images on mobile devices may also impact the workflow of radiologists on call or covering multiple locations as a notification and decision support for undertaking additional procedures.”

“These technologies will continue to have an impact on the medical community.” —Osman Ratib, M.D., Ph.D., FAHA

Limited Bandwidth However, users may encounter some challenges — large files slow performance — trying to access the massive amounts of data sent using mobile devices. Wireless networks need to expand bandwidth to support the volume of image data transmitted. According to Ratib, intelligent data streaming and data reduction algorithms can help mitigate this issue. “The limited performance of processors implemented on phones or portable devices is still an order of magnitude slower in performance compared to the processors available today on computers,” he adds. “This lack of performance horsepower can be very restrictive when advanced image processing tools, such as 3-D rendering, multidimensional navigation, and multimodality image fusion, are becoming basic features that users expect to have for adequate visualization of complex data sets that are acquired on today’s imaging modalities,” Ratib continues. Ratib sees the consumer market and its growing need for multimedia devices driving the emergence of more high-performance wireless devices and applications. “These technologies will continue to have an impact on the medical community and will provide innovative solutions for improvement of the way physicians communicate and practice medicine, which ultimately should have a positive impact on patient care,” he says.3 27

ADVOCATE

Economic

Chairman’s Report Bibb Allen Jr., M.D., FACR

Congress Considers Health Care Reform This summer looks to be a hectic time for medicine; Congress has vowed to tackle health care reform by the August recess, and many of the president’s and congressional leaders’ goals may profoundly impact radiology. As of press time, none of the proposals has been put into legislative language; however, we have seen a number of policy proposals placed on the table for debate. What winds up in the final legislation and what Congress will eventually pass are still in question, and the College will use its resources to help steer the various proposals in a direction that benefits patients and is equitable for radiology. Rebasing the SGR

One of the first measures that will be determined is whether Congress will rebase the Sustainable Growth Rate (SGR) formula, which is used to update the Medicare conversion factor. Because of a series of congressional fixes, medicine faces significantly reduced payments if Congress does not rebase the SGR. The American Medical Association and virtually all specialty societies support this effort. However, the amount of money required to do so is in the range of $300 to $400 billion, and it is unclear whether Congress is ready to write off that amount to the budget deficit. If the SGR is not rebased, medical societies will once again battle for their share of the shrinking pool of Medicare dollars.

The ACR opposes migrating radiology benefit management companies (RBMs) to Medicare. These are for-profit companies whose business model rations the volume of imaging performed — many times against the advice of the ordering physician. Multiple Conversion Factors

The conversion factor is the dollar amount Medicare uses to multiply relative value units (RVUs) to calculate physician payments. In 2007, a bill that would have established five separate service categories — each with its own conversion factor — was proposed but only passed the U.S. House of Representatives. The proposal contained separate service categories for imaging and minor procedures, including interventional radiology, as well as a specific category for physicians providing primary care. 28

June 2009 Volume 64, Issue 6

Under the proposal, in order to curb utilization, service categories with high growth would incur reductions as volume increased, whereas services with declining growth might ironically see increases in reimbursement per procedure. Not surprisingly, this plan has major support from physicians who perform major procedures and whose volume has been flat over the last decade. Additionally, by separating primary care services from the rest, Congress intended to protect primary care from reductions caused by increasing growth. This leaves only imaging, consultative medicine, pathology, and minor procedures to absorb increasing Medicare spending. The ACR continues to oppose the concept of separate service categories and standards of volume performance for imaging. We argue that since radiologists are obliged to perform and interpret examinations ordered by others, reducing the per-examination payment will have no effect on reducing volume, which is part of the proponents’ stated rationale.

As an alternative to RBMs, the ACR proposes combining comparative effectiveness criteria, such as the ACR Appropriateness Criteria®, with electronic order entry. Because major and minor procedures would be in separate service categories, as minimally invasive procedures continue to replace major procedures, irrational payment policy will hamper the transition to more modern techniques. Further, if minimally invasive procedures are performed by different physicians, those performing the procedures would be significantly disadvantaged. Finally, if Congress decides to pursue a multiple service category approach, mechanisms should be in place to ensure that all physicians are held accountable for the imaging they order. This will then ensure that all physicians are responsible for increases in growth. Congress Looks at RBMs

President Obama’s budget includes a provision for Medicare to use radiology benefit management companies (RBMs) as a means of controlling Medicare spending in imaging. This measure is a response to double-digit growth in Medicare spending for imaging over the last 10 years. However, recent data from 2007 and 2008 suggest that not only have imaging expenditures decreased because of the Deficit Reduction Act, but the growth in spending is now aligned with the overall growth in Medicare spending (about 3 percent). Imaging is no longer an outlier. Notwithstanding the recent data, a desire for managing utilization of imaging remains, and Congress is considering RBMs in its health care legislation. The ACR opposes migrating RBMs to Medicare. These are for-profit companies whose business model rations the volume of imaging performed — many times against The American College of Radiology

the advice of the ordering physician. We believe that RBMs would deny or delay needed services for Medicare beneficiaries and create an additional administrative burden on primary care and other ordering physicians in the Medicare program. The plan would take money out of the Medicare system without improving physician education or patient care. As an alternative to RBMs, the ACR proposes combining comparative effectiveness criteria, such as the ACR Appropriateness Criteria®, with electronic order entry. This will give ordering physicians immediate feedback that supports their decisions about the appropriateness of imaging on a case-by-case basis. Compared with dealing with RBM denials, such systems are transparent, educational, and less cumbersome for physician practices. In contrast to RBMs, when physicians have used electronic ordering systems, they have not had to hire additional office staff. Electronic order entry systems with decision support have proven effective at reducing the growth in imaging and are useful across a wide spectrum of patients, including inpatients and emergency department patients. No Targeted Cuts

As discussed in last month’s Bulletin column, MedPAC suggested Congress implement an increase in the equipment utilization for practice expense calculations to 90 percent of a 50-hour week. This is based on a modest amount of data that did not include a robust geographic distribution or the number of hours per week that centers used their equipment. The ACR will educate Congress that the Centers for Medicare & Medicaid Services should rely on reliable data to make decisions to change the utilization assumption. Additionally, adopting a new normative standard would significantly disadvantage rural providers, which would create a future access burden for beneficiaries.

Electronic order entry systems with decision support have proven effective at reducing the growth in imaging and are useful across a wide spectrum of patients, including inpatients and emergency department patients. The ACR intends to focus on ensuring that all physicians who order imaging are accountable for any payment reductions that result from increasing volume. We believe that electronic ordering with decision support for ordering imaging examinations represents a more appropriate alternative than RBMs for managing utilization of imaging. As both the cost and growth in the volume of imaging have decreased over recent years, additional targeted reimbursement cuts for imaging are premature and likely unnecessary to manage utilization. ◆ 29

RADLAW

Protect Your Rights Issues to watch for when you negotiate hospital contracts. By Bill Shields, J.D., LL.M., and Tom Hoffman, J.D., CAE

Foreword Legal issues have become a significant part of the practicing radiologist’s world, and most physicians receive little or no information in this area. This article is an excerpt from Medical-Legal Issues in Radiology, a handbook developed by the ACR Medical-Legal Committee to provide basic information to the radiologist-in-training who is preparing to enter private or academic practice. The handbook is available on CD-ROM by calling member services at 800-227-5463, ext. 4998. — Harry Zibners, M.D., J.D., FACR — John J. Smith, M.D., J.D. Medical-Legal Committee

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any radiology groups have contracts with the hospitals where they work, guaranteeing them the exclusive right to practice radiology in those hospitals, to the exclusion of other practitioners. Radiologists should be aware of two issues that can arise in this area. The radiology group usually pays a price for having an exclusive contract with the hospital; the hospital almost always insists that, in return for exclusivity, the group members surrender their due process rights. “Due process” is an integral part of “peer review”1 and refers to the right of a Harry Zibners, M.D., J.D., FACR, is president of Rad Consultants Inc., providing diagnostic interpretation services to radiology groups in California and Ohio on an independent contractor basis. He is a member of the state bars of California and Ohio. John J. Smith, M.D., J.D., is an attorney and physician with the Washington, D.C., law firm of Hogan & Hartson L.L.P. He has broad medical practice experience as a fellowship-trained musculoskeletal radiologist, providing both clinical care and taking part in clinical trials, and was formerly an associate professor at the Massachusetts General Hospital and Harvard Medical School.

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member of the medical staff, or even an applicant for medical staff privileges, to know why those privileges are being revoked or denied and to offer arguments challenging the decision. This process involves the right to a hearing, often before the hospital’s executive or credentials committee. If a radiology group has relinquished its due process rights, the hospital can replace it simply by nonrenewal of the contract, without the need for a medical staff hearing. This gives the hospital administration considerable power over the radiology group. Therefore, such a contract should be exclusive to the radiology group (i.e., no one else can practice radiology in the hospital); otherwise, the group is giving up a significant right for no return. Some groups are electing to practice in their hospitals without a contract; this puts their security primarily in the hands of their medical staff peers rather than the hospital administration. The legality of such exclusive contracts has been challenged many times, usually in a situation in which the hospital has decided to replace one contracted radiology group with another or in which the existence of a contract prevents a doctor (who is not a member of the radiology group) from working in the radiology department. The challenge is usually based on either or both of two legal theories: either the contract is illegal under the antitrust laws because it improperly restrains competition or the offended radiologist was denied his or her medical staff due process rights. The first argument almost always fails because an impact on competition sufficient to implicate the antitrust laws cannot be shown.2 The second argument often fails because the courts have usually

held that medical staff due process rights are not attached to a decision of the hospital administration.33 ENDNOTES 1. “Peer review” is the process whereby the medical staff attempts to ensure the quality of care in the hospital by monitoring both the clinical aspects of medical staff members’ practices and their behavior. “Due process” attempts to protect staff members being reviewed from arbitrary or wrongful decisions by the reviewing body. Federal law [Health Care Quality Improvement Act of 1986, 42 U.S.C. §11112(a) (1986)] protects medical staff peer review committees from liability for their decisions provided the professional review action is taken: 1) in the reasonable belief that the action was in the furtherance of quality health care, 2) after a reasonable effort to obtain the facts of the matter, 3) after adequate notice and hearing procedures are afforded to the physi- cian involved or after such other procedures as are fair to the physician under the circumstances are afforded, and 4) in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph (3). This law (which also established the National Practitioner Data Bank) was passed in reaction to Patrick v. Burget, 486 U.S. 94 (1988), a case in which a physician successfully argued that he had been victimized by an unfair peer review proceeding, which resulted in massive damages that led to closing of the defendant clinic and personal bankruptcy of several of its physician members. 2. The seminal case is Jefferson Parish Hospital District No. 2 v. Hyde, 104 S. Ct. 1551 (1984), in which the U.S. Supreme Court held that an anesthesiologist’s challenge to a hospital’s exclusive contract with another group was without merit because no antitrust injury was shown (i.e., no impermissible effect on competition). A more recent case is Villalobos v. Llorens, No. CIV. 99-2034 (HL), 2002 WL 448623 (D.P.R. Mar. 20, 2002), in which an anesthesiologist’s antitrust challenge to an exclusive contract was rejected on similar grounds. Physicians asserting antitrust injury usually fail because, among other things, they fail to distinguish injury to themselves from injury to competition. The antitrust laws always protect the latter but not usually the former. For a discussion of antitrust laws in this context, see Zibners, H., “Physician Contracting and Antitrust Law,” in Risk Management, Test and Syllabus, Siegel, BA, ed., American College of Radiology, Reston, Va., 1999. 3. See, for example, Tenet Healthcare Ltd. v. Zamora, No. 13-99-572-CV, 2000 WL 144173 (Tex. App. Feb. 10, 2000), which held that a hospital is not required to extend due process rights to physicians excluded by an exclusive contract because such procedural requirements apply only when a physician’s privileges have been reduced, suspended, or terminated because of professional competence or ethical concerns and not to matters involving an administrative decision (as in this case). This is a common legal rationale in such cases. See Van Valkenburg v. Paracelsus Healthcare Corp., 606 N.W.2d 908 (N.D. Mar. 3, 2000), for a similar holding on a similar basis.

June 2009 Volume 64, Issue 6

Bill Shields, J.D., LL.M. (bshields@acr. org) is ACR general counsel. Tom Hoffman, J.D., CAE (thoffman@acr. org) is ACR associate general counsel. The ACR Legal Office exists to represent the College and to provide legal advice to the leadership and the executive director, as well as to handle the day-to-day legal activities. The attorneys are not licensed in all 50 states, the District of Columbia, Puerto Rico, Guam, and Canada, and therefore, cannot give direct legal advice to members or represent chapters, practices, or individual members. The office can provide general information of interest to members as well as general guidance on a variety of legal topics. All information is provided with the express understanding that no attorney-client relationship exists and that members, practices, and chapters should always consult their personal or corporate counsel on matters of concern.

Got Talent? Are you an ACR member and a pilot? How about a gourmet chef? Are you in a band? The Bulletin is looking for members with diversified interests that go beyond radiology. If there’s a side of you that you want to share with other ACR members, e-mail [email protected] with a brief description of how you break out of a typical physician mold. We will select a few members to profile in future Bulletin issues.

New Offer! Order Your Bulletin Reprint Today! Informative. Credible. Prestigious.

Take advantage of the ACR Bulletin’s new reprint service. This excellent cost-effective resource will enhance your public relations and marketing efforts and maximize your marketplace saturation. Popular uses for reprints include: • Tradeshows • Presentations • Training • Recruiting • Direct mail • Handouts We provide high-quality, professional hard-copy reprints in a variety of formats. To order your reprints or obtain more information, visit www.acr.org/bulletin-reprint or call 800-227-5463.

7372 06/09

The American College of Radiology

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Jobs Classified Ads These job listings are paid advertisements. The ACR offers a bundled advertising package entitling advertisers who purchase an online and ACR Bulletin classified ad to a 15 percent discount on a classified ad in the Journal of the American College of Radiology. To learn more about this bundled offer, e-mail [email protected].

Rates: ACR members: $50 per ACR Bulletin ad. Nonmembers: $125 per ACR Bulletin ad. These fees are in addition to online posting fees. Ad length is a maximum of 50 words. Advertising instructions, rate information, and complete policies are available at http:// jobs.acr.org. Publication of a job listing does not constitute a recommendation by the ACR. The ACR and the ACR Career Center assume no responsibility for accuracy of information or liability for any personnel decisions and selections made by the employer. These job listings previously appeared on the ACR Career Center Web site. Only jobs posted on the Web site are eligible to appear in the ACR Bulletin, on a space-available basis.

CALIFORNIA - Bakersfield - General/ General Diagnostic/Nuclear Radiologist - A 12-member radiology group seeks general diagnostic/nuclear radiologist. Nuclear medicine boards preferred. State-of-the-art practice with the latest equipment in all modalities, a new fullservice imaging center, & busy nuclear medicine department. Productivity based compensation offers excellent income potential. Contact: Girish Patel, M.D., at 661-496-9100 or by e-mail at [email protected]. CALIFORNIA - Modesto Interventionalist - Clinical interventionalist wanted to join 3 fellowship-trained interventionalists in a busy practice. Modesto Radiology is a 15-person group covering 3 hospitals, 2 of which offer interventional. One year to partnership with separate call schedules. No mammo. Contact: Michael Tekautz, M.D., at 209-571-6622, or by e-mail at [email protected].

COLORADO - Denver - General Radiologist/Emergency Radiologist Position for in-house nighttime radiology, with 1-in-3 coverage. Competitive compensation, full benefits including health & retirement, flexible scheduling, & plenty of time off to enjoy the adjacent recreational activities. Contact: Send CV to Jim Hueber by e-mail at [email protected]. DISTRICT OF COLUMBIA - Radiologist - Washington Radiology Associates, P.C. Shareholder/part-time tracks. Private practice with full range of modalities in Washington, D.C., area is recruiting an experienced and/or fellowship-trained radiologist with expertise in ultrasound. Contact: Edward Lipsit at 703-641-9133, ext. 1110, or by e-mail [email protected]. FLORIDA - Hollywood - Chief of Pediatric Radiology - Excellent opportunity with large South Florida group. Three-year partnership or per diem. All pediatric subspecialties presently represented at children’s hospital with new hospital planned. Competitive starting salary. Contact: Jill Avendano by e-mail at jill.avendano@ rahmail.net. FLORIDA - General Radiology - $600,000+ partnership compensation package. Candidates will work with all BC, fellowship-trained radiologists. This dynamic practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage Contact: Keith Nussbaum at 813-899-6224 or by e-mail at knussbaum@FIARad. com. FLORIDA - Interventional Radiology - $600,000+ partnership compensation package. Candidates will work with all BC, fellowship-trained radiologists. This dynamic practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage. Contact: Keith Nussbaum at 813-899-6224 or by e-mail at [email protected]. FLORIDA - Pediatric Radiology - $600,000+ partnership compensation package. Candidates will work with all BC, fellowship-trained radiologists. This dynamic practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage. Contact: Keith Nussbaum at 813-899-6224 or by e-mail at knussbaum@FIARad. com. FLORIDA - Radiation Oncology - Competitive partnership compensation package. Candidates will work with all BC, fellowship-trained radiologists. This dynamic

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practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage. Contact: Keith Nussbaum at 813-899-6224 or by e-mail at knussbaum@FIARad. com. FLORIDA - Women’s Imaging - $600,000+ partnership compensation package. Candidates will work with all BC, fellowship-trained radiologists. This dynamic practice offers PACS, PET/CT, 64-slice CT, & after hours teleradiology coverage. Contact: Keith Nussbaum at 813-899-6224 or by e-mail at knussbaum@FIARad. com. MARYLAND - Baltimore - Radiologist - The Diagnostic Division of Johns Hopkins Department of Radiology is seeking a well-trained and experienced radiologist to join our practice. Competitive salary and excellent benefits. Contact: Elliott Fishman at 410-955-5173 or by e-mail at [email protected]. NORTH CAROLINA - BC Radiologist - Excellent opportunity to join a growing hospital-based practice serving several health care systems. Seeking a congenial, BC radiologist, preferably fellowship trained. The candidate should be comfortable with basic body interventional procedures & mammography. Contact: Nancy Holland at 336-882-1416 or by e-mail at [email protected]. OREGON - Coos Bay - General Radiologists - Large private practice seeks general radiologists for practice location on Pacific coast. Extremely competitive compensation, limited weekend call, 10+ weeks’ vacation. Benefits include CME, medical malpractice, & nighthawk services. Contact: Burt Loessberg at 541-681-8582 or by e-mail at [email protected]. PENNSYLVANIA - Western Suburbs of Philadelphia - Breast Imagers Suburban Philadelphia practice is seeking breast imagers for 3 women’s imaging centers with state-of-the-art equipment including digital mammography, MRI, & systemwide PACS. Full-time partnership track & part-time positions available. Reasonable call. Contact: Vikram Dravid at 610-429-0693 or by e-mail at [email protected]. PENNSYLVANIA - Western Suburbs of Philadelphia - Interventional Radiologist - Full-time partnership track position requires BC radiologist with CAQ in IR. Current team is 6 fellowship-trained interventionalists, 9 technologists, 7 RNS, & 4 PAs. Full spectrum of IR care with admitting & outpatient consult. Contact: Vikram Dravid at 610-429-0693 or by e-mail at [email protected].

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Are You Going Green? Some radiology practices are joining the environmental movement. If your practice is implementing ways to reduce its environmental footprint, the ACR Bulletin would like to hear about what you’re doing. Examples include efforts to reduce the use of toxic materials, minimize chemical waste, and lower total waste volume through such efforts as recycling and reducing water and energy consumption. We’d also like to hear how these activities may actually be saving you money. Please contact us about your green practices at [email protected].

June 2009 Volume 64, Issue 6

ACR 2009

CME Calendar of Events www.acr.org

Education Center Coronary CT Angiography June 19-21; Aug.14-16; Nov. 20-22 The ACR Education Center, Reston, Va.

New Course! ACR-SPR MR Imaging of Congenital and Pediatric Cardiovascular Diseases Oct. 9-11 The ACR Education Center, Reston, Va.

Optimize your clinical practice skills with course leader Shawn D. Teague, M.D., in this intensive training course interpreting coronary CTA exams under the supervision of expert faculty. CME: 28 AMA PRA Category 1 Credits tm

This course led by Cynthia K. Rigsby, M.D., and Laureen M. Sena, M.D., will enhance participants’ knowledge of pediatric cardiovascular MRI and improve imaging and postprocessing skills through a mentored review of 50 cases. CME: 30 AMA PRA Category 1 Credits tm

ACR-Dartmouth PET/CT Course

New Course! Musculoskeletal MR

June 29-July 1; Sept. 14-16; Dec. 7-9 The ACR Education Center, Reston, Va.

In this course led by Marc A. Seltzer, M.D., you will interpret in a frontline fashion more than 150 PET/CT scans covering all clinical applications. CME: 33 AMA PRA Category 1 Credits tm

CT Colonography: Supervised Case Review July 13-14 The ACR Education Center, Reston, Va.

Learn the technique, performance, and interpretation of CTC through the supervised review of a minimum of 50 cases in this course led by Matthew A. Barish, M.D. CME: 19.5 AMA PRA Category 1 Credits tm

Breast MR With Guided Biopsy Aug. 6-7; Nov. 9-10 The ACR Education Center, Reston, Va.

This 100-case course led by Constance D. Lehman, M.D., Ph.D., provides practicing radiologists with intensive, hands-on experience reading breast MRI under expert supervision. CME: 19 AMA PRA Category 1 Credits tm

New Course! Body MR Sept. 25-27 The ACR Education Center, Reston, Va.

This intensive, practical course led by Diego R. Martin, M.D., Ph.D., on abdominal MRI interpretation focuses on the most common current indications for abdominal MRI. CME: 33.5 AMA PRA Category 1 Credits tm

Nov. 13-15 The ACR Education Center, Reston, Va.

This 100-case course led by Mark D. Murphey, M.D., provides practicing radiologists with intensive experience in the technique and interpretation of MR imaging of the knee, shoulder, ankle/ foot, and hip. CME: 31 AMA PRA Category 1 Credits tm

Education On the Road New Course! ACR-RBMA Forum: New Strategies for Business and Clinical Leaders in Radiology Nov. 14-15 The Reston Hyatt, Reston, Va.

Mark your calendars for the first joint meeting of the ACR and the Radiology Business Management Association (RBMA). More information will be available soon. Please visit www. acr.org/4dimensions for updates regarding this exciting opportunity.

To learn about the ACR’s broad portfolio of educational products and services, visit www.acr.org/4dimensions. The American College of Radiology (ACR) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ACR designates these educational activities for AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

MKT CODE: CAL0906BUL 7385 05.09

ACR BULLETIN

1891 Preston White Drive Reston, VA 20191-4326

Now Showing 24/7 Online Lectures…70 Percent Off! Don’t break the bank. Save more than 70 percent on essential lectures from world-renowned radiologists with the new ACR All*Access Pass. The pass gives you and your entire practice or residency training program 24/7 access to more than 160 lectures. And, eligible radiologists can earn CME and SAM credits. Visit http://campus.acr.org or call 800-227-7762 to learn about your ACR All*Access Pass. *All ACR Campus® online video lectures. The American College of Radiology (ACR) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ACR designates these educational activities for AMA PRA Category 1 Credits and SAM credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. tm

MKT CODE: AAP0609BUL 7385.5 06.09