New Imaging Protocol to Assess Endotracheal Tube Placement: A Case-control Study.

PURPOSE: After intubation, a frontal chest radiograph (CXR) is obtained to assess the endotracheal tube (ETT) position by measuring the ETT tip-to-carina distance. ETT tip location changes with neck position and can be determined by assessing the position of the mandible. As the mandible is typically not visualized on standard CXRs, we developed a new protocol where the mandible is seen on the CXR, hypothesizing that it will improve the accuracy of the ETT position assessment. PATIENTS AND METHODS: Two groups of intubated patients studied (February 9, 2021 to May 4, 2021): CXR taken in either standard or new protocol (visible mandible required). Two observers independently assessed the images for the neck position (neutral, flexed, and extended) based on the mandible position relative to the vertebral bodies. With the mandible absent (ie, neck position unknown), we established terms: "gray zone" (difficult to assess the ETT position adequately) and "clear zone" (confident recommendation to retract, advance, or maintain ETT position). We compared the rate of confident assessment of the ETT in the standard versus the new protocol. RESULTS: Of 308 patients, 155 had standard CXRs and 153 had the new protocol. Interrater agreements for the distance between the ETT and the carina and mandible height based on vertebral bodies were 0.986 ( P < 0.001) and 0.955 ( P < 0.001), respectively. The mandible was visualized significantly more often ( P < 0.001) with the new protocol (92%; 141/153) than with the standard protocol (21%; 32/155). By visualizing the mandible or the presence of the ETT within the clear zone, a reader could confidently assess the ETT position more often using the new protocol (96.7% vs 51.6%, P < 0.001). CONCLUSIONS: Mandible visibility on postintubation CXR is helpful for assessing the ETT position. The new protocol resulted in a significant increase in both visualizing the mandible and accurately determining ETT position on postintubation CXR.

Cardiothoracic Radiologist Workload, Work Capacity, and Burnout Post-COVID: Results of a Survey From the Society of Thoracic Radiology.

In this report and analysis of the results of a late 2021 post-COVID pandemic survey of members of the Society of Thoracic Radiology, we compared cardiothoracic radiologist workloads and burnout rates with those obtained from a prepandemic survey of society members. The more recent survey also asked respondents to provide a subjective assessment of their individual workload capacity should they be required to read cases at a section average daily case work volume, and this assessment was correlated with burnout rates. To measure nonrelative value unit workload, we requested data on non-case-related work responsibilities including teaching and multidisciplinary conferences that were not assessed in the first survey. In addition, we asked respondents to provide information on the availability of support services, personnel, and hardware and software tools that could improve work efficiency and reduce radiologist stress levels thereby mitigating burnout. We found that postpandemic case workload and cardiothoracic radiologists' burnout rates were similarly high compared with prepandemic levels with an overall burnout rate of 88% including a 100% burnout rate among women which had significantly increased. The range of radiologists' workload capacity is broad, although 80% of respondents reported that reading at an average sectional case volume was at or above their capacity, and the perceived capacity correlated with burnout measures. The presence of fellows and computer-aided diagnosis/artificial intelligence tools were each associated with significant decreases in burnout, providing 2 potential strategies that could be employed to address high cardiothoracic radiologist burnout rates.

Prevalence of Burnout Among Cardiothoracic Radiologists: Stress Factors, Career Satisfaction, and Modality-specific Imaging Volumes.

PURPOSE: We investigated the impact of modality-specific volumes and other potential stressors on burnout and career-choice satisfaction. MATERIALS AND METHODS: An anonymous survey of 36 questions was sent by email to all 875 faculty members of the STR. These included 11 multiple-choice questions, 23 Likert questions, and 2 free-text questions. The Maslach Burnout Index was used to assess the prevalence of the 3 components of burnout (emotional exhaustion, depersonalization, and low professional accomplishment), and we assessed variations among the potential sources of stress with respect to the respondent sex, career stage, and practice setting. Respondents were asked to estimate daily work volume as if interpreting only chest radiographs (CXRs) or only chest/cardiac computed tomography (CT). Statistical analysis was performed using Excel (Microsoft), open-source statistical computing package pandas and SciPy for Python, and Jupyter Notebook, an open-source interactive computing platform. RESULTS: Although financial concerns (49.3%), lack of input into decisions (48.6%), and inadequate staffing (45.2%) were additional stressors, the major sources were work-life balance (67.4%) and workload (66.8%), which were more frequently cited by women than men (78.9% vs. 60.8%, P=0.001). Emotional exhaustion and depersonalization were related to higher CXR volumes. Although 83.2% were satisfied being a diagnostic radiologist, 18.8% had thought of leaving medicine. More than half of all radiologists interpreted ≥150 CXRs daily (51.1% vs. 53.6%); more in private practice read ≥200 CXRs (23.2% vs. 14.7%). Of the academic radiologists, 80.2% interpreted 21 to 49 CTs; twice as many in private practice read ≥50 CTs (25.5% vs. 12.7%). CONCLUSIONS: The contributing factors to cardiothoracic radiologist burnout vary by sex, career stage, and practice setting. Several stressors, especially work-life balance, were associated with higher burnout prevalence. Most respondents expressed career-choice satisfaction. Defining threshold work volumes associated with higher rates of burnout is an important first step in defining burnout prevention guardrails.

Emotional Harm in the Radiology Department: Analysis of an Underrecognized Preventable Error.

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.

Prevalence of Burnout Among Cardiothoracic Radiologists.

PURPOSE: Burnout is a psychological syndrome in response to chronic occupational stressors. The prevalence of burnout among medical professionals has been increasing, and recent studies have shown that radiologists are among those affected. We investigated the prevalence of burnout and assessed associated factors among cardiothoracic radiologists. MATERIALS AND METHODS: Society of Thoracic Radiology members were invited to complete an anonymous cross-sectional survey that included an adapted Maslach Burnout Inventory and questions about demographics, work place characteristics, and stressors. RESULTS: The survey response rate was 33.1% (290/874). Per-item response rate ranged from 94% to 100% with a median of 99%. The prevalence of emotional exhaustion was 66.8% (186/283), depersonalization was 79% (223/283), and low personal accomplishment was 23% (65/280). There were no statistically significant differences between academic and private practice. There was a trend toward worse burnout in women, but this was not statistically significant. Being in early career (0 to 10 y since fellowship) was associated with low personal accomplishment [odds ratio (OR): 2.07, 95% confidence interval (CI): 1.08-3.99]. Those working fewer than 51 hours per week were significantly less likely to report emotional exhaustion (OR: 0.55, 95% CI: 0.33-0.90). The odds of emotional exhaustion for those producing fewer than 7500 work relative value units per year were approximately half of those exceeding that number (OR: 0.46, 95% CI: 0.22-0.95). CONCLUSIONS: The prevalence of burnout among cardiothoracic radiologists is comparable to that reported for radiologists in other subspecialties such as musculoskeletal and interventional radiology. High work relative value unit productivity and longer work hours are associated with higher prevalence of burnout.

Overcoming Human Barriers to Safety Event Reporting in Radiology.

In high-reliability industries that are dedicated to ensuring safety, safety event reporting is the cornerstone of improvement. However, human factors can interfere with consistent reporting. Common human factors that are barriers to safety event reporting include liability concerns; time constraints; physician autonomy; self-regulation; collegiality; the lack of listening, language training, and/or feedback regarding reported events; unclear responsibilities within safety teams; and a high reporting threshold. Other barriers include fears of challenging authority, being disrespected, retribution, and the creation of a difficult work environment. These factors are reviewed in the health care setting, and the countermeasures that need to be introduced at the frontline employee, leadership employee (physicians and managers), and departmental and organizational levels to create a culture of safety in which all employees feel comfortable raising safety concerns are discussed. ©RSNA, 2019.

Running a Radiology Residency Program: Strategies for Success.

Running a successful radiology residency program requires departments to navigate the evolving educational landscape at the departmental, institutional, and national levels. To attract the best applicants, departments must invest time and money to support the leadership of the program and its faculty to provide innovative educational opportunities in a positive learning environment while simultaneously complying with all of the requirements of the Accreditation Council for Graduate Medical Education. The key administrative requirements of a successful radiology residency program are described and can be grouped into (a) essential administrative components, (b) the clinical learning environment review and self-study process, and (c) resident recruitment. Ten specific strategies for running a successful residency program are also presented. The goal is for this article to serve as a guide for not only existing diagnostic and interventional radiology residency programs but also newly formed programs that are in the process of seeking accreditation. ©RSNA, 2018.

Improving Imaging Care for Diverse, Marginalized, and Vulnerable Patient Populations.

Although much attention has been paid to the reduction of disparities in health care within the United States, these issues continue to exist. Such efforts include increased focus on patient centeredness and cultural responsivity. These concepts are based on the recognition that diverse, marginalized, and vulnerable patients may possess different physical, psychologic, or social characteristics that contribute to their diversity and susceptibility. Such patients may face numerous obstacles and barriers when seeking medical care, including financial constraints, difficulties with communication, a limited understanding of how to navigate the health care system, and not feeling welcomed, respected, or safe. It is essential that the radiologist and members of the radiology care team understand and embrace patients' unique characteristics to provide effective and appropriate care to all patients. This article illustrates the spectrum of knowledge that benefits radiologists and members of the radiology care team when interacting with and providing care for the growing pool of diverse, marginalized, and vulnerable patients. ©RSNA, 2018.

Acing the Joint Commission Regulatory Visit: Running an Effective and Compliant Safety Program.

Ensuring the safety of patients and staff is a core effort of all health care organizations. Many regulatory agencies, from The Joint Commission to the Occupational Safety and Health Administration, provide policies and guidelines, with relevant metrics to be achieved. Data on safety can be obtained through a variety of mechanisms, including gemba walks, team discussion during safety huddles, audits, and individual employee entries in safety reporting systems. Data can be organized on a scorecard that provides an at-a-glance view of progress and early warning signs of practice drift. In this article, relevant policies are outlined, and instruction on how to achieve compliance with national patient safety goals and regulations that ensure staff safety and Joint Commission ever-readiness are described. Additional critical components of a safety program, such as department commitment, a just culture, and human factors engineering, are discussed. ©RSNA, 2018.

Ongoing Professional Practice Evaluation of Radiologists: Strategies and Tools for Simplifying a Complex Process.

The Joint Commission, our major accreditation organization, requires that all physicians who have been granted privileges at an organization must undergo evaluation of and collect data relating to their performance, to make the decisions of privileging more objective and continuous by that organization. For radiologists, this so-called ongoing professional practice evaluation (OPPE) can be assessed by using the six general core competencies. These competencies were initially developed for graduate medical education and defined by the Accreditation Council for Graduate Medical Education and have now been expanded to provide a general framework for defining categories of data to be collected in assessing the performance of practicing radiologists. Within each core competency, various radiology-relevant metrics exist that can be measured to fulfill the OPPE requirements. Each radiology department can determine the specific type of data to be collected, including determining what items are defined as acceptable performance metrics, what data or outcomes require further monitoring, and what specific data or data trends would trigger the need for an additional focused and more thorough professional practice evaluation, also known as a focused professional practice evaluation (FPPE). ©RSNA, 2018.

Barriers to Safety Event Reporting in an Academic Radiology Department: Authority Gradients and Other Human Factors.

Purpose To investigate barriers to reporting safety concerns in an academic radiology department and to evaluate the role of human factors, including authority gradients, as potential barriers to safety concern reporting. Materials and Methods In this institutional review board-approved, HIPAA-compliant retrospective study, an online questionnaire link was emailed four times to all radiology department staff members (n = 648) at a tertiary care institution. Survey questions included frequency of speaking up about safety concerns, perceived barriers to speaking up, and the annual number of safety concerns that respondents were unsuccessful in reporting. Respondents' sex, role in the department, and length of employment were recorded. Statistical analysis was performed with the Fisher exact test. Results The survey was completed by 363 of the 648 employees (56%). Of those 363 employees, 182 (50%) reported always speaking up about safety concerns, 134 (37%) reported speaking up most of the time, 36 (10%) reported speaking up sometimes, seven (2%) reported rarely speaking up, and four (1%) reported never speaking up. Thus, 50% of employees spoke up about safety concerns less than 100% of the time. The most frequently reported barriers to speaking up included high reporting threshold (69%), reluctance to challenge someone in authority (67%), fear of disrespect (53%), and lack of listening (52%). Conclusion Of employees in a large academic radiology department, 50% do not attain 100% reporting of safety events. The most common human barriers to speaking up are high reporting threshold, reluctance to challenge authority, fear of disrespect, and lack of listening, which suggests that existing authority gradients interfere with full reporting of safety concerns.

Residency Mini-fellowships in the PGY-5 Year: Is There Added Value?

RATIONALE AND OBJECTIVES: With the restructuring of radiology board certification, many residencies created PGY-5 "mini-fellowships," during which residents spend focused time pursuing advanced subspecialty training or developing nonclinical skills in leadership, health policy and health-care economics, education, quality improvement, informatics, research, or global health. We surveyed graduates of an academic diagnostic radiology residency to assess the relative value and impact of PGY-5 mini-fellowships on career satisfaction and success. METHODS: From 2012 to 2016, 39 radiology residents at our institution were offered the opportunity to pursue a 3- to 6-month mini-fellowship during the PGY-5 year. Thirty of 39 radiology residents (77%) participated, whereas 9 of 39 (23%) opted out. Of 39 residents, 13 completed two clinical mini-fellowships, 3 completed research mini-fellowships only, and 14 completed one nonclinical and one clinical mini-fellowship. Through SurveyMonkey, 23 of 39 residents (59%) responded to a questionnaire that collected basic demographic information and asked respondents about the value of this experience as it relates to fellowship choice and career using a five-point Likert scale. RESULTS: Of 23 respondents (14 male, 8 female,1 not specified), 78.3% practice in an academic university-based setting, with 8.7% in a community-based hospital practice, 4.3% in the veterans system, and 4.3% in a private practice setting. Of 23 respondents, the most popular clinical mini-fellowships were magnetic resonance imaging (31.6%), neuroradiology (21.1%), and interventional radiology (15.8%). For nonclinical mini-fellowships, the most popular were research (10.5%), education (10.5%), global health (5.3%), and healthcare economics (5.3%). Of 23 respondents who did mini-fellowships, 95% felt that the mini-fellowship prepared them well for their career, 85% felt it gave them the necessary skills to succeed, 85% cited that it gave them additional skills beyond their peers, and 40% felt it helped them create a life-long connection to a mentor. Ninety-five percent of respondents would choose to do the mini-fellowship again. Respondents suggested increasing the duration to 6-9 months and to develop a more structured curriculum and mentorship component. Only one respondent felt that the nonclinical mini-fellowship took away time from furthering clinical skills. CONCLUSIONS: Graduates of a university-affiliated academic radiology residency who participated in clinical and nonclinical mini-fellowships during the PGY-5 year of residency greatly value this experience and uniformly recommend that this type of program continue to be offered to trainees given its ability to develop skills perceived to be vital to ultimate career satisfaction and success.

Honorary Authorship in Radiologic Research Articles: Assessment of Pattern and Longitudinal Evolution.

RATIONALE AND OBJECTIVES: To analyze the pattern and longitudinal evolution of honorary authorship in major radiology journals. MATERIALS AND METHODS: In this Institutional Review Board-approved study, an electronic survey was sent to first authors of original research articles published in the American Journal of Roentgenology, European Radiology, the Journal of Magnetic Resonance Imaging, and Radiology during 2 years (July 2014 through June 2016). Questions addressed the perception of honorary authorship and contributing factors, as well as demographic information. Univariate analysis was performed by using χ2 tests. Multivariable logistic regression models were used to assess independent factors associated with the perception of honorary authorship. RESULTS: Of 1839 first authors, 315 (17.3%) responded. Of these, 31.4% (97/309) perceived that at least one coauthor did not make sufficient contributions to merit authorship and 54.3% (159/293) stated that one or more coauthors performed only "nonauthor" tasks according to International Committee of Medical Journal Editors criteria. Of eight factors significantly associated with the perception of honorary authorship on univariate analysis, two were retained by the stepwise multivariate model: having someone suggest adding an author and a coauthor performing only a nonauthorship task. CONCLUSION: There has been little variation in the perception of honorary authorship among first authors of original research articles in radiology. The suggestion of adding an author and having coauthors performing only nonauthorship tasks are the two most important risk factors for honorary authorship. Our findings indicate that a prolonged course of transformation of current cultural norms is required to decrease honorary authorship.

Clinical and Radiologic Predictive Factors of Rib Fractures in Outpatients With Chest Pain.

PURPOSE: To identify the clinical and radiologic predictive factors of rib fractures in stable adult outpatients presenting with chest pain and to determine the utility of dedicated rib radiographs in this population of patients. METHOD AND MATERIALS: Following Institutional Review Board approval, we performed a retrospective review of 339 consecutive cases in which a frontal chest radiograph and dedicated rib series had been obtained for chest pain in the outpatient setting. The frontal chest radiograph and dedicated rib series were sequentially reviewed in consensus by two fellowship-trained musculoskeletal radiologists blinded to the initial report. The consensus interpretation of the dedicated rib series was used as the gold standard. Multiple variable logistic regression analysis assessed clinical and radiological factors associated with rib fractures. Fisher exact test was used to assess differences in medical treatment between the 2 groups. RESULTS: Of the 339 patients, 53 (15.6%) had at least 1 rib fracture. Only 20 of the 53 (37.7%) patients' fractures could be identified on the frontal chest radiograph. The frontal chest radiograph had a sensitivity of 38% and specificity of 100% when using the rib series as the reference standard. No pneumothorax, new mediastinal widening or pulmonary contusion was identified. Multiple variable logistic regression analysis of clinical factors associated with the presence of rib fractures revealed a significant association of trauma history (odds ratio 5.7 [p < 0.05]) and age ≥40 (odds radio 3.1 [p < 0.05]). Multiple variable logistic regression analysis of radiographic factors associated with rib fractures in this population demonstrated a significant association of pleural effusion with rib fractures (odds ratio 18.9 [p < 0.05]). Patients with rib fractures received narcotic analgesia in 47.2% of the cases, significantly more than those without rib fractures (21.3%, p < 0.05). None of the patients required hospitalization. CONCLUSION: In the stable outpatient setting, rib fractures have a higher association with a history of minor trauma and age ≥40 in the adult population. Radiographic findings associated with rib fractures include pleural effusion. The frontal chest radiograph alone has low sensitivity in detecting rib fractures. The dedicated rib series detected a greater number of rib fractures. Although no patients required hospitalization, those with rib fractures were more likely to receive narcotic analgesia.

Diagnosing Sarcopenia on Thoracic Computed Tomography: Quantitative Assessment of Skeletal Muscle Mass in Patients Undergoing Transcatheter Aortic Valve Replacement.

RATIONALE AND OBJECTIVES: This study aims to assess the use of skeletal muscle mass measurements at two thoracic levels to diagnose sarcopenia on computed tomography (CT) chest examinations and to analyze the impact of these measurements on clinical outcome parameters following transcatheter aortic valve replacement. MATERIALS AND METHODS: This study retrospectively included 157 patients who underwent preoperative CT examinations. The total muscle area was measured on transverse CT images at the 3rd lumbar and 7th and 12th thoracic levels with skeletal muscle indices (SMIs) calculated at each level. SMIs were then compared to clinical outcome parameters, and thoracic cutoff values for sarcopenia at the 7th and 12th thoracic levels were calculated. RESULTS: Correlation between SMIs at the third lumbar vertebra (L3) and the 12th thoracic vertebra (T12) was stronger (r = 0.724, P < 0.001) than that between L3 and the seventh thoracic vertebra (T7) (r = 0.594, P < 0.001). SMIs at L3 and T12 significantly correlated with prolonged length of stay. Thoracic cutoff values for the 12th thoracic level were 42.6 cm2/m2 (men) and 30.6 cm2/m2 (women), and those for the 7th thoracic level were 46.5 cm2/m2 (men) and 32.3 cm2/m2 (women). CONCLUSIONS: Skeletal muscle measurements at the T12 level could permit the diagnosis of sarcopenia and could be used to correlate sarcopenia with outcome parameters in patients undergoing CT limited to the chest.

Low Yield of Chest Radiography in General Inpatients and Outpatients with "Positive PPD" Results in a Country with Low Prevalence of TB.

RATIONALE AND OBJECTIVES: The purpose of this study was to assess the frequency and spectrum of abnormalities on routine screening chest radiographs among inpatients and outpatients with "positive purified protein derivative (PPD)" in a large tertiary care academic medical center in a country with low prevalence of tuberculosis (TB). MATERIALS AND METHODS: The reports of all chest radiographs of general inpatients and outpatients referred for positive PPD (2010-2014) were evaluated for the frequency of evidence of active or latent TB and the spectrum of imaging findings. The results of additional chest radiographs and computed tomography scans were recorded, as were additional relevant clinical histories and symptoms. RESULTS: Of the 2518 patients who underwent chest radiography for positive PPD, the radiographs were normal in 91.3%. The vast majority of the abnormal radiographs demonstrated findings consistent with old tuberculous disease. There were three cases (0.1%) of active TB, all of which were either recent immigrants from an endemic area or had other relevant histories or clinical symptoms suggestive of the disease. CONCLUSIONS: Universal chest radiography in general inpatient and outpatient populations referred for positive PPD is of low yield for detecting active disease in a country with low prevalence of TB.

Managing Incidental Lung Nodules in Patients With a History of Oncologic Disease: A Survey of Thoracic Radiologists.

PURPOSE: The aim of this study was to analyze the impact that a clinical history of an oncologic disease may have on the management decisions for incidentally detected lung nodules on chest computed tomographic (CT) examinations. MATERIALS AND METHODS: An electronic survey was sent to all 796 members of the Society of Thoracic Radiology regarding criteria for the management of incidentally detected lung nodules in oncologic patients, as well as recommendations for nodule follow-up. Nodule characteristics and clinical parameters used by respondents were analyzed. Differences between variables were examined using the χ test. RESULTS: Of the 796 Society of Thoracic Radiology members, 178 (22.36%) replied. Most respondents were subspecialized in cardiothoracic imaging (92.70%) and practiced in an "academic or teaching hospital setting" (75.28%) with a "dedicated oncology center" (94.03%). "History of oncologic disease" was the most important factor (98.87%) for management decisions. In patients with such a history, respondents most commonly used "experience and common sense" (56.74%) and reported "all incidentally found lung nodules" (65.73%, P<0.0001). "Size" and "shape" were the 2 most important nodule characteristics (33.61% and 27.05%, respectively) used to consider a nodule "clinically relevant," and "size" (44.07%) was also the most important nodule characteristic prompting recommendation for short-term CT follow-up. Follow-up CT examinations in oncologic patients were recommended by 75.84% of respondents. CONCLUSIONS: In patients with a history of oncologic disease, radiologists tend to report every detected nodule and to routinely recommend follow-up CT examinations. Although most radiologists rely on "experience and common sense" in managing these nodules, greater standardization of lung nodule management in oncologic patients is needed, ideally through guidelines tailored to this patient population.