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For other articles and previous issues click here. March 13, 2006
Happily Ever After Some radiologists are looking to breast radiology as a perfect marriage of diagnostic radiology and patient interaction and hope for career happiness. When Rebecca Stough, MD, 56, was studying to become a radiologist, mammography was in its infancy and, unfortunately, of very poor quality. Because it was so poor, Stough swore she would never do breast radiology. Instead, she chose general diagnostic radiology with a focus on CT scanning, head and neck radiology, and neuroradiology. Approximately 15 years ago, she started doing breast radiology again and found, much to her delight, that it had changed for the better. Not only had mammography improved but also other imaging tools—ultrasound and most recently, breast magnetic resonance—were available. Together, they could help find breast cancer early when it is most treatable, distinguish cancerous lesions from benign, and discover the true extent of breast cancer so the complete, correct surgery could be performed the first time. Today, Stough is director of imaging at Breast MRI of Oklahoma, LLC and one of five radiologists at Mercy Women’s Center in Oklahoma City, which specializes in breast care. “We are a high-quality breast health institute,” she says. Radiologists like Stough who specialize in breast care are rare. Yet those who do so say it’s an answer to the crisis in this country that is brewing: More women are getting mammograms every year, yet the number of radiologists who specialize in reading them is not. 2,000 Subspecialists Michael Linver, MD, FACR, director of the Breast Imaging Center in Albuquerque, N.M., and Web site editor of the Society of Breast Imaging, figures the number of breast radiologists to be even smaller. He estimates only approximately 1,000 to 1,500 radiologists across the country are true subspecialists in breast care. Whatever their number, radiologists who specialize in breast imaging believe doing so has many benefits, most importantly for their patients but also for themselves. They see clinical, economic, and legal advantages to specializing in breast imaging and related care. “Anytime you focus in one area you tend to know that area better than those who don’t,” says Stephen Rose, MD, director of the TOPS Comprehensive Breast Center and director of the Breast Care Center at Memorial Hermann Southwest Hospital in Houston. Rose is in a practice where five—soon to be eight—radiologists do nothing but breast imaging and breast care. “Because that’s all we do,” he says, “you are able to share your cases with each other and share experiences and improve your skills while you’re doing it.” A study reported in the March 6, 2002, issue of the Journal of the National Cancer Institute found that high-volume radiologists were better able to tell when a mammogram is normal. The researchers looked at three groups of radiologists: low-volume, those who read less than 100 mammograms per month; medium-volume, those who read 100 to 300 per month; and high-volume, those who read more than 300 per month. Each group was given a set of 60 mammograms in which there were 13 cancers. The high-volume group was found to be better at detecting cancers and more accurate at judging normal mammograms. The medium- and low-volume groups failed in both categories. Gerald Kolb, JD, former president and CEO of Breast Health Management, Inc., a breast center management consulting firm based in Bend, Ore., says not only do studies speak in favor of subspecializing but so do the numbers. “It makes sense if you think about it from the perspective of incidence of cancer in the population,” he says. “What we have is somewhere in the neighborhood of three to six cancers per 1,000 mammograms. That’s information from a major study, the range being dependent on the screening history of the population. “A population that has a long screening history will have a lower rate of detection, and a newer screening population will have a higher rate until you catch up with the cancers that are evident on the baseline or initial mammogram.” Since 1992, when Congress enacted the Mammography Quality Standards Act, radiologists in the United States have had to read a minimum of 480 mammograms per year (actually 240 every six months) to qualify as competent. “So if you read 480 mammograms, how many cancers are you going to see? You’re going to see about two, and that is if you catch them both, and that’s where the danger is,” Kolb says. Other countries require their radiologists to read far more. In the United Kingdom, for example, it’s a minimum of 5,000 per year. In British Columbia, which has a state-sponsored screening program, radiologists are required to read a minimum of 2,500 mammograms and take a rigorous continuing education program specifically targeted at interpreting cancers. Proponents of dedicated breast radiology also say that despite common beliefs to the contrary, such a practice has economic advantages. Efficiency Pays Off Kolb is currently chief operating officer of Women’s Diagnostic of Texas, five breast centers in the Dallas-Fort Worth area, where the practitioners are all dedicated breast radiologists. Because they are dedicated to breast imaging and work in a controlled environment, they are able to interpret at a rate of one screening mammogram per minute or approximately 60 per hour. At that rate, they are earning professional fees at more than $2,000 per hour. “That will compare with anything radiologists do. That’s effective time utilization,” Kolb says. A radiologist who is not dedicated to mammography and isn’t provided the appropriate surroundings is going to take three to five minutes to read and report on a screen, Kolb says. Also, he says, because they are typically uncomfortable with mammograms, their recall rate is going to be higher. “So they’re unnecessarily recalling patients and doing it slower.” Reducing Recall “Diagnostic mammograms typically involve the radiologist reading a series of films, the initial views, and then ordering additional views, so there is interaction between the technologist and the radiologist, but, more importantly, the patient is left in the room for a while,” says Kolb. “The typical time for this interaction is anywhere from 30 to 40 minutes, which is really a very ineffective use of the physician’s time because both he or she and the technician are waiting during this process. You don’t want to miss any cancers, but you really want to keep the recall rate low.” In his consulting practice, Kolb has seen recall rates as high as 42%. Typically, in practices where the radiologists reading the exams are general radiologists, the recall rate is 15% to 25%. In practices where the radiologists are dedicated to breast imaging, it runs 6% to 12%, with most falling in the 8% to 10% range, he says. While some radiologists may have higher recall rates to avoid missing cancers, studies have not shown a correlation between recall rates and missed cancers. “If you recall a patient who has a simple cyst, you haven’t helped detect any cancers,” Kolb says. Rose says breast radiology has a reputation for being low paying, but that is not necessarily true. “Reimbursement issues are somewhat manufactured by radiology groups that don’t really understand,” he says. “It depends on how you structure your practice and what part of the country you’re in as far as what your reimbursements are like. However, in general, what I’ve seen in the professional side is not significantly different from other areas of radiology.” Rose has been part of three different breast centers, all of which have done well financially. “It depends on your market, how efficient you are, and what your patient mix is,” he says. Liability Issues “Specializing reduces your exposure in the sense that the more specialized you are, the less likely you are to be sued,” Rose says. “And, if you are sued, you are more likely to win.” One reason Bruce Schroeder, MD, chose to specialize in breast imaging was the liability issue. “Liability actually pushed me into it,” says Schroeder, now director of breast imaging at Eastern Radiologists, Inc. Breast Imaging Center in Greenville, N.C. “I figured that if I’m going to be at risk at all, I want to be the best I can be. Maybe my thinking is completely warped, but rather than shy away from something that is high-liability, I decided I’m going to go whole hog into it and do it as best I can, and hopefully as well as anyone.” Reading mammograms is really difficult, Schroeder says. “It’s really humbling, and no matter how many you do and how good you are, you will not be perfect. You will miss some breast cancer.” However, if he ever were sued, Schroeder says, he would feel confident because of his subspecialization. “You don’t want to be in a situation where someone is suing you over a mammogram and they say, ‘You read only the minimum. There are people who read 10 times more than you.’ You can’t defend that as well.” Another reward radiologists see in specializing in the breast is that they can follow the patient from her screening mammogram to her diagnosis and treatment, if necessary. “We are able to go full circle with these patients,” Linver says. “That’s what’s different about breast imagers. We become more of a clinician.” Linver acknowledges that the clinical side to being a breast imager could be a turn-off for some in radiology. “A large number [goes] into radiology because they don’t want to see patients. They’re not interested in the clinical side. They’re strictly involved with the imaging,” Linver says. However, he says, “to be a breast radiologist you have to have a strong clinical interest, otherwise you’re not going to be any good at what you do and you won’t adequately fulfill the role you need in the patient’s breast care.” Stough says getting to know her patients is one reward of her job. “I have that kind of practice where I have a true relationship with my patients, and that is very, very satisfying,” she says. Some may be reluctant to subspecialize in breast imaging for fear that if it’s all they do it could become monotonous. General radiologists look at all types of images and of a range of diseases and conditions. Linver says the routine of his job has never been an issue for him. “Some radiologists say they enjoy the tremendous variety, but once you become part of the breast imaging ‘family,’ and you begin to see patients regularly and follow them through all the steps of their care, and then see what you’re able to accomplish, you receive a level of gratification that completely replaces the need to do anything else.” Patient Relationships Besides, Stough says, she finds lots of variety and lots of challenges in her work every day. “Every woman’s breasts are like their own,” she says. “They’re not like anybody else’s and they’re not like their mother’s. Sometimes they’re not even alike from one side to another, so it’s very complicated and very challenging.” While breast cancer mortality has been steadily declining since 1990, it remains the leading cause of cancer death among women in the United States. The decline in mortality has been attributed to early detection via screening mammography, coupled with improved therapy. Growth Industry Breast radiologists say more needs to be done to attract young radiologists to their field. What few fellowships there are in breast imaging often go unfilled. Schroeder says it’s a daunting challenge given that breast imaging is not usually considered to be as exciting as CT or MR or other high-tech modalities, reimbursements are not as high as other radiologic subspecialties, and the liability is high. “It’s a formula for what you have. Thirty to 40 spots for breast radiology fellows and half are unfilled.” Stough says it’s also important that radiologists recognize that they don’t have to be at a large university to specialize in breast care. “You just have to be committed to doing breast work and you can be as good as the best,” she says. Some believe the key may be making practitioners aware of the possibilities. Rose says once most radiologists try the subspecialty, they like it. “People who find their way to this area discover it’s what they want to do,” he says. “They’re very dedicated to doing it. Once they do it, they rarely go back the other way.” — Beth W. Orenstein is a freelance medical
writer in Northampton, Pa., and a regular contributor to Radiology
Today.
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