Abujudeh H, Bruno MA. Radiology Noninterpretive Skills: The RequisitesElsevier; 2017; 304 pp; $109.99

Radiology Noninterpretive Skills The Requisites 1st Edition--Hani Abujudeh

In the current era of ever-increasing complexity of the health care system, Radiology Noninterpretive Skills: The Requisites offers radiologists of all levels a comprehensive, efficient, and ultimately practical resource regarding all of the topics implied by the book’s title. The key topics in “quality, safety, and process improvement” are introduced in Section I. Radiology residents will be especially appreciative of Section II, “Core Concepts in Radiology Noninterpretive Skills,” and Section IV, “Special Topics,” which altogether contain the basic information needed to meet the requirements of the Accreditation Council on Graduate Medical Education and cover topics relevant to career development, including leadership, malpractice, social media, and ACR Guidelines and Criteria (the latter of which may be tested during the ABR Core Exam). In Section III, key topics are reorganized by subspecialty. These 4 sections comprise 30 chapters.

Section I, “Quality, Safety, and Process Improvement,” consists of 9 chapters, including “History and Current Status of Quality Improvement in Radiology,” “Key Concepts in Quality Improvement,” “Quality Improvement: Definition and Limitations,” “Quality Improvement Tools,” “Patient Safety,” “Quality Improvement in Radiology,” “Radiology-Related Quality Programs and Organizations,” “Highly Reliable Organizations/Systems in Healthcare and Radiology,” and “Future of Quality Assurance.” The first chapter starts with the whistle-blowing Institute of Medicine (IOM) report, “To Err Is Human,” and then ties in the ensuing history with the ABR and Maintenance of Certification (MOC) examination. The content gives perspective on the history of medicine and radiology’s role in addressing patient safety challenges and associated cultural challenges. The provided historical context is likely to be well received by readers, especially those who had not yet started their medical careers by the late 90s or early 2000s. Following the historical stage and goals described in the first chapter, the second chapter continues discussing the drivers of quality improvement (QI) in health care and describes tools and concepts that help identify projects that are most likely to improve patient care (eg, the Donabedian model). Quality improvement metrics and philosophies such as lean, the Six Sigma model, and the ACR’s Imaging 3.0 initiative are discussed in the third chapter. By way of a case study, the fourth chapter describes the use of QI tools such as run charts, flow charts, Pareto charts, and fishbone/Ishikawa/cause-and-effect diagrams; the authors include “practical tips” at key steps. The fifth chapter reapplies earlier concepts such as the 6 aims from the IOM, quality control tools, and philosophies such as lean/Six Sigma to the patient safety mission, comments on specific challenges in radiology such as perceptual errors, and discusses the Universal Protocol, intravenous contrast safety, radiation safety, communication between radiologists and providers, ACR Appropriateness Criteria, ACR Practice Guidelines and Technical Standards, and peer review. Chapter 6 details ABR MOC requirements and provides steps for conducting a QI project, leveraging the tools that were introduced in earlier chapters.  Chapter 7 describes the major, well-known radiology campaigns such as Image Gently, Step Lightly, and Image Wisely, in addition to other, likely lesser-known concepts to radiologists such as the American Board of Internal Medicine’s Choosing Wisely. Several other quality programs are discussed, including (but not limited to) the Joint Commission, the Center for Medicare and Medicaid Services, the Physician Quality Reporting System (PQRS), and Clinical Decision Support. The concept of a highly reliable organization is thoroughly detailed in the eighth chapter, stressing the fundamental principles necessary to transform health care organizations into high-reliability systems with an emphasis on systems thinking and just culture. The section concludes with perhaps one of the deepest chapters, in which the authors outline opportunities they believe to enhance the quality of imaging locally and nationally within the context of previously introduced concepts such as peer review, communications, Six Sigma, etc. The future roles of accountable care organizations, program performance indicators, pay for performance, PQRS, radiology benefits management, utilization management, and bundled versus capitated payment models are also discussed in detail. In summary, Section I effectively introduces the past, present, and future of QI and patient safety in such a way that a neophyte can grasp the fundamental issues and probably start to ask better questions in the workplace.

Section II, “Core Concepts in Radiology Noninterpretive Skills,” consists of 9 chapters including “Evidence-Based Imaging,” “Patient-Centered Radiology,” “Professionalism and Ethics,” “Communication,” “Error in Radiology,” “Error Management and Reduction,” “Accounting in Radiology,” “Radiology Informatics,” and “Statistical Tools and Quantitative Reasoning.” Chapter 10 reviews bias in imaging research, with tables listing the different types of bias. A probably less widely known concept is included in the section on understanding the value of imaging, wherein a successive, tiered approach to evaluating the literature and its applicability to patients and society is described. Chapter 11 describes the numerous elements required to deliver optimal patient satisfaction and patient-centered outcomes. The 12th chapter contains text on the basics of professionalism, conflicts of interests, ethics, and other related topics. The next chapter discusses communication among radiologists, providers, and patients, argues the best structure of a radiology report, and provides an overview of systems for radiologist decision support. The idea that the goal of adequate communication is to answer the clinical question and drive patient care is stressed. The authors include several evidence-based examples of terms considered vague or clear by clinicians. Chapter 14 discusses the major sources, consequences, and management of consequences of error, and Chapter 15 follows with methods for error management and reduction. Report clarity, critical results reporting, and verbal communication when necessary are stressed in their own respective sections. The section on Penn State’s “Failsafe” program is of note; it includes a sample letter to a patient who requires imaging follow-up—courses of action are advised depending on whether the primary care physician is in or out of the hospital system, and this can be easily adapted to any department as part of a QI project. The focus is changed by Chapter 16, which covers various radiology accounting subtopics that are detailed enough for an aspiring department head, not detailed enough for a department manager, and probably not all that helpful to the average radiologist in day-to-day practice. The following radiology informatics chapter gives an excellent list and descriptions of common terminology related to the radiology information systems, PACS, etc. It provides enough detail for a noninformaticist without being superfluous. Finally, Chapter 18 offers an excellent review of statistics that is likely to be a helpful reference for most radiologists, regardless of training level, including residents who desire a more in-depth treatment than is usually found in review books, but not so onerous as that in a statistics textbook.

Section III, “Practice Specific and Subspecialty Radiology Topics,” consists of 8 chapters, including “Imaging of Pregnant and Lactating Women,” “Safe Use of Contrast Media,” “Noninterpretive Skills in Ultrasound,” “Noninterpretive Skills in Magnetic Resonance Imaging,” “Optimizing Radiation Dose for Computed Tomography,” “Interventional Radiology,” “Quality Considerations in Children,” and “Emergency Radiology.” Chapter 19 gives a concise but complete summary on issues related to maternal and fetal radiation dose risk and dose estimation during pregnancy and for lactating mothers. Modality-specific indications (eg, CT, MR, US, versus fluoroscopy) are included in separate sections. Issues related to contrast media are also discussed. Chapter 20, in 18 pages, effectively condenses all the information found in the ACR Manual on Contrast Media into relatively concise text, tables, and figures. Chapters 21 through 23 discuss issues specific to ultrasound, MRI, and CT, respectively, including bioeffects, contrast agents, artifacts, and QI opportunities. The 24th chapter covers safety, teamwork, preprocedural care (such as pain control/sedation, coagulation/hemostasis risk), and intraprocedural care (such as radiation safety, infection prevention, universal protocol, and postprocedural monitoring). The presented concepts are probably already part of competent interventional radiology departments, but the chapter may be useful to those who wish to have an organized review and tables related to these topics. In a similar fashion, the 25th chapter on quality considerations in children discusses concepts that are probably already part of a competent pediatric imaging department, but the terminology and tables contained within the chapter may be desirable to those who wish to have a concise, organized reference. There is a subsection on the ACR Appropriateness Criteria as it relates to children, but one may be better served by referencing the source documents, which are available online for free. The final chapter in this section, “Emergency Radiology,” is a particularly well-written and thoughtful text that can probably stand on its own as a practical review on communication, patient safety, and risk management for any radiologist. The authors stress good communication between radiologists and patients, radiologists and families, and radiologists and clinicians. Conflict mitigation and de-escalation steps are very well outlined and described and can probably be helpful to all radiologists who interact with patients frequently (eg, interventional, breast, and pediatric radiologists). The subsection on risk management is notable for several reasons, particularly for its treatment of intrinsic and extrinsic factors that lead to radiologist error (ie, poor-quality examinations, fatigue, poor viewing conditions, failure to consult previous studies, inadequate staffing, inadequate training, etc.). The following subsection on risk management paradigms includes clear diagrams of program components that enhance the text and can serve as introductory references for radiologists who wish to delve into the world of risk management and departmental leadership. Other topics that were also (and seemingly redundantly) covered in earlier chapters are included, such as some physics concepts by modality. Due to its comprehensive content, this chapter almost seems a bit misnamed and—to its credit—can probably stand as a review of several important topics for most radiologists, especially trainees.

Section IV, “Special Topics,” consists of 4 chapters, including “Malpractice in Radiology: A Hapless Relationship,” “Leadership: A Manifesto for the Nonclinical Education of Radiologists Looking to Succeed in Difficult Times,” “Imaging Appropriateness Guidelines and Clinical Decision Support,” and “Internet, Social Media, and Applications.” Chapter 27 offers plenty of background and advice regarding radiology malpractice and the defense thereof. Subsections on teleradiology and mammography are included, followed by related comments found in the ACR Practice Parameters and Technical Standards document. The advice on how to handle disclosing mistakes and reporting abnormal radiographic findings on a previous exam is clear and direct. The next (short) chapter stresses early leadership training with the philosophy that leaders are made and not born, describes the characteristics of leaders, lists a curriculum leadership for the 21st century, and offers advice on obtaining the skills needed to be successful. The author is passionate and compelling in advocating for early leadership training and the idea that radiologists must lead themselves or risk being led by people who do not understand radiology or medicine. The next chapter discusses imaging appropriateness guidelines and clinical decision support in clinical practice. Those who are interested in the development of appropriateness criteria, the role these criteria have played in radiology, and the development of clinical decision support may find this chapter interesting. Finally, the last chapter in the book discusses the digital revolution, social media, and their relationship to consultation, research, collaboration, and education.

In summary, Radiology Noninterpretive Skills contains plenty of well-written content that should be helpful to radiologists who want to advance into leadership and management positions, understand how to optimize their practice for the sake of patient safety and improved outcomes, and gain a better understanding of the complicated world that revolves around and influences their practice of medicine (which probably should be all of us). The content in the first 2 sections and Chapter 26 on emergency radiology are especially suitable for such individuals, as much of the content is not part of standard radiology training curriculum but is probably important for the survival of the practice. Overall, this textbook is recommended to all radiologists, especially those who are or aspire to be in any kind of leadership position, no matter how big or small.

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