|Scott Reeder, MD, PhD, FSCBTMR
|Professor and Vice Chair of Research
|Chief of MRI, Department of Radiology
|University of Wisconsin, Madison
Dear Friends of the Society for Advanced Body Imaging (SABI),
I hope each of you and your families are safe and well in this time of great global challenge and uncertainty. We have all struggled and sacrificed in small and large ways, as we have faced this pandemic together.
As the pandemic exploded around us in mid-March, I was inspired by the writings of Richie Davidson, a leading authority on wellness and compassion.
“One thing that strikes me as notable is that we are being asked to practice ‘social distancing’ - to stay home and cancel everything. This is a compelling opportunity to recognize that … social distancing is … an act of generosity and compassion toward others … Let that sink in – the primary motivation for social distancing is to benefit others.” – Richie Davidson, PhD
Opportunity, generosity and compassion. These important words have driven so much of what we do as medical professionals and members of the larger community. Thank you for all that you have been doing, whether serving on the front line, reading exams remotely, educating our learners through innovative remote venues, leading dramatic operational changes in your organization, or by supporting loved ones at home.
We at SABI are with you in this struggle. Be sure to lean on your network of friends and colleagues within SABI, as we continue our collective goal of furthering health care through advanced medical imaging. I am pleased to note that the society is working to provide you up-to-date information to help manage the COVID crisis (eg. Webinar on COVID-19 by Dr. Ella Kazerooni), and SABI has just released a series of twenty lectures from recent annual meetings to enhance our educational mission during these difficult times.
At this moment, we also remain hopeful that the 2020 SABI Annual Meeting in New Orleans this October will continue as planned. Our program chair and President-Elect, Dr. Beth McFarland has led the creation of an outstanding program, beginning with an Artificial Intelligence workshop we are very excited to bring to you. Many thanks to all faculty who have graciously agreed to present and enhance our program. Given the enormous uncertainty regarding all forms of travel and gatherings, please rest assured that SABI executive team and Board of Directors are monitoring the situation very closely, and we will update you as the situation unfolds.
In the meantime, please reach out to your friends at SABI to let us know how we can help you, your trainees, and your patients. Feel free to contact us SABI@acr.org with any suggestions, comments or feedback, or just to let us know how you are managing. None of us are alone in this.
As we all face continuing uncertainty, I remain unshakable in my certainty about a positive future for both the global community and for our smaller SABI community. We shall persevere as we continue in solidarity in our mission of innovation, education, mentoring and inclusiveness. This mission has never been more important.
Be well and be safe.
With best wishes,
Scott B. Reeder, MD, PhD, FSABI
"COVID-19: The Economic Impact"
|As radiologists fight the current pandemic, practices
find themselves struggling to remain financially viable.
|Zeke Silva III, MD, FACR
Chair, ACR Commission on Economics
COVID-19 struck our communities so rapidly that few radiology practices had time to adequately prepare. Over days to weeks, we ramped up to fight a new disease approaching our shores. We learned about the radiology of the disease and helped prepare our institutions, departments, and staff. Then, something else occurred — in many places overnight. It became clear that we must cancel all non-urgent medical services to limit the use of resources necessary to fight COVID-19 and for the safety of our patients and staff. Gone were screening studies, non-urgent surgical planning, and non-urgent interventions and therapies. As a result, much of our practice revenue suddenly disappeared. People around the world are making sacrifices, and our circumstance is certainly not unique. Like many across the globe, radiologists are working to halt the spread of the virus while also incurring real financial consequences that threaten the future of many practices.
As we cancelled the majority of our imaging, difficult questions arose. How will we continue to pay and employ our administrative and clinical staff? How will we, as practicing radiologists, pay ourselves? The repercussions are already being felt. Many radiology professionals, including radiologists, RTs, and nurses, have lost their jobs. Others face an uncertain furlough period. Institutions struggle with their reserves as investment portfolios suffer.
At such a trying time for everyone, discussing finances is not an easy conversation to have. But not addressing the topic can bring serious negative consequences to our broader communities and the very patients we serve. There are local solutions, which are too diverse and specific to discuss here, although I do encourage the sharing of best practices within our communities, such as Engage. Rather, I will discuss national programs and policy changes that apply during the COVID-19 emergency, recognizing that these could change and other options could surface.
Please check the regularly-updated ACR COVID-19 Economic and Regulatory Updates for Radiologists page for the latest information on the federal programs I will discuss below.
CMS Accelerated and Advance Payment Program
In late March, CMS announced it is expanding its Accelerated and Advance Payment Program . Almost all practices are eligible, assuming they have submitted Medicare claims within the last 180 days, are not under investigation, and have not filed for bankruptcy. Practices may request a specific monetary sum — up to 100% of their Medicare amount for a three-month period. No interest is charged. Repayment begins 120 days after the date of issuance of the funds, with 210 days available to repay the balance.
Small Business Administration Economic Injury Disaster Loans Program
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) includes several provisions that may help radiologists. None of the provisions are radiology-specific.1 The law made changes to the Small Business Administration Economic Injury Disaster Loan (EIDL) program to cover economic injury resulting from the disaster. This includes loss in revenue. The maximum amount of these loans is $2 million, with a 3.75% interest rate and maximum 30-year note.
The Paycheck Protection Program
The Paycheck Protection Program allows loans of up to $10 million for businesses with fewer than 500 employees. The maximum amount is 2.5 times the average monthly payroll prior to the pandemic, with payments deferred for six to 12 months. This amount is subject to loan forgiveness provisions for amounts spent in the eight weeks after loan origination for items such as payroll, rent, and utilities.
Funding for Healthcare Providers
The CARES Act also includes $100 billion in direct financial support to practices providing testing, diagnoses, or care for COVID-19 patients. This funding will involve an application process through the Assistant Secretary for Preparedness and Response as part of the Public Health and Social Services Emergency Fund. The funds may be used for lost revenue due to COVID-19.
On April 7, CMS Administrator Verma stated that $30B in funds from the Public Health and Social Services Emergency Fund, via the CARES Act, could be distributed directly to physicians based on Medicare volume as grants.
General Payment Relief
Several changes have occurred to improve payment, which require no action by radiologists. This includes a suspension of the 2% sequestration imposed on our payments and relief for sites where the Geographic Practice Cost Index is below the 1.0 national average. Sizable expansion of telehealth coverage has taken place as well. These policies will increase overall payments. Accommodations to lessen the penalties and burden of the Merit-Based Incentive Payment System program were also provided.2
The ACR’s Commission on Economics will continue to monitor these policy changes and influence policy to help practices survive locally and share best practices nationally. I invite you to review all of the ACR COVID-19 Resources available at ACR.org/covid19.
Reading the Signs
Radiologists can, and should, add value to the care
of intimate partner violence patients -
in and beyond the reading room.
Recognizing the signs of abuse and sharing your
findings with other clinicians can change a life
- maybe save a life.
-Annie Lewis-O'Connor, NP, PhD
“Sadly, you may see patients who die as a result of intimate partner violence (IPV),” says Annie Lewis-O’Connor, NP, PhD, founder and director of the Coordinated Approach to Resilience and Empowerment Clinic at Brigham and Women’s Hospital in Boston. “Recognizing the signs of abuse and sharing your findings with other clinicians can change a life — maybe save a life.”
Raising awareness of what the Centers for Disease Control and Prevention (CDC) calls “a serious and preventable public health problem” should be the goal of all clinicians, Lewis-O’Connor says. Relying on the expertise of radiologists to help identify patients who present with injuries commonly associated with IPV can be a powerful tool when reaching out to women and men in abusive relationships.
IPV is defined by the Violence Prevention arm of the CDC as “abuse or aggression that occurs in a close relationship,” past or present. While IPV encompasses abuse beyond physical injury — including sexual assault, stalking, and psychological aggression (using verbal or non-verbal communication to harm or gain control over another) — radiologists are in a unique position to identify the signs (and patterns) of physical injuries that may suggest IPV.1,2
While considerable research has focused on abuse cases of children and the elderly — leading to increased training and prevention efforts — relatively little literature focuses on how radiologists can play a larger role in helping IPV patients.
“Radiologists are trained to simply report traumatic findings from the current examination without making any active effort to highlight any possibility of this life-threatening issue,” says Bharti Khurana, MD, radiology fellowship director for emergency MSK radiology at Brigham and Women’s Hospital and assistant professor at Harvard Medical School.
Fostering awareness of IPV and familiarizing radiologists with the most common imaging findings of abuse can aid in proper diagnosis and better patient care. Radiologists are often able to form unbiased conclusions based solely on imaging, without having direct contact with the victim or the abuser.2
“There is much to be done in terms of raising awareness among radiologists and physicians in general about IPV,” says Elizabeth George, MD, neuroradiology fellow at University of California, San Francisco, and one of the authors of a defining IPV study while chief radiology resident at Brigham and Women’s Hospital. There is a need for more multidisciplinary research to integrate clinical and imaging data — and to create robust systems for the identification and ongoing care of IPV victims, she says.3
“It is being increasingly recognized that radiologists have a significant role to play in the identification of IPV,” George says. “We have access to a wealth of information in the form of current and prior imaging,” she notes. “Equipped with this objective data, we can work closely with referring physicians and healthcare clinicians as an unbiased witness to improve patient care.”
“Radiologists are only starting to understand the spectrum of imaging findings in IPV,” George notes. “IPV-related findings have not yet been part of radiologists’ training.” Victims of IPV receive more imaging studies and have a higher frequency of potential violence-related imaging findings when compared with control subjects of the same gender and age range.3 “A lot of the injuries are usually distal on the body, often signally defensive injuries,” Lewis-O’Connor says. “If you are being punched, you are going to put your hand up to protect yourself. If you are being kicked in the abdomen, you are going to pull your legs up. These injuries are red flags for me.”
“The face is considered a target area, especially mid-face contusions and periorbital fractures. In the presence of defensive injuries, such as forearm or hand fractures or contusions, the likelihood of these injuries due to violence becomes high,” Khurana says. “By recognizing the high imaging utilization, location, and imaging patterns specific to IPV — as well as old injuries of different body parts on prior studies and injuries inconsistent to the history — the radiologist can generate an objective report,” she says.
“We are already trained to identify these injuries in isolation,” George notes. “Understanding the pattern of associated and prior injuries — and being mindful of them until it becomes routine — will help us put IPV detection into practice.”
Radiologists can, and should, add value to the care of IPV patients — in and beyond the reading room. “What might at first glance seem to be an accidental injury, on careful review of additional and prior findings, could be indicative of ongoing nonaccidental trauma,” George says. By developing expertise in IPV recognition, having discussions with referring providers, and understanding the coordinated care that follows, radiologists can further the goal of patient-centered care and make a life-changing difference for their patients.
Any type of injury can happen because of IPV. But if there are specific findings that we can give the probability for, we can increase radiologists’ role — and give them the confidence to make the invisible visible.
Motivation and diligence will not go unchallenged, however. IPV continues to be profoundly underdiagnosed, mainly due to a lack of early detection which can result from the reluctance of victims to report it to healthcare providers. Screening with IPV in mind can lead to the detection of characteristic injuries or patterns that may inform a conversation that prevents future violence.4
The burden of identifying IPV is not the sole responsibility of radiologists, but falls on the healthcare team when a study shows injuries consistent with IPV, says Lewis-O’Connor. While conducting a team huddle, it may become clear that imaging results don’t match up with the patient’s history. Plus, radiologists may find healing injuries the referring provider didn’t know were there.
When IPV is suspected, all members of the healthcare team must be extremely mindful of a patient’s situation — even when they have the patient’s best interests in mind. Only a handful of states in the country allow or require reporting of IPV, Lewis-O’Connor says. You can ask patients questions related to their situation — and ask if they want help. In the majority of states, law enforcement can’t be called unless the patient requests it. Allow the patient to self-determine, provide choices, and respect their decisions.
While many lives are lost to IPV each year nationwide, Lewis-O’Connor says, pursuing a suspected case could ultimately make things worse for the victim once they leave a healthcare setting. Thus, providing a safe space in a non-judgmental manner allows patients to engage in the future.
Many cases of IPV go unreported by victims because of feelings of guilt, shame, or fear of reprisal — especially against their children, who are also at risk. The overwhelming majority of IPV patients are women, and Lewis-O’Connor notes that she has seen many come in soon after having a child.
Concerns of patients are real — “What happens if there’s not enough evidence to arrest an abuser, but the abuser finds out it was reported?” she asks. “What if the victim fears for her child or depends on the abuser for housing, food, or money?” Considering reporting is complicated and some find it more harmful than good, she says, you have to be careful when explaining options to patients and listen without prescribing. “It’s not as tidy as everybody would like it to be,” she says.
To put that into perspective, Lewis-O’Connor says that during her career she has had two patients die of breast cancer and three murdered as a result of IPV. Knowing that the worst can happen may prompt healthcare providers to share findings with other clinicians and hospital social workers, she says, so that potential victims are offered timely assistance.
While identifying victims of abuse is arguably the biggest challenge in combating IPV, opportunities exist to connect with patients.
Researchers at Massachusetts General Hospital (MGH) have explored integrating IPV screening when women present for breast imaging or annual mammograms. Women are given a questionnaire posing questions such as, “Do you feel safe at home?” or “Do you feel safe in your relationship?”
If women indicate not feeling safe at home, they are referred to the institution’s Helping Abuse and Violence End Now (HAVEN) program that is located on campus or provided with contact information for offsite HAVEN centers.5
While this type of patient self-reporting can have positive outcomes, providers need more guidance on IPV, according to Khurana. Screening questions can motivate a patient to disclose information, but if a patient decides not to, a provider might not raise their own concerns about IPV. “Right now we are essentially depending on patients’ self-reporting,” she says. “Even if a patient does not disclose IPV, services and safe numbers can be provided as part of universal education,” adds Lewis-O’Connor.
If a past injury shows up on new imaging, a greater awareness of IPV might prompt a radiologist to raise questions about abuse. However, Khurana believes that expecting radiologists to seek out IPV findings and then raise concerns with the appropriate clinician or healthcare support staff is not realistic without some kind of systemic help.
Along with a team of multispecialty physicians from Brigham, MGH, Harvard School of Public Health, and other institutions, Khurana is now leading an effort to use machine learning to narrow findings that suggest the probability of IPV injuries and integrate those findings into radiology reporting systems.
“Our goal is to create a fully integrated, multidimensional clinical decision support tool that uses patterns derived from expert analysis of historical radiological and clinical data, classification models, and statistical evidence to classify injuries for their likelihood of being due to IPV,” she says. Clinicians would be automatically alerted if a patient’s injuries have low- or high-risk probability of IPV.
Providers may overlook the signs of IPV because of their unconscious bias toward a victim’s or abuser’s physical appearance, education level, or socioeconomic background. Research acknowledges that some healthcare providers can be hesitant to suggest IPV, often for fear of offending patients or their partners. The automated prediction of IPV based on historical radiological and clinical data could avoid such bias and help validate radiologists’ concerns.6
Khurana hopes her work with data scientists will lead to an alert system for radiologists based on patients’ imaging history. Using machine learning to recognize signs of IPV on current and prior images, the alert would provide a visualization of risk factors, empowering healthcare providers to open a dialogue with potentially at-risk patients. Once validated, Khurana hopes to make the algorithm accessible through
ACR’s Data Science Institute™ and integrate outputs into radiology reports.
“In addition, our multidisciplinary team plans to design conversational guides using medical images for training social workers and clinicians to approach patients identified as high-risk for IPV,” she says. Visually pointing out an injury on imaging studies to a victim may encourage them to talk about their situation.
Further research and training is needed to create awareness of IPV among radiologists who might be the first physician to suspect violence when presented with serial imaging studies. “We as a specialty should lead this work, educate ourselves, and increase awareness among our colleagues,” George says. “To make a meaningful impact in the multidisciplinary care of these patients, radiologists must work together with clinical colleagues in integrated groups.”
“IPV is so common, but these patients often get missed,” Khurana says. “Any type of injury can happen because of IPV. But if there are specific findings that we can give the probability for, we can increase radiologists’ role — and give them the confidence to make the invisible visible.”