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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Jay Cinnamon for a lecture entitled The Radiologist.

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And 2026 is the Doctor in Dr.

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Cinnamon has been a practicing neuroradiologist

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for 35 years.

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He spent the first 13 years in academic medicine,

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mostly at Emory Healthcare in Atlanta, Georgia.

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And for the last 22 years,

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he's practiced at quantum radiology

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and independent private practice based in Marietta, Georgia.

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Dr. Cinnamon did pioneering clinical work in multis slice

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ct, and various neuroradiology clinical applications.

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Most recently, he's been speaking about the changing culture

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in radiology and the impact these changes have had on

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patient care burnout, the relevance of AI

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and the search for personal fulfillment.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may

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have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before time is up.

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With that, we are ready to begin today's lecture. Dr.

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Cinnamon, please take it from here.

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Thank you, Ms. Whitehurst.

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Um, it's, it's great to be here. Lots of fun to be here.

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Um, really, really appreciate the invitation here.

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And, um, my subject here, um,

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I'm just gonna move this out of the way a little bit.

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Um, oops. There we go.

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My subject here is going to be the radiologist in 2026,

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is the Doctor in.

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And, uh, first things first, um,

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I do wanna say thank you very, very much for the invitation.

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Thank you to modality for inviting me,

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and thank you for all of you, those, all

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of you who've tuned in for this, um, to, to listen.

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And I hope it'll be, um, interesting for all of you.

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It's a little bit different than, um, than some

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of the other lectures that you might hear on, um,

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on modality, but hopefully it will stimulate you

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to think a lot about where we are right now in radiology

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as radiologists, and where we may be heading, um,

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over the next, uh, few years.

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Um, my educational objectives here are to explore

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how we see our current day roles as diagnostic radiologists

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and how we may choose to move forward from here, uh,

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to explore rebuilding the clinician radiologist relationship

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and why we might choose to do so.

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And I'll explain that more as we go along,

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and to explore how we move back

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to being patient centric rather than study centric in

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diagnostic radiology.

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And this is going to be a recurrent theme, um,

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that we're going to try to emphasize about being

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patient-centric rather than study centric.

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Because I think I'll try to show to you

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how years ago when I was training back in the eighties, uh,

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in the early nineties, um, it was

2:47

by definition a very patient-centric field.

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But as, uh, we've moved on

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with new technological advances over the last 30 years,

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I think we've unfortunately become a little more study

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centric than patient centric.

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Um, I'm not going to be talking about rocket science here.

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Uh, this is not really going to be a earth shattering, uh,

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new science, but it will have be lots of social science.

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Uh, the organizational psychologists

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and the cognitive scientists and the,

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and the social scientists, they've done a lot

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of work on understanding some of these issues as they relate

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to other fields.

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And what I'm going to do is try to incorporate some

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of those ideas, uh, from the organizational psychologists

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and the social scientists into application to

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what we do on a, on an, on an, uh, daily basis.

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So as part of an overview view, I wanna do transfer,

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talk about the transformation

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of radiology over the last 40 years.

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This kind of sets the background for where we've come from

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and where we are right now,

3:45

including the good, the bad, and the ugly.

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And then talk about the negative psychological and cultural

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and healthcare effects that this transformation had on us.

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And essentially, who am I as a radiologist?

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What am I, um, what can we do today to fix this?

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And, and why should we,

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why should we care about fixing this?

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If the system seems to be working, what,

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why should we be looking for something that's better?

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So we'll start with here, basic, very o simple overview,

4:11

transformation of radiology over the last 40 years.

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And anyone who is pretty much over, I guess 45, 50,

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probably 50 years of age, remembers this.

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Um, and, uh, again, I'm, I'm 65 years old.

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I trained in the eighties, went

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to medical school in the early eighties.

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I started my residency in 85, 86,

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finished my fellowship in 92.

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And so I lived in an age where, um, pre-packs

4:37

and, uh, pre-electronic imaging, everything was, uh, filmed.

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And so you started with an x-ray,

4:43

and the x-ray was then developed, put on an alternator.

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You read it out with an old-fashioned dictaphone on a tape,

4:49

tape recorder that then went to a transcriber that taped,

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typed out a report and that the one made it to the chart.

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Um, and the timeline for this was days.

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Now, why is that important? It was, we, well,

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some very simply, um, with this kind of a path.

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We didn't wait for five days

5:07

for a report to reach the chart.

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We would go down to the radiology department

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6, 7, 8, 9 times a day to go over studies

5:16

with the radiologists.

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So if you sent the patient down

5:18

for an ultrasound at 10 o'clock in the morning,

5:20

you gave the, the radiologist a couple

5:22

of hours to read the ultrasound.

5:23

You went down at one o'clock

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and you said, you know, I'm sorry to bother you.

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Um, but would you mind going over the ultrasound on

5:29

my patient, Mrs. Jones?

5:30

And you talked about the patient and,

5:32

and you talked about what the imaging showed

5:34

and with the radiologist,

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and it was a very dynamic relationship that existed between,

5:39

um, the clinicians and the radiologists.

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So much so that on clinical rounds, when I was doing my,

5:45

my internship in internal medicine, um,

5:48

what we would do is we would show up at seven o'clock in the

5:50

morning to round on our patients.

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This was the medical students, the interns, the residents.

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We began rounding on our patients at

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seven o'clock in the morning.

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And at nine 30 in the morning, we had attending rounds,

6:00

which is when the attending came in.

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And we would circle back on all of the patients,

6:04

on the teams, usually two or three teams of medical students

6:07

and interns and residents,

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and circle back on all 25, 30 patients

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and going over them with the attending.

6:13

And that would start at nine 30.

6:14

And then at 1130, we would head down to radiology

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and we would go down to the radiology department.

6:20

And, uh, someone would say, okay,

6:21

the four west team is here.

6:23

And we'd go to the radiologist

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and all the x-rays, the cat scans, the x-rays,

6:27

the ultrasounds, everything would be on an alternator.

6:29

And the radiologist would say, okay,

6:30

which patients would you like to go through today?

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And we would give them a list

6:33

of maybe 10, 11, 12 patients that we'd want to go through.

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Um, and we would present the information to the radiologist,

6:39

and the radiologist would then go over the imaging findings,

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and we would discuss the

6:43

patients together with the radiologist.

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And the radiologist would be now able

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to narrow down the differential diagnosis, um,

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based on the clinical information that we

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provided to the radiologist.

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And this is what it kind of looked like. Uh, this is Dr.

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Melvin Zaleski, um, who was a radiologist at, at Einstein,

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where I went to medical school up in the Bronx.

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And the team would come down and Dr.

7:05

Zaleski would go over the, the, the patient studies

7:07

with, with the team.

7:09

And there was a very dynamic interaction.

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So it even went so far as to Dr. Baker, who was the director

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of NA Radiology at the time.

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He actually did, he was a real innovator.

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And what he did, he said he actually sent the radiologists

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up to the floors

7:24

to accompany the clinical teams on clinical rounds while the

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radiologists, while the clinicians were

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rounding on the patients.

7:31

So a radiologist would actually accompany the clinical team

7:34

and would be able to interact

7:36

with the clinical team real time

7:38

as the attendings were essentially reviewing the patients

7:42

and going over the patients

7:43

with the interns and the residents.

7:44

And then Mike turn to the radiologist said, well,

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what do you think we should do next?

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And the radiologist was there real time to provide the clin,

7:52

uh, the clinicians with the information

7:54

and the guidance necessary.

7:55

And the idea was that back then, clinicians

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and radiologists were besties.

8:00

They were best buddies.

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Everybody knew each other on a first name basis.

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Everybody got along really well with each other.

8:06

Um, everybody, um, participated.

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It was really a, a team approach.

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Everybody was, you know, very happy in the sense

8:13

that everybody was feeling fulfilled and part of the team

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and working together for the betterment

8:18

and for providing better care, optimal care to the patients.

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But then we went through a massive transformation.

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Um, and this really occurred in the nineties,

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and the massive transformation existed with mult, with,

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with rapid imaging.

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So multi slice CT came on the,

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the scene in the mid nineties, um, along

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with digital imaging and pax.

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And what that did was it changed everything.

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So for example, from the early seventies

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to the early nineties when we had basic step

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and shoot ct, this is a picker, uh,

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I think a picker 8,000 CT scanner and an old CT scanner.

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And what happened in, when I was training,

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we would do a CT brain five millimeter slices.

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It would be 24 to 30 images, it would take 20 minutes

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for the patient on the table to get the study done.

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CT abdomen pelvis was 10 millimeter slices,

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and it was 45 images.

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That was 30 to 45 minutes.

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And if you wanna do, for example,

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a post myelogram lumbar spine CT

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or even a regular lumbar spine ct,

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five millimeter thick slices, 45 to 60 images,

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and that was 45 minutes with the patient on the table.

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And that was, then those,

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then those images were printed up on, on image on film.

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They were brought to the radiology

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radiologist a little while later.

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And we got to read them

9:34

whenever we got a chance to read them,

9:35

usually later on in the day.

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But the concept of CT angiography of the brain,

9:40

that wasn't even on our radar screen,

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that was not even something we could, uh, toy with.

9:45

And the concept of doing physiological imaging,

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profusion ct.

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If you asked us back in the, uh, eighties,

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what about profusion ct?

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We would literally turn to you

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and say, what are you smoking?

9:55

You cannot do profusion CT on CT imaging.

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You know, it is not dynamic. It is not physiologic.

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It was a completely different domain.

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Um, but then came multi slice CT and then came packs.

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And we made two steps forward,

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but we also took two steps back.

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The two steps forward were ultrafast imaging acquisition

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and ultra fast image access.

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Images could be sent to packs, be available within seconds,

10:21

within minutes, and available to us

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with the old studies right there.

10:24

And then no hanging of films, nothing, everything is there

10:29

and much larger data sets.

10:32

But the two steps back were we essentially severed the

10:36

clinician radiologist dynamic

10:37

because no longer did clinicians need to come down

10:40

to the radiology department

10:41

to go over studies with the radiologist.

10:43

They could access these images on the floor,

10:45

they could access these images remotely.

10:48

Um, no longer did a clinician need to come down

10:50

to the radiologist to interact with him or her

10:52

and to go over the patients

10:54

and review the patients real time.

10:56

And this invariably had an effect on clinicians, um,

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as we all know, and it has an effect on radiologists,

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and I'm going to mostly focus on the effects on a

11:07

radiologist, but I'll touch on briefly on

11:10

the effects of clinicians.

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So a lot of this has to do with a matter of perspective.

11:16

And so, you know, you have different perspectives, um,

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from the clinician to the radiologist

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and from the radiologist to the clinician.

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So for example, we, from the clinician's perspective,

11:30

the requisition process became very, very easy.

11:33

You got a requisition,

11:35

you essentially clicked whatever studies.

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Now it's all electronic. You click whatever studies

11:39

you want on a patient.

11:41

And it's very, very, not very different from ordering tacos.

11:46

You go down the list, you check your pick,

11:49

pick your tortilla, you pick your meat,

11:51

you pick your toppings, you click the boxes, you submit

11:55

and gracia there, your order will be submitted

11:58

and the patients will have the studies.

12:02

So what has led to is, as this says, well,

12:06

ordering this X ratio was a waste of time.

12:08

As we all know from the radiology environment, it has led

12:11

to an, an inordinate number of x-rays

12:14

and studies that are ordered that are just not necessary,

12:17

that are just a waste of time.

12:18

Because no longer do the clinicians need

12:20

to ask the radiologist their, um, their, for their guidance.

12:24

Right now it's all electronic ordering.

12:26

You just click the boxes and submit.

12:28

And, uh, the patients are going to then be, uh,

12:31

essentially pipelined to have those studies done.

12:34

We very, very rarely get involved on the frontline to kind

12:38

of, uh, filter out the studies that need

12:40

to be done from the filters that really are not going to be

12:43

to the benefit of the patients.

12:44

Um, and obviously it's different when it comes

12:46

to interventional radiology.

12:48

It's probably a little bit different when it comes

12:50

to pediatric radiology as well,

12:52

because pediatricians tend to seek Catholic guidance

12:54

of the pediatric radiologists more so than with,

12:57

uh, adult patients.

12:59

But from the perspective of the clinicians, uh, now we

13:01

and the radiologists, we're seeing a lots of tests

13:03

that are ordered inappropriately and unnecessarily.

13:08

So the clinicians, essentially what we've become is,

13:11

you know, send off the, send off the blood

13:13

and get the CBC result, send off the patient

13:18

and get the impression, no acute pathology, send the patient

13:21

to radiology and get the result.

13:22

We've essentially reduced ourselves to a blood test.

13:27

Um, send off the blood, get the results,

13:30

send off the patient to radiology, get the impression

13:32

because we have severed that relationship

13:35

between the clinicians and the radiologists.

13:39

And this has been cited by lots of people,

13:41

much smarter than I, Dr.

13:43

Bro, Dr. Brady, past president of the European Society

13:46

of Radiology wrote about this back in 2021,

13:49

the vanishing radiologist and an unseen danger

13:52

and a danger of being unseen.

13:54

It is vital to going to the, the abstract,

13:56

the underlying part is vital for the successful future

13:59

of radiology that we remain conscious of the need

14:03

to maintain visibility of who we are

14:05

and what we contribute to patient care.

14:08

And from the other perspective,

14:09

from the perspective of the clinicians.

14:11

Dr. Wachter, who is chair of the Department

14:13

of Medicine at UCSF wrote all the way back in 2015,

14:17

I am deeply concerned, remember, this is an internist.

14:19

Now, I am deeply concerned that mine is the last generation

14:22

to have learned the habit of going

14:24

to the radiology department.

14:27

It saddens me that our current trainees will never know

14:30

how much they can learn from a great radiology teacher

14:33

and how their patient's care can be improved

14:35

by actually talking to a real live radiologist.

14:39

This is back in 2015 when he wrote his

14:41

book, the Digital Doctor.

14:43

So again, this is the reflections of what it is

14:46

that we've now severed the relationship

14:48

between the clinician

14:49

and the radiologist for the most part, since now we've aun

14:53

to the point of where in no longer with electronic imaging

14:57

and pacs, no longer is it necessary for clinician to

15:00

initiate a conversation with the radiologist.

15:03

And as I'll talk about in a little while, the fact

15:05

that this is has on radiologists is my primary concern.

15:10

And that's what we're gonna talk about now

15:11

because in my, in my opinion, um, we've really, um,

15:16

engaged in very negative psychoso psychological culture

15:20

and healthcare effects on this transformation.

15:22

Who am I? What am I?

15:23

In other words, not only has this severing the relationship

15:27

between the clinician

15:28

and the radiologist had a toll on patient care,

15:32

as I'll show you in a moment

15:33

with some real life clinical examples.

15:35

But it also has, in my opinion, an effect on

15:39

what are we doing and who are we doing

15:41

and issues that relate to us, such as burnout

15:43

and, um, purpose

15:46

and, uh, finding meaning in what we're doing.

15:49

This is what the social scientists have worked at in many

15:51

other fields, but we haven't yet applied it to radiology.

15:56

So Dr. Bernard Lone was a very,

15:58

very noted world renowned cardiologist.

16:01

He's actually the cardiologist who,

16:03

who invented the cardiac defibrillator.

16:06

And he was also the pioneering doctor cardiologist

16:09

who developed the concept of the CCU,

16:11

the coronary care unit.

16:13

In addition to that, he was also the co-founder

16:15

of the International Physicians for Prevention

16:18

of Nuclear War, um, back in the, in the eighties.

16:21

And for this, he won a Nobel Peace Prize in 1985.

16:26

So this was this book that the Lost of Art of Healing

16:29

that he wrote was a combination of memo memoirs

16:32

and reflection of where medicine has gone.

16:34

And this is a direct quote, every advance exacts, uh, uh,

16:38

at very advance exacts a cost

16:41

medicine grew even more depersonalized,

16:43

technology took precedence and patients became secondary.

16:47

A paradox of my life,

16:48

and its ultimate irony is that my research work facilitated

16:51

that, which I, that which I utterly delore, he was all about

16:56

interacting with the patients and figuring out

16:57

what is the best for the individual patients.

17:00

And as we've, as we achieve greater

17:02

and greater technological advances, unfortunately, lots

17:06

of times the price we're paying is on the quality of care

17:10

that we're delivering to patients.

17:12

And this is where it comes to the radiologist.

17:15

The question I have for all of us is, are we study centric

17:20

or are we patient centric?

17:23

And let me show you an example. Okay?

17:26

When I wake up in the morning, do I ask myself,

17:29

am I a doctor who's a radiologist

17:32

or am I just an image reader?

17:34

And I'm going to show you some examples of where the kind

17:37

of hat that you put on in the morning when you wake up,

17:40

the doctor hat or the image reader, will translate

17:43

to many different dimensions of how we do our job on a,

17:47

on a, on a day-to-day basis.

17:48

And it relates to what we do

17:50

before the study is done, how we review

17:54

and interpret it, interpret the study, and make a diagnosis.

17:57

How we dictate report a study,

17:59

how we communicate the findings, and even quality control

18:03

and quality improvement.

18:05

So let's talk about before the study.

18:07

47-year-old female with lower midback pain, no significant

18:12

past medical history, no neurological impairment.

18:14

The doctors order a thoracic spine without contrast.

18:18

An MRI lumbar spine without contrast.

18:21

So what does lower midback pain mean?

18:25

Does lower mid back pain mean back pain in the T 10,

18:29

T 11 T 12 area,

18:31

or does it mean back pain in the T four, T five T six area?

18:35

What does that mean? Um,

18:37

so the question is, what do we wanna do here?

18:40

Do we wanna do, they've ordered a MRI thoracic spine without

18:44

contrast, they've ordered MRI lumbar spine without contrast.

18:47

What if we find out

18:48

that this patient really is lower mid back pain like from T

18:52

10 and T 11 T 12?

18:55

If we are study centric, we're gonna do two studies.

19:00

We're gonna do a thoracic spine MRI,

19:02

and we're gonna do a lumbar spine MRI.

19:06

And on the other hand, if we are patient-centric, well,

19:10

you all know what we can do.

19:11

We can do an MRI of the lumbar spine.

19:13

If we've really decided determined

19:16

by looking at the electronic medical record

19:18

or actually contacting clinician that

19:20

what they're really concerned is from T 10 down,

19:23

then do an MRI of the lumbar spine

19:24

and just increase the field of view.

19:27

Increase your field of view a little bit on the,

19:28

on the sagittal images to cap

19:30

to capture the lower thoracic levels.

19:32

And, uh, add a couple of axial sequences, axial images,

19:35

higher ups instead of starting at T 12, start at T 10

19:39

with your axial images.

19:40

Now what's the difference?

19:41

Difference is if you've done two studies, thoracic spine,

19:45

MRI, lumbar spine MRI, you've doubled the charge

19:47

to the patient, you've doubled the time of the acquisition

19:51

and you've potentially doubled the stress to the patient.

19:54

But if you've done one study a lumbar spine, MRI,

19:57

where you've just increased the field of view

19:59

to capture the lower thoracic levels,

20:01

you've cut everything in half

20:03

and the patient is going

20:04

to be maybe less distressed, maybe even happier.

20:09

Here's another patient, same concept, 62-year-old male

20:12

with left vocal cord paralysis.

20:13

So we all know that vocal cord paralysis

20:15

because of the recurrent laryngeal nerves

20:17

run down into the superior mediastinum.

20:20

If you're really going to do a vocal cord paralysis

20:23

CT examination, you have to go down to the Rina

20:26

because you have to see

20:27

where the recurrent laryngeal nerves loop

20:29

around the mediastinal vessels

20:30

to make sure there's no mediastinal mass causing

20:32

the vocal cord paralysis.

20:34

So often clinicians will offer order a CT neck with contrast

20:38

and a CT thoracic spine, a thoracic,

20:40

a thoracic chest CT with contrast.

20:44

So again, if we are study centric,

20:46

we're gonna do two studies.

20:49

We're gonna do a CT neck and we're gonna do a thoracic ct.

20:54

But if we're patient centric, we're just going to do CT neck

20:57

and just extend it down to the Corona.

21:00

It's going to save the patient radiation exposure for half

21:03

of the thorax.

21:04

It's going to save the patient, um, a double bill.

21:08

And, um, it's more patient centric.

21:11

Let me cut to the chase here.

21:13

If this was your family member

21:16

and your family member was going in for an evaluation

21:18

of vocal cord paralysis, would you want them

21:21

to have two full cts with double exposure,

21:25

a tho full thoracic ct when all you really need

21:29

to do is go down to the carina?

21:30

Or would you rather them have one ct, a CT neck

21:34

with a few extra cuts that go down to the carina,

21:37

saving them half of the bill

21:39

and a good portion of the radiation to their thorax?

21:44

And this brings me to another thing, the word case.

21:48

We've all learned to use the word case.

21:51

We use the ca the word case, um, all the time.

21:55

Next case, next case. Here's an interesting case.

21:58

Here's a sad case. Okay?

21:59

I don't use the word case,

22:02

I haven't used it in decades.

22:05

This image on your left is my hip. Very embarrassing.

22:10

I live in Atlanta. I come from New York.

22:13

Seven years ago we had a snowstorm on a Friday afternoon.

22:16

I was getting out of my car in the driveway.

22:18

I felt pretty slippery. I said,

22:20

oh gosh, I better be careful.

22:21

Um, I'm not really wearing good shoes

22:24

because we didn't expect a snowstorm.

22:26

And I take three steps to my front, front door

22:29

and I go right down on the hip.

22:30

And yes, I am the commercial.

22:33

I call my wife, I have fallen and I can't get up,

22:36

and I have a broken hip.

22:38

And the next day I get a total hip prosthesis right there.

22:42

The bottom line is I didn't wanna be known as a case a guy

22:47

with a femoral neck fracture.

22:49

Next case I wanted to be known as j Cinnamon

22:52

with a broken hip.

22:54

For me, cases are for bottles of wine, cigars,

22:59

eyeglasses, or pencils.

23:02

So I would suggest that we as a group

23:08

ban the word case.

23:10

Let's not use the word case.

23:12

Let's use the word patient's study.

23:15

This will make it more personal,

23:17

it'll make it more individual or make it more humanistic.

23:21

Gonna come back to that in a moment.

23:23

Let's talk about how this relates to review

23:26

and interpretation of diagnosis.

23:28

Again, am I a doctor or just an image reader?

23:32

Okay, 61-year-old male comes in

23:34

with transient left upper extremity weakness,

23:37

non-conscious head, CT from the emergency room,

23:40

completely normal,

23:41

maybe an old lacuna infarction in the left corona radiata,

23:45

otherwise normal, certainly nothing that corresponds

23:47

to left upper extremity weakness.

23:50

The patient undergoes a perfusion ct, a perfusion ct,

23:53

and there's no core infarction.

23:56

The RCBF is of under 30% is zero,

23:59

and the tmax is also, um, zero over six is over, also zero.

24:04

But if you look at the individual images,

24:06

there's a little bit of prolongation

24:08

of the tmax in the right frontal lobe along the cortex.

24:12

Next day I'm reading the MRI, this MRI

24:15

and the patient on the diffusion weighted imaging sequence

24:18

has a few small foci

24:20

of restricted diffusion in the same area

24:23

as the perfusion CT from the day before.

24:26

And small areas of infarction here,

24:29

you can see really in the cortex here.

24:31

Um, just very small areas.

24:33

So the question I had is, well, do I stop here?

24:37

Do I just dictate multiple small areas

24:39

of acute infarction within the high right middle cerebral

24:42

artery vasculars territory involving the cortex

24:44

and subcortical white matter

24:46

of the posterior right frontal lobe?

24:48

Or do I dig deeper?

24:50

So I go back to the CT angiogram study that was read

24:53

by my colleague the day before.

24:55

And the CT angiogram study shows

24:58

as these images will show in a second

25:01

that there is in fact some atheros plaque, um,

25:04

in the right internal carotid artery bulb.

25:07

But here's the thing, when I looked at the curved

25:10

reformatted images, I said, okay, there's plaque here.

25:14

There's plaque here.

25:16

And this just didn't smell right to me.

25:20

I just didn't like the way this looked.

25:24

And you look at the circle of Willis

25:26

and the circle of Willis is wide open.

25:29

So my conclusion here when ID when I dug the deeper into the

25:33

history, was a 61-year-old male was normal when he went

25:35

to sleep, woke up with left upper extremity weakness

25:38

and SL slurred speech.

25:40

The symptoms had resolved by the time he came

25:42

to the emergency department.

25:43

But as the MRI showed, he did in fact have a smo,

25:46

a few small, very distal MCA branch infarcts.

25:51

And I didn't like the way this looked

25:54

and I putting it together.

25:56

All of his other vessels looked wide open to me.

25:59

This just smelled like this is unstable plaque.

26:03

And this gentleman may have very well had a warning sign in

26:07

having essentially his neurological symptoms resolved

26:11

and being left with a few small subclinical infarctions in

26:15

the distal MCA territory.

26:17

So I took it upon myself

26:18

to call the neurologist, the stroke neurologist.

26:21

And I said, this just doesn't smell right to me.

26:24

I think he needs to run this by the neurointerventionalists.

26:26

And I think he need to consider having this gentleman

26:29

stented now

26:31

to protect him from having a devastating embolism

26:34

to an his M1 segment, leaving him

26:37

dev uh, devastatingly impaired.

26:39

And sure enough, this is what they did.

26:41

They took him, um, the next day for a stent.

26:44

They stented him and he was discharged two days

26:48

after admission completely neurologically intact.

26:50

Now, what are the teaching points of this?

26:53

The saline points here.

26:54

And remember, what's this patient Saline points

26:56

of the patient not the case, not the saline points

26:58

of this case, the saline points

27:00

of this patient's experiences, this patient's studies.

27:04

First of all, we do have to be Sherlock Holmes.

27:07

We do have to think and investigate and think harder

27:10

and probe and delve deeper into things

27:13

to see whether things add up.

27:14

Don't just stop and say acute infarctions,

27:17

distal right MCA territory sign report next patient.

27:21

Okay, don't do that. We we're Sherlock Holmes.

27:24

And this is something that's hard to convince.

27:27

The, the, we, we as a radiology department,

27:29

a radiology group,

27:30

have not necessarily convinced the clinicians

27:32

that we use intuition to interpret these studies.

27:36

This didn't smell right to me.

27:38

And so we, we need to, we need to convey to clinicians that

27:42

that things ha we use intuition.

27:44

We use judgment and,

27:47

and a gut feeling on sometimes, sometimes when we, and

27:49

and when we review studies

27:51

and don't be afraid to express that, um, if that's the case.

27:54

But of course, I don't know whether what I did when, uh,

27:58

was the right thing in this patient.

28:00

I hope it was. Um, but I can't clone that patient

28:03

and send them down two paths where one, where he got stented

28:06

and then sent home and another where he was anticoagulated

28:09

and stent home, sent home.

28:10

We don't know what's going to happen.

28:12

I don't know whether I, I actually helped this patient,

28:15

but that's the art of medicine and I hope I did.

28:17

Um, by taking the initiative

28:19

that said this didn't smell right,

28:21

calling the stroke neurologist

28:22

and said, I think you need

28:24

to really get everybody's head together

28:26

because I think this patient may need stenting.

28:29

Okay, let's move on to dictation and reporting

28:32

and see am my doctor or just an image reader?

28:35

So the old way, in my day when I was training,

28:38

we would have a study.

28:39

We would review the study, we would have a report.

28:42

The report would go to the clinician

28:43

and then the clinician would notify the patient

28:47

of the results of his or her study.

28:49

But that's different now.

28:51

Now, once the report is generated, it goes

28:54

to we open chart architecture, it goes to the clinician

28:58

and to the patient at the same time.

28:59

And as you all know, very often the patient sees the report

29:03

before the clinician sees it

29:05

and the patient calls the clinician

29:06

and says, you know, can you go over my report?

29:08

And the clinician says, gimme a minute.

29:10

I need to open it up and take a look at it.

29:12

So it's a different environment now

29:14

that the patients are seeing the reports right off the bat.

29:17

And this goes back to, uh, this hearkens back to one

29:21

of my teachers at, at Einstein, Dr. Burt Bell,

29:24

professor of medicine.

29:25

He was the director of ambulatory medicine

29:27

at, uh, at Einstein.

29:28

And he taught us, remember, we treat people

29:34

not diseases.

29:36

So lemme give you two examples here.

29:38

The patient on your left has a quadin, a cistern, quadin,

29:43

cy cistern, lipoma, um, show it

29:45

to you magnified in a in a second.

29:47

The patient on your right has a simple pineal cyst.

29:50

So here you can see the patient on the left has a small

29:53

lipoma, right inferior to the quad trigeminal plate.

29:56

Um, the patient on the right has a pineal cyst,

30:00

um, sitting right here.

30:01

So the question comes up is, what are we,

30:05

what are we gonna do with this, with these two patients?

30:07

How are we going to dictate our report?

30:10

An incidental tactal plate lipoma, quadge plate lipoma, an

30:15

incidental sub centimeter pineal cyst.

30:17

So what are we going to do?

30:18

Are we, we're gonna comment on it, on it in the report.

30:21

Incidental node is made of a quad,

30:23

general quad general plate cistern.

30:24

Lipoma. Um, are we going to comment on it in the impression,

30:29

are we going to completely ignore it in our reports?

30:32

Because both of these things are likely to be

30:34

of no significance, especially the lipoma.

30:38

Are we gonna recommend neurosurgical evaluation

30:40

and send the patient through,

30:41

we recommend neurosurgical evaluation

30:44

or we gonna recommend a one year follow up?

30:46

Um, or are we gonna do something else?

30:49

And what if this patient was your brother?

30:52

What would you put in the report?

30:54

What would you tell your brother for either

30:56

of these patients regarding the lipoma

31:00

or regarding the pineal cyst?

31:01

Okay, just for anybody who's not a, a radiologist,

31:04

the lipoma is completely benign, no potential for growth,

31:07

no potential for any kind of symptomatology.

31:11

The pineal cyst has an extremely small potential of growth.

31:16

Less than 1% of these will grow over time.

31:18

And even of the ones that grow over time,

31:20

a smaller percentage will cause symptoms.

31:23

And when they cause symptoms,

31:24

the symptoms will be very dramatic.

31:26

They will either cause what's called paranoid syndrome,

31:29

paralysis of upper gaze by pushing on the tactile plate,

31:33

or they will cause hydrocephalus

31:34

by closing off the aqueduct sylvis.

31:36

Sylvia, in either situation, the patient will undoubtedly

31:40

immediately show up to the emergency room or to the doctor.

31:44

'cause if you can't, if you have paralysis of upper gaze,

31:47

you can't look down, you're going

31:48

to find somebody to help you with that.

31:51

And if you have a severe, severe headache that's developed,

31:54

you're going to get help from that too.

31:55

And that's going to lead to imaging at that point.

31:57

So the question is, what do you do in each

32:00

of these situations?

32:01

I'll tell you what I do.

32:04

Quad genital plate cistern, lipoma, my dictation,

32:06

my report is this is an incidental finding that is

32:09

of no clinical significance

32:11

and does not require any additional imaging follow up.

32:15

That's what I put in for quad plate cistern,

32:17

because this is what,

32:19

if this was a patient, it was my brother.

32:21

That's what I would tell him. Don't worry about it.

32:23

You have a small lipoma, it's an incidental finding.

32:25

It's of no significance. Forget about it. Okay?

32:29

Now, a pineal cyst, you could go a bunch of different ways.

32:33

If I have, um, a previous study from two years ago

32:37

that shows that it hasn't changed, then I am, I am going

32:40

to dictate that this is unchanged since two years ago.

32:43

It is an a finding that is of no clonal significance

32:46

and does not require any additional imaging follow up.

32:49

Now, am I completely excluding the extremely remote

32:52

possibility that this will grow?

32:55

No. On the other hand, if it grows, as I've mentioned,

32:57

the patient will show up to the emergency room immediately.

33:00

So I'm not worried that this is a small cancer

33:03

that's growing to the point of where it can't be treated.

33:06

If this syst, if this is the unlucky patient, one in 10,000

33:09

that's gonna cause symptoms, that patient will show up

33:12

and will then be treated at that point.

33:13

But I am more concerned that letting that patient know

33:16

that he or she can sleep at night without worrying

33:19

that this is going to be problematic.

33:21

Now, let's say I don't have an MRI that's two years old,

33:24

that shows that it hasn't changed in size, then at

33:27

that point, I may very well dictate this demonstrates

33:29

completely benign features.

33:31

The overwhelming majority of pineal cysts, uh,

33:34

are incidental findings of no clinical significance.

33:37

And in the absence of new neurological symptoms does not

33:40

require additional imaging follow up.

33:42

That's my style. I'm not telling that, that

33:45

that should be your style.

33:46

That's my style because I'm talk,

33:49

I'm thinking about the patient.

33:50

I'm not thinking about the MRI.

33:54

Our language has evolved.

33:56

My personal language has e evolved from calling cerebral

34:00

atrophy to volume loss to involutional changes

34:04

to age appropriate involutional changes.

34:07

As I turned 65, if I were to have a CAT scan and MRI

34:10

and my SULs, I were a little bit prominent,

34:13

don't tell me that I have atrophy.

34:15

I'd much rather just know

34:16

that I have age appropriate revolutional changes.

34:18

Um, I might have atrophy, but,

34:21

but if they're just a little bit prominent,

34:23

I'd rather just know

34:24

that I have age appropriate revolutional changes.

34:26

And here's a patient 59-year-old female presents

34:30

to the emergency department with headaches.

34:32

And I looked at the CAT scan, sure,

34:34

her cerebellum looks a little bit small.

34:37

Do I want to call it cerebellar atrophy?

34:40

Do I want to call it cerebellar revolutional changes?

34:43

Do I want to call it anything? I dug down a little bit.

34:46

I looked at, um, our electronic medical record,

34:49

and this is what I found as her snapshot diagnoses,

34:53

generalized anxiety disorder, panic disorder,

34:57

postmenopausal disorder, primary insomnia.

35:01

You all know that if I put in my report cerebellar atrophy,

35:05

all I'm going to do on this poor lady has increased the

35:08

amount of anxiety and stress in her life.

35:12

So I chose to not talk at all about cerebellar volume loss.

35:16

And I just said, no hydrocephalus,

35:18

no shift in the midline structures,

35:20

no abnormal extra axial fluid collections,

35:22

no focal abnormalities in the brain,

35:24

parenchyma my impression, no acute intracranial pathology.

35:28

And I didn't talk at all about the cerebellar volume loss

35:31

because I'm thinking about this lady.

35:34

I'm not thinking about her CAT scan. Okay?

35:39

Communication. Again, am I a doctor or just an image reader?

35:42

And how this relates to communication. So sit down.

35:46

Let me tell you a story.

35:47

Once upon a time I ate your hamster this morning, I'm going

35:50

to tell you three quick stories, okay?

35:53

This MRI neck on 11-year-old girl came in,

35:56

this was on November 23rd, 2021.

35:59

What's the importance of that date?

36:02

November 23rd, 2021 was the day

36:04

before Thanksgiving that year.

36:07

And she comes in with painless lymph adenopathy.

36:09

And as you all can see, she's got multiple,

36:12

very significantly enlarged lymph nodes.

36:16

And the question was, what do I do with this?

36:19

So I called the pediatrician

36:21

and I said, here's the bottom line.

36:23

She's got multiple enlarged,

36:25

very enlarged unilateral lymph nodes.

36:27

Maybe this will turn out to be a benign process,

36:29

but my leading differential diagnostic consideration,

36:32

it's gotta be lymphoma or leukemia.

36:36

What you're going to need to do is you're gonna need

36:38

to set her up with a an ENT for a biopsy.

36:42

Um, maybe it'll turn out to be something benign.

36:44

And in fact, for this young woman, it did turn out

36:47

to be an autoimmune condition.

36:48

But certainly the leading consideration here is lymphoma.

36:53

So I called the pediatrician

36:54

and I said, here's the bottom line.

36:56

You're gonna have to set her up for a biopsy.

36:59

But here's my question for you.

37:00

It is the day before Thanksgiving.

37:03

When do you want me to release the report?

37:06

I can release the report today

37:08

or I can wait over the weekend and release it on Monday.

37:11

Nothing's gonna change in this patient. Okay?

37:14

You know, the family, I don't know the family.

37:17

Is the family gonna be more in pins

37:19

and needles, more anxious if they don't see a report

37:21

at all on their daughter?

37:23

Or are they gonna be much more anxious if they

37:26

see the report that the leading consideration

37:28

is a cancer diagnosis?

37:31

And the pediatrician said, I'm gonna call you back.

37:34

She called me back two hours later

37:35

and she said, okay, I've spoken with the family.

37:38

I've got the patient set up on Monday for a biopsy.

37:42

But my question to you, Jay, she was talking to me,

37:46

what made you even think about

37:48

that question about when to release the report?

37:51

And the answer is very simple.

37:53

I wasn't thinking about the MRII was thinking about the

37:57

11-year-old girl and her family.

38:01

Here's another patient, 11-year-old male with headaches.

38:05

And this patient has a very subtle abnormality, um,

38:08

in the medial parietal area, which if you look,

38:12

you can see these small little bubbles of

38:15

hyperintense lesion,

38:17

hyperintense structures here in the

38:19

parenchyma on the coronals.

38:24

You can see it here. And what this is,

38:27

this is what's called a multinodular

38:30

evacuating neuronal tumor.

38:32

But the problem with this name is

38:35

that this is not really a tumor.

38:37

This doesn't grow. This typically does not cause symptoms.

38:41

Um, you can follow it if you want, but it won't change.

38:44

But it's got the name tumor in it.

38:47

So when I read this

38:49

before signing off the report,

38:50

I called the pediatric neurologist

38:52

and I said, here's the bottom line.

38:54

She's got, um, he's got an MVNT,

38:56

a multi multinodular evacuating neural tumor.

39:00

But you know that as soon as I send off the report,

39:02

the family may see this report

39:03

and they're gonna be scared outta their wits

39:05

that the their child has a tumor.

39:07

Do you wanna call them ahead of time just to let them know

39:10

that even though it's cold a tumor, it's not really a tumor

39:15

and it's not something that they have to be scared about.

39:18

And again, the pediatric neurologist thanked me

39:20

for thinking ahead because again,

39:22

I was thinking about this young boy, not about the images.

39:28

And finally, the third story, this patient

39:30

with metastatic melanoma, you can see that back in April

39:34

of 2024,

39:35

there were multiple small enhancing lesions, um, in the brain.

39:40

Patient had atomy to address the largest one,

39:42

but there were still multiple small lesions.

39:44

Patient was on immunotherapy.

39:46

And then three months later, all

39:49

of the lesions had essentially resolved.

39:51

So what I did, I called the physician assistant, um,

39:56

and I said, Hey, maybe you wanna call this patient

39:59

to tell him that these lesions are gone, at least for now.

40:03

And she said to me a direct quote, thank you

40:06

for seeing the person behind the images.

40:09

Now we have the American College

40:12

of Radiology has practice parameters for communication

40:15

of diagnostic imaging findings.

40:17

They include non-routine communications.

40:20

Um, so what with essentially findings that suggest the need

40:24

for media or urgent intervention.

40:26

So you read a head CT and there's acute hemorrhage on that.

40:29

You can't just dictate a report.

40:30

You're obligated to call the clinician

40:32

and say, this patient has an acute hemorrhage findings

40:35

that are discrepant with a proceeding interpretation

40:37

of the same examination.

40:38

And will failure to act in

40:39

adversely affect the patient health?

40:41

So I'm reading an acute CT angiogram study,

40:44

an acute stroke patient, and I say, there's no thrombus,

40:47

there's no significant stenosis,

40:48

but I failed to pick up a four millimeter aneurysm.

40:51

But our 3D lab picks it up

40:53

and a few hours later, I see the 3D lab picks it up.

40:56

I didn't pick it up in my preliminary report.

40:58

I'm obligated to call them

41:00

and say the basic interpretation is correct.

41:03

There's no thrombus, there's nothing that needs to be, um,

41:06

intervened on with, uh, active intervention.

41:09

But I missed the four millimeter aneurysm

41:11

that our 3D lab picked up, or findings that are significant

41:15

and unexpected that may have a reasonable probability

41:17

of impacting the patient's health.

41:19

I'm reading an MRI study of the lumbar spine

41:21

and I incidentally pick up a solid renal tumor.

41:25

I'm obligated to make direct contact with the clinician

41:28

or his or her office to say, Hey, um,

41:31

there's an incidental finding here that is of significance

41:34

and you need to act on it.

41:35

These are what the American College of American College

41:38

of Radiology has mandated for us,

41:41

our lines of communication.

41:43

But why don't we call with the good news?

41:46

Why don't we call when there's

41:48

that patient whose metastases have dissolved away

41:51

to tell the clinician, Hey, um, you can call them,

41:55

give them good news.

41:56

They love it. We do this all the time in our practice.

41:59

At least I do it in my practice.

42:00

I wish more my colleagues would do it,

42:02

but I do this all the time.

42:04

And the clinicians love it to be able to the idea, be able

42:07

to call their patients and tell them good news.

42:10

Two quick more comments, we go

42:12

before we go on to the very last part of the talk.

42:14

And that has to do with voice recognition

42:16

and template reporting.

42:17

In the old days when we used, um, regular dictation system,

42:22

hold up the microphone.

42:23

This is j Cinnamon dictating on Mary Jones medical record

42:26

number 1 2 3 4 5 6 7 non-contrast CT scan of the brain.

42:31

And, you know, we would dictate this out.

42:33

Now with voice recognition, ponder this.

42:38

We don't even say the patient's name.

42:41

We don't say the patient's name.

42:44

All we do is it automatically a, uh,

42:47

populates the voice recognition field and that's it.

42:52

And this has direct effect.

42:54

This was brought out in a,

42:55

in a 2008 A-R-S-N-A-A group from, um, uh,

43:00

from uh, hospital in Jerusalem.

43:02

What they did was they took 485 patients in inpatients.

43:06

And when the patients came in,

43:07

they took a photograph of the patient.

43:10

Um, so that when the radiologist brought up the study, um,

43:13

the picture of the patient came up on the

43:15

big monitor next to them.

43:16

And what they found was the radiologist's empathy

43:19

and eye for detail went up.

43:20

Their ability to, their accuracy

43:22

and reporting went up as a, as a result

43:25

of putting a face to the study.

43:29

And the other point is,

43:31

although template reporting is a very good thing,

43:34

and many, many people advocate this very significantly, um,

43:38

it's, it's a way to get through studies quickly.

43:39

It's a way to, for clinicians to scan reports quickly.

43:43

You certainly do have to ponder when a report comes out

43:46

with template reporting.

43:47

You certainly have to wonder whether the clinicians are

43:50

wondering, has this been an AI generator report

43:54

or has this been replicated by some

43:58

handsome radiologist sitting in his reading room,

44:01

reading the study?

44:03

So I don't use template reporting very much at all

44:06

because I want them to know that I'm reading this

44:08

and I'm dictating it and I'm thinking about it.

44:11

And I'll share my ideas in the reports.

44:13

It doesn't mean that my reports are

44:14

overly verbose, they're not.

44:16

But I will talk about what I'm finding and I will drill down

44:20

and explain what I'm thinking

44:21

and then put it all together at the end.

44:24

Uh, very quickly.

44:27

It even relates to qc, um, quality control.

44:31

This patient, as you can see,

44:32

had a very high grade stenosis in the left

44:34

internal carotid artery.

44:36

And, um, when we look at the CT angiogram portion

44:41

of the brain, we can see that the a one segment

44:43

of the left anterior cerebral artery network is hypoplastic.

44:46

So the bottom line is that if this internal carotid artery

44:49

occludes, the patient's gonna have a devastating stroke.

44:52

Um, as a result of occlusion,

44:54

it's gonna propagate all the way up

44:56

with very little potential

44:57

for collateral flow across the circle of Willis.

45:00

And what I did was on that patient, I essentially, um,

45:04

called the clinicians and they said, I think you need

45:07

to act actively on this patient.

45:09

And that's what they did. They stented the patient

45:11

and hopefully he will not have that devastating stroke.

45:15

Finally, what can we do today to fix this severing

45:18

of the clinician relationship?

45:19

And why should we, um, do this?

45:22

Well, many people are talking about job

45:26

dissatisfaction, um, and burnout.

45:29

And this is where the social science comes in.

45:32

So, Amy Nuki,

45:34

and I hope I'm not butchering her name, um,

45:36

organizational psychologist at Yale.

45:39

She says, employees have one of three work orientations,

45:42

a job, a career, or a calling.

45:45

People with a calling view their work as an end in itself.

45:49

Their work is fulfilling not because of external rewards,

45:52

but because they feel it contributes to the greater good

45:54

and draws on their personal strengths

45:56

and gives them meaning and purpose.

45:58

And purpose is the most important word in this entire

46:02

paragraph in my opinion.

46:04

Purpose, purpose, purpose, purpose.

46:07

This is the key to burn to fighting burnout.

46:10

If you have purpose, you won't burn out.

46:12

If you don't have purpose, then what are you doing?

46:16

You, of course you're gonna burn out.

46:19

Seneca, the ancient Roman philosopher,

46:21

a person cannot be happy if he sees it only himself

46:23

and judges all in relation to his personal benefit.

46:26

If he wants to live for his own benefit, he must also live

46:30

for the benefit of others.

46:31

And Sean Aor, who wrote the, the, the book,

46:34

the Happiness Advantage,

46:35

happiness is the joy we feel striving

46:37

after our potential data abounds, showing

46:40

that happy workers have higher levels of productivity,

46:43

produce higher sales,

46:44

perform better in leadership positions,

46:46

and receive higher performance ratings and higher pay.

46:50

And this from Dr. Murthy.

46:52

Um, um, a surgeon general, um, previous Surgeon General,

46:56

who wrote a long report on epidemic of loneliness.

47:00

Just cutting to this, the mortality impact

47:02

of being socially disconnected is similar to that caused

47:05

by smoking up to 15 cigarettes a day,

47:08

and even greater than that associated with obesity

47:10

and physical inactivity.

47:12

And very quickly, I'm two more minutes

47:14

and I'll be done and take any questions.

47:16

There are, um,

47:18

just highlighting this has comes from his report as well.

47:21

What workplaces can do makes, so again,

47:23

this is social science.

47:25

This is social science.

47:26

It's up to us as to whether we wanna incorporate this into

47:29

our practices.

47:31

But this is proven social science.

47:33

Make social connections a strategy,

47:35

a strategic priority in the workplace at all levels.

47:40

Um, leverage existing leadership

47:42

and employee training, orientation

47:44

and wellness resources

47:45

to educate the workforce about the importance

47:48

of social connection for workplace wellbeing.

47:52

And consider the opportunities

47:53

and challenges posed by flexible work hours

47:56

and arrangements, including remote, hybrid,

47:58

and in-person work, which may impact workers' abilities

48:01

to connect with others, both within and outside of work.

48:04

This relates to us in a very straight way.

48:07

We have remote, um, uh, uh, um, shifts in our practice.

48:11

And yes, I enjoy being able to work at home

48:14

and, you know, being in my jeans and my sneakers

48:16

and not have to, you know, dress in any kind

48:18

of professional way or scrubs.

48:20

Um, I enjoy that. But on the other hand, I know that

48:23

that is not a key to that is not, um, that's not going

48:27

to help me find purpose in my work

48:30

unless I'm very proactive, sitting at home, calling doctors,

48:33

giving them good reports, giving them bad reports,

48:36

interacting with the doctors, the clinicians

48:38

to find out more about their patients.

48:40

Uh, so we have to be conscious of this even

48:42

as we move more into, more, into more teleradiology.

48:44

And again, I'm not passing judgment. This is social science.

48:47

It's such up to us

48:48

to figure out the balance on these things.

48:51

Humans, this is Sebastian J. Humans don't mind hardship.

48:55

In fact, they thrive on it.

48:56

What they mind is not feeling necessary.

48:58

Modern society has perfected the art

49:01

of making people feel not necessary.

49:04

And finally, Carol Direct,

49:06

the psychologist at Stanford has quoted in Sean Aker's book.

49:09

There's something as a fi if you think you can't change

49:13

your mindset, you're wrong.

49:15

You can definitely change your mindset.

49:16

There's a fixed mindset versus a growth mindset.

49:19

People with fixed mindsets miss choice, opportunities

49:22

for improvement and consistently underperform.

49:25

While those with a growth mindset, watch their abilities

49:28

and move ever up ever upward.

49:30

Of course you can change,

49:31

of course you can move from the silo reading into a much

49:34

more proactive engagement with clinicians

49:37

and make yourself available to guide them.

49:39

And it'll be better for patients.

49:41

It'll be better for your, your own sense of purpose.

49:44

It'll be better. It'll fight burnout.

49:46

Of course, you can move into a growth mindset.

49:48

You just have to choose to do so.

49:51

Agnes car, associate Professor

49:53

of Philosophy, university of Chicago.

49:54

Ambition is the outcome you want to attain.

49:56

By the way, this is Adam Grant, extremely noted, uh,

50:00

organizational psychologist, the Wharton School of, uh,

50:03

of business at in Philadelphia.

50:05

Ambition is the outcome you want to attain.

50:07

Aspiration is a person you hope to become.

50:10

What counts as not knowing how hard you work,

50:12

but how much you grow.

50:15

So what we've seen is whether I wear my doctor hat

50:18

or if I'm wearing my image reader hat, it relates

50:21

to everything that we do in the course of our work.

50:24

Triaging patients for the right studies, protocol,

50:27

design issues, prioritization,

50:29

drilling down on history, all these things.

50:31

But at the same, same time, it's how we view our own jobs.

50:35

How we infuse meaning and purpose into our workday.

50:38

How we combat combat burnout

50:41

and how we treat people rather than disease.

50:44

All of these things, again, this is the social science,

50:46

burnout, growth, loneliness, happiness, advantage,

50:49

longevity, aspiration, purpose, personal fulfillment.

50:53

This can all be addressed if we rebuild that relationship

50:56

with team clinicians and radiologists.

50:59

But it will take proactive measures on our part to do that,

51:03

if they're not coming to us, we need to go to them.

51:08

And here's some action items to launch the paradigm shift.

51:12

Ask yourselves when you're reading a study,

51:13

have you treated the patient like a family member?

51:16

Have you drilled down on the clinical information?

51:18

Have you thought deeply about the wording in your report?

51:22

Do you wanna make a call to anyone?

51:24

Not just the ones that you have to make a call,

51:26

but the just, you wanna make a call.

51:27

It is so rewarding when an oncologist hears

51:30

that you're calling to give them good news.

51:32

They are so appreciative. It will make you feel good.

51:35

It will empower you to make a call.

51:36

Again, it will in, in inject a little bit

51:39

of diversity into your rote workday.

51:42

Uh, and and,

51:44

and finally, stop please using the word case.

51:48

These are patients patient studies.

51:50

Let's move away from the term case.

51:53

Let's try to completely abort, abort the term case.

51:56

Let's not talk about cases.

51:57

Let's talk about patient studies

51:59

and there will be tremendous personal award

52:02

if we can do these things.

52:04

Thank you very, very much for your attention.

52:06

Happy to take any questions you may have.

52:08

Thank you so much for sharing this lecture with us today.

52:11

Dr. Cinnamon, someone commented that this was very timely

52:14

and I agree, so appreciate you walking through all of that.

52:18

We have a couple questions in that q and a box.

52:21

We also received a couple in French that I've translated.

52:26

Um, so I'll kick us off while you find your,

52:29

the q and a box to open.

52:30

Sorry about that. Yeah, lemme find it again. Yeah.

52:33

Um, so, so one of the questions that actually came in

52:35

through French that I um, translated was, um,

52:39

how can radiologists strengthen their collaborations

52:41

with clinicians in an increasingly digital environment?

52:45

And maybe, maybe there's something that you are doing

52:49

specifically to help with that,

52:51

that you could tell us about.

52:54

Great, great question.

52:55

Um, so I'll tell you what in theory, um,

52:58

somebody or you could do.

53:00

Um, but I will also, um, admit that I have not

53:04

yet successfully convinced my practice

53:07

that we need to do this.

53:08

So full disclosure here, um, that I'm working to try

53:11

to persuade my own practice to do some of these things.

53:14

And I've not yet gotten to that point.

53:16

So this is not necessarily an easy, it's an easy

53:20

paradigm shift to implement.

53:22

It's not such an easy paradigm shift to

53:25

persuade people who've been in one mindset.

53:27

Um, and again, my practice is a great practice,

53:29

very ethical, brilliant people in my practice.

53:32

I'm not saying anything disparaging.

53:34

I'm so proud to be in my practice

53:36

and my colleagues are incredible people.

53:39

So I don't mean to pass judgment on any of them.

53:41

I'm just telling you the realistic situation.

53:44

So the emergency room in our flagship hospital is the

53:47

largest emergency room in North America.

53:50

It is a three three, it is a freestanding three story

53:54

building with three ca with four cat scanners in it

53:57

and one em MRI in the emergency room

54:01

and room for another cat scanner and another MRI.

54:05

And what I've been trying to advocate is

54:07

that we move a reading room to that area.

54:11

Right now, our reading room

54:12

for all those emergency studies is in the main hospital

54:15

complex across the street.

54:17

And what I believe we should be doing is moving a reading

54:21

room there.

54:22

Now, undoubtedly, clinicians coming in, going

54:25

to slow reduce your productivity.

54:28

That is correct. You will not be able

54:30

to read the same number of studies while you're constantly

54:33

interacting with clinicians and they're

54:35

coming in to go over studies.

54:36

But I will argue a couple of things.

54:38

Number one, it is better for patients.

54:41

Number two, every practice has some sort of a, um,

54:46

backbone, an administrative backbone.

54:48

Uh, we have a big office that, that services our practice.

54:51

When our office administrators decide that they need

54:54

to buy 10 new computers, nobody asks them, well,

54:57

what's the return on investment for those 10 computers?

55:00

There's no ROI for a new computer.

55:03

So I'm going to make the argument

55:05

that there's no direct ROI in terms of RDUs

55:09

for talking with clinicians.

55:11

But the ROI is much more for found.

55:13

You're building a bridge with clinicians.

55:15

You're creating, um, a better conduit of conversation

55:19

for better care of patients.

55:21

You are taking away that 28-year-old woman

55:24

who does not need a CAT scan of her lumbar spine

55:27

for back spasms, um, irradiating her ovaries

55:30

and giving her a $5,000 bill when all she needs is a muscle

55:35

relaxant and some painkillers, um,

55:37

and sending her home without any imaging whatsoever

55:40

and without any unnecessary radiation.

55:42

So you're doing the right thing, even though

55:45

that takes time away from reading studies.

55:47

So yes, it requires strategic planning,

55:50

but in my opinion, we need to go there.

55:52

If we, we need to go to the emergency rooms

55:54

and put reading rooms there.

55:56

We need to go to the ICUs

55:57

and put reading rooms there, we may need to go

55:59

to the clinics and put reading rooms there.

56:01

And I have to tell you, I'm not the originator of this.

56:04

Okay? When I left Emory 22 years ago, my colleagues

56:07

who were there, they initiated this, they get credit

56:10

for this, they put reading rooms in the clinics, um,

56:14

they put reading rooms in some of the front,

56:16

front on play places.

56:17

So I give kudos to my former colleagues at Emory

56:20

for taking the initiative on this.

56:22

I can't, I can't claim to be the original thinker on this.

56:26

Um, but I think we need to do it on a much larger scale.

56:28

Um, um, I am actually, I'm seeing one of the two questions,

56:33

um, and one of the questions is the elephant in the room,

56:37

um, um, by Dr. Solomon and I agree a hundred percent.

56:40

Um, I believe you ignored the elephant in the room.

56:43

The takeover radiology by private equity

56:45

that is materially affecting the quality of imaging.

56:47

I could not agree with you 100%.

56:50

Our practice, um, is an independent practice.

56:53

We refused, um, to be sell out to private equity.

56:56

Partly for that reason,

56:57

we did not wanna lose our own sense of control.

57:01

It is a challenge.

57:03

The only thing I can say is we need to make the argument

57:08

that we are not taking care of cases.

57:11

We are taking care of patients.

57:14

And if these, if you can tell people in private equity

57:17

who are pulling the strings that what would you want us

57:20

to do if this was your family member?

57:23

We have turnaround time, re re requirements.

57:25

You have to turn around a stroke study

57:27

in whatever it is, 12 minutes.

57:28

Of course, the, the hospital monitors our turnaround time,

57:31

but it doesn't monitor whether we're right or wrong.

57:33

And the answers, I could miss a thrombus in the M1 segment,

57:37

but I've turned around the, if I've turned

57:38

around the report in seven minutes, I've met the metric

57:41

and done a great job, but I haven't fulfilled my own mission

57:45

to do what's right for the patients.

57:47

You gotta turn to these people

57:48

and you gotta passionate, you gotta have the right people,

57:50

the right communication skills.

57:51

It says this is just not right. This is about patience.

57:55

This is not about widgets.

57:56

This is about patients, people breathing people.

57:59

We have to take care of them. This is the right thing to do.

58:03

Um, I admit it's a hard answer

58:07

and it may be a lousy answer.

58:08

We gotta do the best we can. Um, Ashley, go ahead.

58:12

I'm, should I, um, should I, let me just see here.

58:15

Um, I got a nice hands, hands up from an old,

58:19

from a former resident.

58:20

Dan, hope you're doing great. Great guy. Dan Measle. Dr.

58:23

Dan Measle. Phenomenal resident.

58:25

Hope you're doing, hope you're doing great. Dan.

58:27

Um, um, uh, let's see here.

58:30

There's a question here from, uh, I,

58:33

I apologize if I'm not spell

58:34

pronouncing your name correctly.

58:35

Dr. Morose. Um, um, oh, I would like

58:40

to ask how you manage to grow this mindset,

58:43

especially when AI

58:44

and other sub specialties come for our job

58:46

and territories as radiologists.

58:47

I recently have started to, uh, usually yes.

58:51

Um, AI is the big question.

58:54

I don't know how AI is gonna play out.

58:56

Um, what I tell people, at least for now, is

58:59

that one big difference between AI

59:01

and me is that, um, I can feel for the patient.

59:04

Um, the AI cannot feel for the patient.

59:07

I see the patient's pain.

59:09

When I taught at Emory, I, I asked the residents

59:11

and fellows, I don't want you to read the scan.

59:13

I want you to read it into the scanner.

59:15

I want you to see the patient's physical pain.

59:17

I want you to see their mental pain.

59:18

I want you to see the anxiety

59:20

and the fear among the family members.

59:22

I want you to feel that as best as you can, feel that,

59:24

and that will empower you

59:26

to do a better job reading the study.

59:28

Um, AI cannot feel, I can feel,

59:33

I can be proactive.

59:34

I can say something is not smelling right here.

59:36

Something is not adding up here. I can, I can do that.

59:41

How we harness AI to help us. AI can definitely help us.

59:45

When I'm reading my 12th CTA on a shift

59:48

and I need an AI to see,

59:51

is there a seven millimeter lung nodule that I've missed?

59:54

I definitely need AI to pick that out for me if it can, so

59:57

that I don't miss it because the data sets are too big.

60:00

It's not humanly possible to go

60:01

through a hundred studies in a shift, 12 of which are CTAs,

60:05

half of those who've had patient studies in the past

60:08

that I have to compare it to when I have to turn

60:10

around the report in 12 minutes.

60:12

It's not possible. So AI can help.

60:15

The question is, will AI replace us? I don't know.

60:19

I hope it doesn't because I feel for the patients AI

60:23

doesn't, that's probably not an adequate answer.

60:31

Well, Dr. Cinnamon, should we wrap there?

60:33

We can, yeah, I think we can.

60:35

Um, I, I think those are all,

60:36

uh, those are all the questions.

60:37

I don't, did I miss anything on the questions or, um,

60:41

No, I think you covered pretty much everything.

60:43

Some of the questions earlier you referenc

60:45

or you answered throughout the, your presentation.

60:48

So yeah, thank you so much for being here

60:50

and for this, again, very timely conversation

60:52

and a presentation.

60:54

Thank you for inviting me.

60:55

It was a great thrill. Thank you. Thank you.

60:58

Absolutely. And thank you everybody for being here today

61:01

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61:04

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61:05

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61:08

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61:09

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61:12

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61:15

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61:17

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61:20

Intracranial Trauma ct.

61:22

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61:24

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61:28

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