Teaching Radiologists to be Leaders

Editor's Note: It’s no longer enough for radiologists to be imaging experts. Health care is becoming big business and radiologists need to understand how to navigate the system. Diagnostic Imaging’s Business of Radiology series provides radiologists with the business education they need to succeed.

Radiologists should know how to read an MRI. But should they also know how to read a profit and loss statement? In this environment of accountable care organizations and code bundling, teaching radiology residents more than clinical skills is gaining steam. While incorporating business knowledge is a mandate for accredited programs, how they execute it is up to them.

Residency program faculty increased their recognition that teaching health care policy and radiology business practice is important even more in the past five years, said Jonathan Medverd, MD, an associate professor of radiology at University of Washington and past president of the Washington State Radiological Society. He surveyed residents, fellows, and faculty on the topic in 2010, publishing results in the JACR in 2012. While [[{"type":"media","view_mode":"media_crop","fid":"39344","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7192662643775","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3944","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]most programs offered this type of education when surveyed, few found it effective. What’s changed?

Medverd said there’s now general agreement that radiology residents need these experiences, partly so they’ll have this knowledge when they enter practice. “It used to be thought of as the practice manager’s problem,” while radiologists focused on the medicine, said Medverd. No longer.

By exposing residents to policy issues and the nuts and bolts of health care economics, “we’re trying to develop leaders in our program,” said Barbara Weissman, MD, radiology residency program director at Brigham and Women’s Hospital. Programs like Weissman’s are drilling down into the “products” that radiologists provide, and how they get paid for it.

Since Medverd published his study, the Accreditation Council for Graduate Medical Education (ACGME) changed its Outcome Project, which used to focus on six core competencies to assess residency education. Now ACGME uses a milestone program, incorporating health care economics as a milestone. How a residency program fulfills this mission is up to them. With 180 to 190 accredited radiology programs, each one is inventing the wheel, which is inefficient, said Medverd. However, a lot of the curriculum depends on local experts to teach these topics, and the local expertise may be limited in some locations.

Here are three approaches radiology programs are taking to teach leadership and the business of radiology.

The School Approach
Brigham and Women’s radiology residency program runs an “It’s Your Business” program that includes three sessions on the business of health care, a session on pertinent Washington political topic updates, and one on financial planning. “We’re trying to allow residents to see the context beyond their training and the unique responsibility physicians have in the health care system to their patients to understand the business of health care, to effectively deliver healthcare,” said Andrew Menard, JD, a research associate in radiology at Brigham and Women’s.

As part of the business of health care sessions, discussions include who their customers are, reimbursement, and the business context around what they’re doing in the reading and scanning rooms. They go through the “alphabet soup” of phrases like ICD10, RVU, DRG, plus the cost of radiology (technical, professional, and overhead). They explain to the residents that health care can only be consumed with the help of an expert, so the physician’s role is mandatory. “It isn’t simply to take orders and do the exam in front of you – the physician has a unique role and responsibility as the key central player in delivering health care in a meaningful way,” Menard said.

To make it more relevant to residents, health care reform lectures earlier this year focused on Boston health care and the proposed acquisition of three hospitals by Partners Healthcare System, which operates Brigham and Women’s. “We wanted to make sure they understood how they got to where they are, why the attorney general was opposing acquisition and why we were trying to acquire,” said Menard. “A lot of time the residents have fragmented views,” without time to fully research a topic. They wanted to expose the residents to the major issues in the debate, using concepts like sustainable growth rate.

They talked about other hot business concepts like resilience, using the example of the Boston Marathon bombing. “We looked at why Boston performed so well in the bombing and fell apart with all the snow,” said Menard.

Most of the residents in their program haven’t taken an economics class before, so lectures including concepts like supply and demand helped fill in knowledge gaps. “The residents get quite engaged,” Menard said of the interactive presentations.

“By the time they leave the program we want them to be conversant and comfortable with the business they’re stepping into so they can create a sustainable role for themselves and their patients,” said Menard.

The University of Washington in Seattle also offers a specific in-school approach to learning. Medverd runs the biannual “Business of Radiology” curriculum, which includes seven to 10 sessions, about 12 hours total. Though residents get this curriculum twice during their tenure, Medverd finds that the senior residents take away different things than junior residents, given their increased experience. Medverd brings in guest lecturers; one popular session included the executive director of the state medical association along with a trial lawyer.

While the topics change, one recurring theme is health care financing, and how medicine went from the Marcus Welby, MD model to the accountable care organization. In addition, they might cover medical/legal issues, business 101 (balance and income sheets for radiology), key measurement metrics in radiology practices, current payment plans methods (including code bundling), practice governance (given the consolidation and partnering with hospitals/health care systems), and incentives for participating in measurement projects. Medverd said he always tries to show the impact on the radiologist. “Should you stick your head in the sand and concentrate more on how to interpret? Or does the trend suggest that you should be learning more about what Medicare is doing so you understand how to better contribute to your practice when you’re in one?”

The State Approach
In addition to in-school learning, Medverd runs a state-wide advocacy effort that any Washington radiology resident can participate in. “I think what’s gained the most traction and enthusiasm for residents in Washington state residency programs has been to encourage them to come along with the state society advocacy efforts, when we talk to legislators and have constituency meetings to educate them about issues on the docket.” As past president of the Washington State Radiological Society, he’s found it valuable for residents to learn about the issues, and participate in the legislative conversations. “They’re learning major lessons about health care financing, health care organization, health care competition, health care leadership.” Before the meetings, faculty give residents specific readings, and also a talking point briefing. At the legislative meetings, the residents are encouraged to speak on these topics.

Medved said he often takes 20 residents to the Olympia state house each year for the meetings. A smaller group of five to seven residents then go to Washington DC for the annual ACR meeting with additional legislative activity, usually with funding from the residency program or state society. Both the state and the national meetings make the residents realize that there are legislative issues that affect them, and that they can make a difference in speaking up.

The Hands-On Approach
Instead of teaching seminars on business topics, the Mayo Clinic in Arizona opted to include residents in operational group leadership teams for their new residency program, said Maitray D. Patel, MD, diagnostic radiology residency program director. During team meetings once or twice a month, residents get hands-on training in that environment. They look at issues like equipment depreciation, evaluating whether to replace or discard equipment. They’ll help analyze the productivity of the allied health staff. Patel hopes this approach will give the residents transferable skills.

There are plenty of resources on business topics available to residents, said Patel, who thought it would be more effective for residents to “look under the hood.” He said that each resident will have different interest in the business of radiology. “We’re trying to show them what kinds of decisions have to be made about your practice, even in an academic center like ours,” Patel said. “We didn’t want them to walk away joining a practice and not understanding it.” Each group tracks business performance measures, like RVUs per FTE and per health staff member, allied staff per radiologist, year to year volumes, the number of appointments cancelled, and the number of after-hours procedures, to determine staffing and scheduling.

Self-Directed Learning
Residency programs also encourage residents to learn on their own. Medverd said that residency programs without access to faculty with this expertise sometimes encourage residents to learn from places like the Radiology Leadership Institute, an ACR initiative with on-demand courses online. “It’s designed to bring leadership skills and education to radiologists, but also to radiology trainees. Some programs that don’t have and don’t want to home grow (a program) have encouraged residents to look at opportunities through RLI.”

Our slideshow on self-directed learning opportunities includes programs for both residents and practicing radiologists. They offer one-off educational opportunities all the way up to certificate programs and MBA credit.

“I’m encouraged that if you give trainees an opportunity to taste it in a fashion that also introduces why it’s important to them, that they really respond,” said Medverd. “That’s good news for the future of the profession and for patients. Radiologists or any doctor that’s engaged not just in the medical aspects of their practice, but organizational and business aspects, is more in tune with patient needs and how to achieve best outcomes for those patients.”