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Breast Imaging |
1 From the Iris Cantor Center for Breast Imaging, Department of Radiology, David Geffen School of Medicine at UCLA and UCLA-Jonsson Comprehensive Cancer Center, 200 UCLA Medical Plaza, Rm 165-49, Los Angeles, CA 90095-6952 (L.W.B., L.W., P.H., J.W.S.); Mallinckrodt Institute of Radiology, Washington University School of Medicine and Siteman Cancer Center, St Louis, Mo (B.S.M., D.M.F.); Cancer Control Department, American Cancer Society, Atlanta, Ga (R.A.S.); Department of Radiology, Mount Sinai School of Medicine of New York University and Mount Sinai Hospital, New York, NY (S.A.F.); and Department of Radiology, Indiana University School of Medicine, Indianapolis (V.P.J.). From the 2001 RSNA scientific assembly. Received February 5, 2002; revision requested April 2; final revision received October 2; accepted October 14. Address correspondence to L.W.B.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: A telephone survey was conducted with 201 4th-year residents (postgraduate medical school year 5) and 10 3rd-year residents (postgraduate medical school year 4) at 211 accredited radiology residencies in the United States and Canada. Survey topics included organization of the breast imaging section, residents’ role in the section, clinical practice protocols of the training institution, residents’ personal thoughts about breast imaging, and their interest in performing breast imaging in the future.
RESULTS: Of 211 programs, 203 (96%) had dedicated breast imaging rotations; 196 (93%) rotations were 8 weeks or longer; 153 (73%), 12 weeks or longer. Residents dictated reports in 199 (94%) programs. Residents performed real-time ultrasonography (US) in 186 (88%) programs, needle localization in 199 (94%), US-guided biopsy in 174 (82%), and stereotactically guided biopsy in 181 (86%). One hundred eighty-four (87%) residents rated interpretation of mammograms more stressful than they did that of other images, and 137 (65%) believed mammograms should be interpreted by subspecialists. One hundred thirty-five (64%) residents would not consider a fellowship in breast imaging if offered, and 133 (63%) would not want to spend 25% or more of their time in clinical practice on interpretation of mammograms. The most common reasons given for not considering a fellowship or interpretation of mammograms were that breast imaging was not an interesting field, that they feared lawsuits, and that it was too stressful. Fellowships were offered at 53 programs, and at 46 programs, a total of 63 fellows were recruited.
CONCLUSION: Residency training in breast imaging has improved in terms of time and curriculum. However, a majority of the residents would not consider a fellowship and did not want to interpret mammograms in their future practices.
© RSNA, 2003
Index terms: Breast • Breast, US, 00.1298 • Economics, medical • Education • Radiology and radiologists, socioeconomic issues
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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However, mammography is facing a crisis due to inadequate reimbursement levels, long waiting times, costly regulations, litigation directed at radiologists for delay in diagnosis of breast cancer, difficulty in recruitment of breast imaging faculty to academic medical centers, and a sense that there is a growing shortage of radiologists dedicated to readingmammograms and performing other breast imaging procedures (1,5–12). Federal regulations mandate minimal professional qualifications and experience for physicians who interpret mammograms (10). Training sufficient numbers of residents to interpret mammograms in the future may become increasingly difficult.
Results of previous surveys of radiology residents have shown that residency training in breast imaging is improving in terms of time devoted, faculty, curriculum, and the resident’s role (13–17). We conducted a telephone survey of radiology residents across the United States and Canada to investigate the training and attitudes of residents regarding breast imaging.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Of the residents in 224 programs, those in five declined to participate and those in six agreed to participate but they did not schedule time to complete the survey despite several reminders; furthermore, one program was discontinued and one had a combined breast imaging service with one of the other programs. In 10 programs, a 4th-year resident was not available, and the survey was conducted with a 3rd-year (postgraduate medical school year 4) resident. Whether the residents were in the 3rd or 4th year, they had to have completed at least one rotation in breast imaging to participate.
The survey tool was developed by several of the authors (L.W.B., B.S.M., R.A.S., D.M.F., S.A.F., V.P.J.) who were involved in breast imaging education and who were familiar with current issues regarding mammography. The survey about research electives was conducted by four medical students, including two of the authors (L.W., P.H.). Each individual survey was conducted independently by one of the research assistants with on-site supervision of one of the authors (L.W.B.). The results were evaluated by all of the authors, including the study statistician (J.W.S.).
Informed consent was obtained from the participants. Prior to conducting the actual interview, the radiology residents were advised that the purpose of the survey was to learn more about resident training in mammography and that their individual responses would be confidential. Questions covered a wide range of topics, including organization of the breast imaging section at the training institution, the residents’ role in the section, the characteristics and protocols of the practice, the residents’ personal thoughts about breast imaging, and their interest in performing breast imaging in the future.
Organization of the Breast Imaging Training Program
Questions included whether the breast imaging training program was a separate independent entity in the department, what the length of rotations was in weeks, what the total number of weeks of breast imaging rotations during residency was, and whether the faculty were subspecialists (ie, that they spent at least 50% of their time in breast imaging).
Residents’ Role in the Breast Imaging Section
The purpose of these questions was to learn to what extent residents generated reports, whether they used the standardized mammographic terminology, and what the number of mammographic examinations they interpreted with supervision was. In addition, resident training in screening mammography, diagnostic mammography, clinical breast examination, medical audit, clinical image quality, breast ultrasonography (US), and interventional procedures was determined. Since the residents’ participation could not always be categorized as a simple "yes" or "no," the residents were provided a five-response scale, which ranged from "always" to "never."
Characteristics of the Breast Imaging Practice
These questions addressed clinical practice protocols of the training programs regarding screening and diagnostic mammography, patient communication, clinical breast examination, and performance of breast US and interventional procedures. Again, the residents were asked to answer by using a five-response scale, which ranged from "always" to "never." The "don’t know" response was an appropriate response when residents were not aware of a particular practice protocol.
Residents’ Perceptions and Attitudes Concerning Breast Imaging
The residents were asked to compare their level of concern when they interpreted diagnostic mammograms with their level of concern when they interpreted other types of images (specifically computed tomographic [CT] scans of the abdomen with contrast material or other types of images in general) by using a five-response scale, which ranged from "much less" to "much more." For these questions, the residents were asked to base their answers on their own personal perceptions and thoughts. The issues addressed were concerns about potentially missing important findings, under- or overestimating the clinical importance of a finding, not making appropriate recommendations for further work-up, disagreeing with another radiologist, retrospective review by another physician showing an abnormality that was missed, decreased technical quality or decreased observational ability after reading of multiple images, workload stress levels, and malpractice liability.
Interest in Interpretation of Mammograms and Fellowship Training in Breast Imaging
To evaluate their interest in interpretation of mammograms, the residents were asked to state their strength of agreement by using a five-response scale, which ranged from "strongly agree" to "strongly disagree," with statements provided. Statements included the following: "Mammograms should be interpreted by subspecialists in breast imaging," "You would consider a fellowship in breast imaging if offered," and "Even if you do not participate in a fellowship in breast imaging, you would like to interpret mammograms for a substantial portion (
25%) of your future practice." If residents responded that they would not consider a fellowship in breast imaging if offered or would not like to spend a substantial portion of their practice (25%) interpreting mammograms in their future practice, they were asked which items from a list of possible reasons would apply. They were also asked to provide any additional reasons for their decision.
One of the authors (L.W.B.) compared the results of this survey with data from similar questions from previous surveys of residents regarding training in breast imaging. The dates of those surveys included 1980, 1991, 1993, and 1996 (13–16).
The UCLA Medical Center institutional review board reviewed the survey and data collected and did not object to the analysis and publication of the data.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Organization of Breast Imaging Training Programs
The residents reported that training in mammography was offered in each of the 211 programs. Of the 211 programs, 203 (96%) had rotations devoted exclusively to breast imaging, compared with 74% in 1994 and 40% in 1990. Of the remaining eight programs, seven programs included mammography training in general radiology rotations, and one program included a combination of mammography training and general US rotation. Of the 211 programs, 202 (96%) had a separate breast imaging section (not combined with another section), compared with 81% in 1992. Of the remaining nine programs, six included breast imaging in a general radiology section, two included breast imaging with general US, and one combined breast imaging with nuclear medicine. Regarding length of training in breast imaging, 196 (93%) of the 211 residents reported that training was 8 weeks or longer, compared with 79% in 1992 and 46% in 1990; and 153 (73%) reported that the rotations lasted 12 weeks or longer. Of the remaining 15 of 211 residents, eight reported that the length of training in breast imaging was shorter than 8 weeks, and seven did not know or were not sure about the total length of training. The residents reported that 86 (41%) of the directors or section heads for breast imaging in the 211 programs worked exclusively in breast imaging, and 158 (75%) spent 50% or more of their time working in breast imaging. The 125 directors or section heads who did not work exclusively in breast imaging also worked in another subspecialty area or in general radiology.
Residents’ Role in the Breast Imaging Rotation
During the rotations, the residents indicated that they interpreted from 40 to 575 mammograms per week with supervision, with a mean of 162 per week. Regarding screening versus diagnostic mammography, 201 (95%) of the 211 residents indicated they had experience in screening, and 204 (97%) indicated they had experience in diagnostic mammographic work-ups. Table 1 includes additional information about the residents’ role and training in the breast imaging section.
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Table 3 details whether findings of other breast imaging procedures were interpreted or whether the procedures were supervised or performed by breast imaging faculty (ie, the radiologists who interpreted the mammograms).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Comparison with previous surveys also revealed increased time devoted to these rotations during the past decade. Rotations of 8 weeks or greater increased from 63 (30%) in 207 programs in a survey of residents in 1990 to 177 (79%) in 224 programs in a survey of residents in 1994 and to 200 (95%) in 211 programs in a survey in 2000 (14–16). Increased time devoted to breast imaging can be attributed to several factors, including the initiation of a separate breast imaging category on the June 1990 American Board of Radiology Oral Board Examination, more questions on breast imaging on the American Board of Radiology Written and American College of Radiology In-Training examinations, and an increasing volume of breast imaging in radiology practices. Furthermore, the interim regulations of the Mammography Quality Standards Act of 1992 included baseline training requirements for physicians in interpretation of mammograms. The Mammography Quality Standards Act Final Regulations, which were implemented on April 28, 1999, by the Food and Drug Administration, mandate both initial training and initial experience requirements. For a physician to qualify to independently interpret mammograms, he or she must be board-certified in diagnostic radiology by a body approved by the Food and Drug Administration or have 3 months of formal training in mammography (10). In addition, there is an initial experience requirement that a physician interpret 240 mammograms with direct supervision during the 6-month period immediately prior to qualifying as an independent interpreting physician. If a resident takes and passes the board examination (including all 10 sections) at the first allowable time, the 240-mammogram initial experience requirement does not have to be fulfilled during the last 6 months before qualifying but can be fulfilled by such an experience during the last 2 years of residency. If a resident does not pass the board examination at the first allowable time, he or she must have 3 months of training in mammography and interpret 240 mammograms with direct supervision in the 6 months immediately prior to qualifying. The Mammography Quality Standards Reauthorization Act of October 10, 1998, extended these requirements to October 2002. To ensure that residents will be able to interpret mammograms when they enter clinical practice, many programs include 3 months of breast imaging in their residency curriculum.
In addition to the length of time devoted to rotations, proper training also requires dedicated faculty supervision, an organized curriculum, and exposure to adequate numbers and types of examinations, which include breast US and interventional procedures. A survey of residents in 1990 indicated that 95 (46%) of 206 supervising faculty (directors or section heads) spent at least half of their time in breast imaging (14). In our 2000 survey, residents reported that 87 (41%) of the 211 directors or section heads worked exclusively in breast imaging, and 158 (75%) spent 50% or more of their time in breast imaging. Findings in a recent report indicated that academic medical centers are having difficulty recruiting and retaining faculty in general (12). According to this study, in 106 academic radiology programs surveyed, most of which are affiliated with medical schools, there were more than 570 job vacancies. Results of this study (12) indicated that in addition to 69.5 breast imaging faculty positions, these vacancies included 84.5 neuroradiology, 84.5 abdominal imaging, 78 vascular/interventional, 55 general radiology, 43.8 pediatric, 36.5 chest, 32 musculoskeletal, 31.5 nuclear radiology, 25 research, 17 US, and 13 other faculty positions. Considering the overall shortage of radiologists and the financial disincentives of academic practice, this problem is not likely to be remedied in the near future.
The Society of Breast Imaging has developed specific recommendations for a residency curriculum in breast imaging (19). The Society of Breast Imaging curriculum includes training in epidemiology, breast anatomy, pathology and physiology, mammographic equipment and technique, quality control, interpretation and reporting, screening and problem-solving mammography, breast US, breast MR imaging, and interventional procedures. Although our survey could not address each aspect of the Society of Breast Imaging recommendations, we were able to explore many key items. Answers to questions about the resident’s role in the breast imaging section, the characteristics of the practice, and the practice protocols indicated that the majority of residents were receiving adequate training and experience in patient treatment, imaging modalities, and interventional procedures (Tables 1–3).
Despite apparent improvements in training and curriculum, results of our survey revealed that the majority of residents had negative attitudes about breast imaging. For example, the residents found the interpretation of mammograms to be more stressful than interpretation of other images (Tables 4, 5). Furthermore, 147 (70%) of the 211 residents were more concerned about missing a potentially important finding at mammography than at transverse abdominal CT. Although they indicated that the workload for mammography was about the same as it was for other types of imaging examinations, with 64 (30%) indicating that the workload for mammography was less, 100 (47%) indicating that it was the same, and 47 (22%) indicating that it was more, 174 (82%) thought that the stress levels regarding possible misdiagnosis were greater for mammography (Table 5). Of the 211 residents, 196 (93%) reported that patient stress was greater for mammography. The latter may be related to the increased patient contact associated with breast imaging, compared with the patient contact of other areas of radiology, but it could also reflect the higher levels of anxiety of patients related to a possible diagnosis of breast cancer (20,21).
We were surprised by the level of concern the residents reported about medical malpractice liability related to interpretation of mammograms. For example, 197 (93%) of the 211 residents indicated they had "somewhat more" or "much more" concern about malpractice liability related to interpretation of diagnostic mammograms when compared with interpretation of other images (Tables 4, 5). The residents’ awareness of medical malpractice issues may reflect concerns of their faculty and community radiologists or the frequent coverage of malpractice issues in the radiology literature (22). In 1990, the Physician Insurers Association of America reported that failure to diagnose breast cancer had become the second most common reason that physicians were sued and the leading cause for indemnity payments (23). In a 1995 follow-up study, the Physician Insurers Association of America reported that failure to diagnose breast cancer had become the number one cause of medical malpractice lawsuits (11). A substantial number of residents we interviewed indicated that malpractice exposure was one of the leading disincentives to interpretation of mammograms.
The disinterest in breast imaging expressed by current residents should raise concerns about the ability to meet future breast imaging needs. Although 137 (65%) of the 211 residents indicated that specialists should interpret mammograms, only 65 (31%) of the residents would even consider a fellowship in breast imaging if it were offered to them. Of 53 institutions offering fellowships in breast imaging, only 46 had been successful in recruiting fellows. Results of our survey showed that there were a total of 63 breast imaging fellows at these institutions, compared with 76 fellows identified in 1994 (16). We are not certain how this compares with unfilled positions in other subspecialties. Such comparative information will be available with the initiation of the fellowship matching program.
Of equal concern is the fact that only 62 (29%) of the 211 residents agreed with the statement that they would "like to spend a significant portion (25%) of their time interpreting mammograms" in their future practices (Table 6). The leading reason residents would not consider a fellowship in breast imaging and did not want to interpret mammograms in the future was a perception that it was "not an interesting field." In decreasing order of frequency, other reasons residents selected for not wanting to pursue fellowship training in breast imaging or to interpret mammograms in clinical practice included "fear of lawsuits," "too stressful," and "low pay" (Figs 1, 2). We are uncertain how this compares with residents’ perceptions of other subspecialty areas, and many residents may identify other subspecialties that are not interesting fields for them. However, these findings suggest that it will be a challenge to provide adequate interpreters for increasing numbers of examinations in the future.
The residents’ perception of "low pay" for breast imaging could also be related to the notoriously low reimbursement for mammographic services that is having a negative impact on both academic and community practices. For example, the number of facilities at which mammograms are interpreted in Maryland is reported to have decreased from 167 to 150 in 1 year, and the number of accredited mammography centers nationwide has decreased from 9,873 in March 2000 to 9,534 at the end of October 2000 (7). In addition to a number of factors, such as phasing out older practices and equipment and consolidation of practices, inadequate reimbursement has been identified as the primary reason that facilities are discontinuing mammographic services (5–7). Findings of a recent study of the financial status of mammographic services at seven university-based programs revealed that all programs sustained losses in the professional component of mammographic services (5). The greatest discrepancy between costs and reimbursement proved to be in diagnostic mammography. The authors concluded that reimbursement rates for mammographic procedures, especially diagnostic mammography, needed to increase to reflect the resources necessary to provide these services. However, attempts to address this issue with the Centers for Medicare and Medicaid Medical Services have been disappointing. According to a Centers for Medicare and Medicaid Medical Services notification on January 1, 2002, the Medicare Ambulatory Payment Classification rate applied to hospital-affiliated outpatient facilities for diagnostic mammography was scheduled to be reduced (24). These decisions have a major impact on teaching institutions because they are all hospital-affiliated practices. Therefore, decreased Ambulatory Payment Classification reimbursements will further discourage academic training hospitals from supporting breast imaging programs. The current situation also suggests that the practice of treating a high-volume procedure such as mammography as a loss leader is having adverse consequences on interest in specialization in a field that is regarded by radiology in general, and perhaps visibly by one’s colleagues, as a money loser.
There may be other key reasons why residents are not pursuing breast imaging fellowships. One reason involves Mammography Quality Standards Act regulations. In many programs, mammography rotations may be delayed until the last 2 years of the 4-year residency to ensure that residents meet Mammography Quality Standards Act regulations. In some programs, rotations in breast imaging also may be deferred so that residents can spend more time in their first 2 years in subspecialty rotations that are required for night call coverage. However, residents are under pressure to make a decision and apply for radiology fellowships by their 3rd year of residency. Therefore, during the first 2 years of training, residents are considering fellowship options based on their experiences during rotations in a variety of subspecialty areas. It is important to understand that while federal regulations do not require that mammography rotations be in the last 2 years, the fact that the Mammography Quality Standards Act requires that interpretation of at least 240 mammograms with direct supervision must be completed in a 6-month period during the last 2 years of residency may lead to the scheduling of the mammography rotation to be coincident with that requirement. To stimulate a possible interest in breast imaging as a subspecialty, we recommend that residents have an introductory rotation in breast imaging during the first 2 years of residency.
The current shortage of radiologists in the United States and Canada also has a negative impact on recruitment of fellows. Radiologists are in such demand that the advantage of a fellowship in obtaining a job has diminished.
The main limitations of our study involve possible sampling errors, since we could interview only one resident in each program and primarily used 4th-year (postgraduate medical school year 5) residents, the majority of whom were chief residents who may not have been representative of all of the other residents in their programs. In addition, problems identified in breast imaging may well exist in other subspecialties because of the current shortage of radiologists. Comparison of specific items, such as residents’ perceptions of the subspecialty, with their perceptions of other subspecialties was also not possible because of a paucity of information in the current literature.
In conclusion, compared with results of previous surveys, findings in this study indicate that residents are spending more time in dedicated breast imaging rotations, and the curriculum and the role of the resident in the services appear to be improving. A number of problems that deter residents from pursuing breast imaging either as specialists or as general radiologists have been identified. These problems represent complex challenges without easy solutions, but it is critical that we begin to address these issues immediately so that training programs can provide adequate numbers of skilled interpreting physicians in the future.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  A. R. Melton Are Current Mammography Quality Standards Act (MQSA) Physician Guidelines Truly Adequate? Am. J. Roentgenol., August 1, 2008; 191(2): W79 - W79. [Full Text] [PDF]
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L. W. Bassett Breast Imaging: Current Utilization, Trends, and Implications Am. J. Roentgenol., September 1, 2007; 189(3): 612 - 613. [Full Text] [PDF]
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 J. G. Elmore and R. J. Brenner The More Eyes, the Better to See? From Double to Quadruple Reading of Screening Mammograms J Natl Cancer Inst, August 1, 2007; 99(15): 1141 - 1143. [Full Text] [PDF]
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 C. A. Beam, E. F. Conant, and E. A. Sickles Correlation of Radiologist Rank as a Measure of Skill in Screening and Diagnostic Interpretation of Mammograms Radiology, February 1, 2006; 238(2): 446 - 453. [Abstract] [Full Text] [PDF]
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J. G. Elmore, S. H. Taplin, W. E. Barlow, G. R. Cutter, C. J. D'Orsi, R. E. Hendrick, L. A. Abraham, J. S. Fosse, and P. A. Carney Does Litigation Influence Medical Practice? The Influence of Community Radiologists' Medical Malpractice Perceptions and Experience on Screening Mammography Radiology, July 1, 2005; 236(1): 37 - 46. [Abstract] [Full Text] [PDF]
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C. D'Orsi, S.-P. Tu, C. Nakano, P. A. Carney, L. A. Abraham, S. H. Taplin, R. E. Hendrick, G. R. Cutter, E. Berns, W. E. Barlow, et al. Current Realities of Delivering Mammography Services in the Community: Do Challenges with Staffing and Scheduling Exist? Radiology, May 1, 2005; 235(2): 391 - 395. [Abstract] [Full Text] [PDF]
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J. G. Elmore and P. A. Carney Computer-Aided Detection of Breast Cancer: Has Promise Outstripped Performance? J Natl Cancer Inst, February 4, 2004; 96(3): 162 - 163. [Full Text] [PDF]
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D. B. Kopans Mammography Screening Is Saving Thousands of Lives, but Will It Survive Medical Malpractice? Radiology, January 1, 2004; 230(1): 20 - 24. [Full Text] [PDF]
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