Gastroenterology is a unique specialty using endoscopy to manage hepatic, pancreatic, and gastrointestinal diseases. Advanced gastroenterology, also known as advanced endoscopy or interventional endoscopy, is a subset of gastroenterology focused on providing more complex endoscopic procedures. Although gastroenterologists traditionally use endoscopy to diagnose and treat multiple gastrointestinal diseases, technological advances have provided new tools for gastroenterologists to influence patient care. Of these recent advances is the artificial intelligence (AI). Artificial intelligence is a computer-based system analyzing medical images through algorithms triggered by pattern recognition. Such medical images may be interpreted during an endoscopic procedure, clinical photographs, or video. Therefore, gastroenterologists could use artificial intelligence as an adjunct to help discover subtle changes and differentiate pre-cancerous from cancerous lesions.

One of the most common endoscopic procedures gastroenterologists perform is a colonoscopy. Although colonoscopy is used to help diagnose and treat multiple gastrointestinal diseases, colonoscopy is also used to screen for colon cancer. Gastroenterologists can use colonoscopies to help discover both precancers and cancers in the colon. However, precancers can be missed by gastroenterologists using standard colonoscopy. It is estimated that up to 15-20% of colonic precancers can be missed following a screening colonoscopy.

As technology continues to grow, the implementation of novel inventions into endoscopy has and will continue to improve patient care and outcomes.

Furthermore, with the recent recommendations by the United States Preventative Task Force, lowering the initial age of colon cancer screening from 50 to 45, more than a million Americans are eligible for a colonoscopy screening. Conversely, the number of gastroenterologists has not changed; therefore, overworked gastroenterologists may add extra colonoscopies to their already double-booked schedule. To address these practice gaps, recent literature investigated the role of artificial intelligence as a colonoscope adjunct to improve precancer detection rate during a screening colonoscopy. In two systematic reviews and meta-analyses published in 2021, both studies reported an increase in precancer detection rate by 44% using artificial intelligence-assisted colonoscopy. Furthermore, two other clinical trials using artificial intelligence called GI-Genius (Medtronic, Minneapolis, Minnesota, United States of America) reported an increase in precancer detection rate by 15% and 45%.

Despite an increase in precancer detection rate using artificial intelligence-assisted screening colonoscopy, one may argue that a high precancer detection rate may not decrease a gastroenterologist’s rate of missing a precancer. To address this concern, an additional article recently published in July 2022 by Wallace et al. reported an improvement in precancer miss rates using artificial intelligence-assisted colonoscopy compared to standard colonoscopy alone. Therefore, artificial intelligence could be used as an adjunct to aid overworked gastroenterologists in accurately detecting precancerous lesions during screening colonoscopies.

Although advanced gastroenterologists perform complex therapeutic procedures endoscopically, they also perform advanced diagnostic techniques to help diagnose and prognosticate multiple conditions, including malignancy. One of these diagnostic techniques is endoscopic ultrasonography, characterized by a modified conventional endoscope with an ultrasound probe at the distal end of the endoscope. This special endoscope creates an ultrasonographic image transmitted to a monitor for advanced gastroenterologists to visualize both anatomical and pathologic findings while performing endoscopy in real time. Although advanced endoscopy is a useful tool for healthcare providers, it requires a lot of training and may only be found in larger tertiary care centers. Therefore, limited exposure may cause advanced gastroenterologists to misinterpret or miss a lesion. To address this hurdle, artificial intelligence could be used as a tool to improve misinterpretation and detection among gastroenterologists. In a meta-analysis published in June 2022, artificial intelligence-assisted endoscopic ultrasonography was able to detect early esophageal cancer with an accuracy of 98% and a sensitivity and specificity of 95%.

In contrast, artificial intelligence-assisted endoscopic ultrasound was able to detect early gastric cancer with an accuracy of 94%, a sensitivity of 87% and a specificity of 88%. Another challenge advanced gastroenterologists may face is the differentiation of different pancreatic cystic lesions under endoscopic ultrasonography. In a study assessing artificial intelligence-assisted endoscopic ultrasonography’s ability to detect malignant potential in a pancreatic cyst, artificial intelligence was able to report malignant potential with an accuracy of 94% compared to a human interpretation accuracy of 56%. Such differentiation is important as artificial intelligence could help physicians risk-stratify which patients require monitoring and which patients require a surgical intervention. By improving ultrasonographic interpretation and detection, advanced gastroenterologists could rely on artificial intelligence to strengthen patient care and outcomes. 

With the advent of artificial intelligence in gastroenterology, both gastroenterologists and Interventional Endoscopists may be able to improve patient care by increasing the detection of polyps, differentiating cancerous from non-cancerous lesions, and more. As technology continues to grow, the implementation of novel inventions into endoscopy has and will continue to improve patient care and outcomes. Artificial intelligence will serve as a valuable diagnostic and therapeutic tool in the endoscopic world of gastroenterology.

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Healthcare is constantly changing at a rapid pace. One of the key medical disciplines promoting this change and advancement in medicine is radiology—aka diagnostic imaging. Specifically— this change is based on radiology’s advances in technological capabilities. Radiology is the discipline within medicine that uses imaging technology to diagnose and in some cases treat disease. Generally speaking, one can divide radiology into two large categories that include diagnostic radiology and interventional radiology. Interventional radiology is a therapeutic and diagnostic specialty that comprises a wide range of minimally invasive image-guided therapeutic procedures as well as invasive diagnostic imaging. 

So where is all the advancement in radiology occurring? A significant focus of development is within the space of Artificial Intelligence or AI. Artificial intelligence in radiology has several goals that include improving quality, productivity, and automation. So what is AI and how can it be used in radiology? Artificial intelligence used within the space can be seen as a self-learning software that assists in identifying potential abnormal findings on images. This assistance has the ability to improve how quickly a study is interpreted by potentially identifying areas on the image which the radiologist (physician) can review to determine if the disease is present. The optimal end result is AI would assist in the quality of the interpretation and how quickly it can be interpreted—a win-win situation.

Advances in technology have long been a catalyst for change in radiology, this has facilitated the pace by which healthcare in general is evolving.

Nuclear imaging has also seen a significant resurgence within the specialty—with particular emphasis within the PET/CT space. Nuclear medicine is the subspecialty within radiology which uses radioactive material (radioisotopes or tracers) inside the body to see how organs or tissue are functioning or in some cases to target and destroy diseased tissue such as cancer. PET imaging or Positron Emission Tomography falls into this subspecialty of radiology. It is a scan that measures the physiological function of tissues by looking at blood flow, metabolism, neurotransmitters, and radiolabeled drugs. New radioisotopes which have recently been released have specific targeting capabilities to help diagnose, stage and monitor common diseases such as alzheimer’s and prostate cancer, both major illnesses impacting the lives of thousands of people.   

As many readers will know, COVID-19 has had a significant impact on the business of healthcare—that includes radiology functions. With the help of the extreme measures early in the pandemic, alternative approaches to providing care while also social distancing needed to be implemented or augmented. Long before the pandemic, diagnostic radiology was already a pioneer in the telemedicine/radiology space with the ability for a radiologist to work remotely and  read (interpret) diagnostic images via PACS (Picture Archiving and Communication systems). These systems receive diagnostic images from all imaging modalities such as Computed Tomography, Magnetic Resonance Imaging, X-Ray and so on. These images are sent via a secure network to the database for the images to be uploaded and then ultimately transferred. Radiologists view these images on a workstation and will often use software tools at their disposal to enhance their interpretation. The radiologists dictate a report with his or her findings and they are sent to the appropriate referring clinician. The data which comprise the images are ultimately stored and archived for future review or comparison if necessary. 

Why is Teleradiology a hot topic if it has existed for many years now? When you combine the rise in imaging procedure requests, the diagnostic radiologist shortage occurring nationally and the reliability and efficiency in which teleradiology offers, you have a recipe for growth. This growth is accelerated with the specific rise in high-tech imaging such as CT, MRI or PET and allows for expanded access to subspecialty radiologists after normal operating hours for medical centers, private centers, and even rural centers. There is no shortage of vendors offering these platforms. One needs to wade through the abundant number of players in the marketplace to see if their platform meets your needs. 

Advances in technology have long been a catalyst for change in radiology, this has facilitated the pace by which healthcare in general is evolving. Out of all the emerging and advancing technologies discussed, AI seems to be where the current spotlight is on. One can expect AI to continue its growth in the discipline as healthcare evolves to value-based arrangements and there is a continued emphasis on productivity, quality and superior outcomes.

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In the 1987 film “Wall Street” Michael Douglas’s character, Gordon Gecko, stated “greed, for the lack of a better word, is good”. He made this claim to support the idea that our advances as a country were directly attributable to the greed of mankind. Just look at the amazing technology available in healthcare to see that, at least at some point in time, Gordon’s statement rang true for us as well. It’s incredible to think that we’ve only had MRI machines for 42 years and CT scans for just 50 years. And all the amazing breakthroughs in medicine that were developed because of what these technologies can see. The creation of these machines was not 100% altruistic and the advances made to them over time to make them more hi-tech and faster weren’t done just to improve outcomes.

In this instance, regardless of your political views on capitalism, we could all agree that greed just might have done some good. Greed in healthcare is prevalent on all sides, vendors, administrators, staff, the government, insurance companies, the legal system, etc. and they all want their piece of the pie. And when someone finds a way to get a larger slice, you better believe they will; that drives more innovation. At some point, our primary consumer will say, ‘enough is enough’ and the spending will have to stop. Coming out of the COVID pandemic, we may have reached this point. This past year we have seen a massive staff exodus, decreased revenues, increased costs of care, and we see that continuing to operate the business of healthcare the way we have always done, is illogical. So how can we leverage technology from the world outside of healthcare to improve the patient experience?  

Healthcare systems need to develop solutions designed to address the shortfall in human capital without allowing startup costs to deter them.

True, greed is already present in healthcare. While COVID has led to much needed pay increases to frontline staff who have gone years without a raise that matches the annual cost of living increases; it took staff departures, closures, and negative impacts on patient care before that happened. And at the other end? Why does anyone in healthcare need to earn seven figures a year or more? We collectively seem to have forgotten that everything is paid for by the patient. Everything. We owe it to them to start exploring new ways to do our work and leveraging the tools created for capitalist purposes for the improvement of healthcare.

Healthcare systems need to develop solutions designed to address the shortfall in human capital without allowing startup costs to deter them. We need to look at who is doing what work, day in and day out. Who is placing IVs? Who is taking vitals? Who is doing procedures? And on and on. Once we know what the work is and who is doing it, we need to figure out what work can be improved by technology. One easy solution: self-scheduling platforms for appointments. It’s ridiculous that you can book travel on your own to anywhere in the world, but you can’t book a CT by yourself.

There are plenty of solutions outside of healthcare that could be applied today. Artificial Intelligence, Deep Learning, etc., should be looked at for all aspects of our healthcare systems. We could have AI screening patient records and results to triage our schedules and ensure no information is missed. AI to pre-read our images, reports, specimens, etc., to reduce defects and mistakes. Intuitive systems take a provider’s report or results typically filled with medical jargon and translate it into information that is understandable to the patient and their family, and in a tech format that is accessible to them. And we need to mandate the connectivity of all electronic medical records, PACS, etc., requiring full and on-demand access to any previous records regardless of where it was done, whenever it’s needed. I can search Google, Yahoo, etc. for any information and at the same time, I can’t get results from a year old blood test without signing a release and communicating directly with the facility.   

What if we went all in? Fully leveraging the technologies that made the creators of Google, Facebook, Instagram, etc., insanely rich? In our world today, a large majority of the population live their lives entirely for the world to see, we only have to pull up any number of applications or social media platforms and we can learn what someone had for lunch, whether they are a cat or dog person, what music they like, even down to how warm they prefer their home. A simple algorithm could pull all this data, prior to a patient’s arrival, checking them in for all their appointments, alerting the caregivers’ topics to avoid, important dates, room color, background music, and setting room temperatures. An AI could screen them at the beginning of the process by asking a few questions, getting vitals from smartwatches, etc., to make the care teams apprised of potential illnesses. Geofencing technology would allow these changes to precede them for all of their appointments while at the facility. Smart sensors can detect their medication compliance so that it can be discussed during visits. All their lives that they have shared online can be picked through for keys to what they can do to improve their own health. And when they are done, their car can be notified so it will be ready when the patient’s visits are completed. A 100% automatically customized experience based on all their smart devices, posts, likes, and dislikes. Surveys would be a thing of the past because the care team would know as soon as the patient posted about their experience. We would finally know our patients and how they wish to be known on a much deeper level. 

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It is without a doubt that medical imaging has seen exponential growth in advancements in technology. We are technologically far moved from where we stood 20 years ago.

Merely 15 years ago, we were seeing a 64 slice CT scanner advertised as “the fastest scanner on the market.” Many outpatient facilities were racing to buy a relatively expensive open MRI to capture claustrophobic patients. Ultrasound was beginning to offer 3D imaging, which seemed futuristic. There were stirs of conversations of general radiography going completely filmless and to most seemed preposterous. Now as we reflect on our advancements, these “upgrades” are laughable to most in the imaging world.

As of today, it is not unheard of to see a facility with multiple dual source CT scanners that can perform 300 or more slices and scan a single body part (including cardiacs) in under one second. MRIs have almost made it a standard that the bore size and bore length are comparable to the size of a CT scanner. These types of bores have almost completely eliminated open MRI scanners. In ultrasound, 3D and even 4D come standard on most pieces. Conventional X-ray almost unknowingly skipped right past the computed radiography phase of advancement and jumped straight to digital exposure with images being revealed instantly.

Given these advancements, are we utilizing the updated technologies to their full extent? Conversely, are we making these advancements too accessible? This is a discussion that seems to cause reflection on how we treat these technologies to analyze, care, and diagnose our patients.

Are we utilizing these technologies to their fullest extent?

In short, we are engaging most of these advancements correctly in clinical settings. However, there are opportunities as technologists and administrators where we could better fulfill patient care with our imaging technologies.

As improvements are made with each modality, more opportunities arise to use technology and engineering to decrease patient dose, exposure time, scan time and improve image quality. Cognitively evaluate the crossing point of cost and use of equipment with patient outcomes. For example, some dual source CT scanners offer flash or quick scan modes that can be used on examinations. These modes DRASTICALLY decrease dose and scan time. However, these are hefty price tags that many community hospitals cannot afford. There are other advanced scanners available to greatly improve image quality and patient experience. These offer more affordability for the locations that do not support the volume.

The options are almost endless and can easily conquer the decision-making skill of even the keenest administrator. Extensive research, observation, knowledgeable managers and experienced staff can be resourceful in making those decisions. Medical imaging is advancing what seems to be daily. Decisions would need aid to conclude on how to use your money wisely, where to place the equipment to get the most utilization and which technologies are needed to ensure you are serving your patient population.

Are we making our technological advancements too accessible?

Healthcare has become extremely reliant on medical technologies and is becoming more prevalent in the clinical setting. As previously mentioned, our radiological advancements have given us opportunities to improve patient outcome.

Most often, we see a rush to image in the Emergency Department. Time is of the essence with true emergency patients, but this also does not open the doors to rush to imaging. There are numerous examples that plague advanced imaging modalities. In addition to our equipment advancing, so has the criteria and research. The newest technology used to ensure proper imaging has been mandated by the CMS to utilize Appropriate Use Criteria (AUC). The AUC is an intelligent technological advancement developed on indications with scores ranging from 1-10. A score of one being inappropriate use of imaging and a ten being completely appropriate. These diagnoses are taken through a clinical decision support mechanism backed by evidence-based research.

Even though AUC scores an examination as a one, providers continue to image patients. We are utilizing the technologies supplied and bypassing just to rely on the speed of imaging. Some providers have openly admitted that the advancements have allowed them to lean heavily on the results from imaging.

With updated picture archiving systems and dictation systems, radiologists are able to have extraordinary turnaround times. Again, due to the advancements, providers are relying on and pushing radiologists to have quick turnaround times.

The issues does not reflect provider only reliance. There is much to be said about technologists’ performance given these advancements. Undoubtedly, a technologist’s role is crucial and a technologist will face a multitude of issues throughout a shift. Technological advancement has made their duties accelerate rapidly. Contrarily, it has caused contentment with suboptimal imaging and quality. Digital radiography has changed the process of portable examinations. Digital radiography has completely eliminated “the walk of shame” back to the floor to re-shoot an image. Instead, the complacency with attention to detail has given the option of an immediate fix and repeat without the pressure of returning to the floor to re-image. As with most discussions, there are always nuances to how a subject is perceived. However, it is not debatable that advancement in radiological technologies has improved patients almost universally for their visits. Each modality has seen their fair share of improvements in technology. Some modality advancements were quick and ever-changing while some divisions saw only little change. Nonetheless, it has been favorable for the field. It should be taken with great observation how we use our radiological technologies in the clinical setting. Advancements will continue to grow and we will continue to see enhanced treatments, diagnoses and most importantly, patient outcomes.

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Since the SARS-CoV-2 virus was first identified in December 2019, the world has been forever changed. The COVID-19 pandemic took the world by surprise as, seemingly, no one was prepared for the magnitude of change that the COVID-19 pandemic would bring. In the United States, an already strained healthcare system became overwhelmed with the breadth of the unique struggles that accompanied the pandemic. One such problem, that is often attributed to the pandemic, became known as the Great Resignation.

The dynamic of the Great Resignation is an epidemic in its own rite, but there’s no denying that the healthcare industry was devastated by the loss of skilled and competent healthcare workers. The medical imaging community was hit especially hard as many hospitals and imaging departments struggled to have enough employees to provide quality services without interruption. The problem seemed to have a cascading effect with what many believed there to be no end in sight.

During every conversation, I made a point to treat my employees as people instead of human capital. I let them know how important they are and seek to develop more leaders with the same qualities.

As a leader, I knew I had to face this problem head on, and rather than focus on the complexities of the situation, I was determined to find a solution. Every analysis and evaluation concluded with the same strategy; to focus on recruitment and retention. But how could I set my department and organization apart from the thousands of other medical imaging departments facing the same problem? My experience has been that servant leadership was the most effective method for retention. I set out to build a culture and create an environment that people would enjoy working in, as much as one could enjoy work, and ultimately believe this is sound advice for any leader in any profession.

My first realization was that no matter my aptitude for the business, I could not be a leader if I didn’t have a team to lead. I always struggled even to take a day off since I had a feeling that my department couldn’t run without me. That couldn’t have been further from the truth as the harsh reality that set in was my department didn’t need me at all! I could be replaced in an instant and they would all be just fine. The second realization was that even though they could make it without me, I could not make it without them. I set out to let them know how important they were to me, our patients, and our organization.

The Great Resignation has shown that people seem to have no problem leaving jobs or companies behind, and throughout my career, there had been jobs and companies that I had no trouble leaving. By the same token, there had been jobs that I could almost never imagine leaving. What differentiated the two? The bonds that were created between leaders and co-workers make up the difference. People have a much harder time leaving, families, friends, and mentors. I set out to create that environment by initiating team-building exercises and creating relationships between myself, my employees, and amongst themselves.

Before long, as the culture shifted, my team was working to recruit people into the organization. As they gave testament to the work environment, more applicants started flowing in because we were developing the reputation that our department was a great place to work! I tried to take time out of my busy days to chat with students, and my teams, one on one, to establish myself as an approachable leader. For the longest time, when I would summon people to my office, the response was always, “Oh no! What did I do wrong?” That always bothered me. I wanted to dispel the negative connotations related to coming to my office for a chat.

During every conversation, I made a point to treat my employees as people instead of human capital. I let them know how important they are and seek to develop more leaders with the same qualities. Today, I can confidently say that I feel that I have the best team around! I am honored to have the opportunity to work with them and be someone they trust and respect. I am extremely thankful for those leaders who believed in me, motivated me, and allowed me to serve. Even more so, I value the lessons I’ve learned from the bad leaders, as they’ve taught me what leadership styles to avoid. 

To be a servant leader is to take the organizational chart, turn it upside-down, and place yourself at the bottom. We must remember that our role is to be supportive, to create an environment in which people can grow, to create a culture in which people can thrive, and to be a leader that you would want to follow. The job market, at the moment, is wide open and there are multitude of opportunities available. Many offer better pay, larger bonuses, and other superficial attractions. I ask everyone who is reading this to ask themselves, “Why would people want to work for us?” It is no longer a question of “Why do you want this job?” but, rather, “Why wouldn’t you want this job?” Only when you can ask that question, you created the right environment to attract and retain the best of talent.

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Medical imaging is one of the most rewarding and vital fields within the healthcare industry. Medical imaging impacts a high percentage of all patients treated and provides valuable information to clinicians. Like most aspects of health care, medical imaging is a “People Business.” Medical imaging serves people by people using specialized equipment. So, it takes many types of “people”, including technologists, reading physicians, and the basis of healthcare, the patients. The biggest challenge medical imaging faces today is the lack of “People.”

In most cases, it is the lack of people, including the lack of technologists. Technologists today are highly educated and trained in a specific imaging discipline to acquire high quality images for accurate interpretations. These individuals are coveted and highly sought after. With almost endless opportunities (hospitals, physician offices, independent diagnostics testing facilities, etc.), these individuals seek out workplaces that provide support, professional growth, flexibility, and respect. The tool we have found most impactful is listening to these individuals, understanding their needs, and anticipating what motivates them. Technologists are obviously there to get paid well and make a living, but to truly keep more of them requires awareness of motivation. Motivators include things like flexible shifts, cross-training availability, ample time off, involvement in operation decisions, and a stellar array of benefits, to name a few.

The people of imaging! Technologists, Radiologists, and Patients (and many others) represent the beautiful part of this industry. It is an amazing synergy between human interactions and technology.

Utilizing active daily huddles and short meetings to engage the staff helps keep them informed. Celebrate victories and talk openly about issues. Affiliations with accredited technologist programs are key avenues to providing depth to departments that allow for time off for technologists. Highly efficient workflows allow the technologist to be efficient with patient flow and maximize daily throughput. Training and feedback are needed to provide them with the tools and understanding on how to best treat the patient. Amble technology and fully integrated systems allows for an efficient flow of information between radiologists and technologists. 

Reading physicians “People” for medical imaging come in many different varieties (Radiologist, Cardiologist, Orthopedist, OBGYN, etc.). Like technologists, individuals are in short supply, but thankfully with the emergence of technology, this has brought interpretations to areas that wouldn’t be available otherwise. Remote reading utilizing high-speed networks has brought 24/7 coverage with sub-specialized reads to many facilities. Imaging is functional in many settings, from large academic medical centers to a patient’s home with a portable X-ray unit. Images are seamlessly transmitted to a clinician’s screen. It is important to provide all pertinent information (Prior imaging, Patient history) to the clinicians in an easily retrievable manner. Technology has allowed the industry to continue to acquire millions of images a day that are reviewed timely by highly trained clinicians using voice recognition technology to deliver life-saving information. Modern voice recognition technology allows the reading physician to quickly speak the words they want in the report while providing options to embed endless information in their final report. This allows these individuals to live where they want but provide their expertise to areas that otherwise would not be serviced. Offices are often set up with the latest technology to provide soft lighting, proper acoustics, workstations that allow standing or sitting, and limited interruptions. Technology such as video chat and integrated instant messaging allows for collaboration for remote readers and mitigation of interruptions. 

Patients “People” today are more informed and better educated about the services available. Internet reviews and governmental data provides an endless amount of decision-making information. The basic expectation for patients is to receive the correct study, in a time-efficient manner with immediate results. Some differentiators are bleeding-edge equipment (Advanced MRI Systems, Dual Source and faster CT scanners.), AI Technology (Smart Reading List, Reading Aids), and world-class customer service. Patients are also noise and radiation dose conscious. The expectations are for full sound systems providing on-demand selectable music for long studies and procedures. Using patient feedback is key to stay on top of the evolving needs of today’s patients. Relevant surveying while sharing the information (Good and Bad) with all the “people” involved provides a competitive edge. Patients want immediate access to their images and reports (Image Sharing Services). This allows them to share the information with anyone on the care team.

The people of imaging! Technologists, Radiologists, and Patients (and many others) represent the beautiful part of this industry. It is an amazing synergy between human interactions and technology. The technologists have access to multimillion dollar equipment which allows them glimpses inside other humans with detail. Radiologists are provided with highly detailed images and can evaluate them using today’s tools (AI, CAD, High-Resolution Monitors, etc.) that provide life-changing information. The patients have the benefits of receiving detailed information in most cases by a minimally invasive means with almost immediate results. To combat the medical imaging “People” challenge combines engagement techniques and technology. The current market for people in health care is tremendous and as competitive as it has been in decades. Even though not perfect, we have found success with constant feedback from everyone involved and the adoption or implementation of modern technology.

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There is no doubt that medical imaging is the most frequently used diagnostic tool in medicine. Since it is being mostly utilized to get rapid results for both acute and chronic ailments, without the use of invasive measures, it should come as no surprise that imaging is the largest source of outpatient revenue for many hospitals, bringing in about 35% of the bottom line on average. Having such a high percentage and bearing such great responsibility and pressure in the scope of our healthcare institution, the understanding and management of that operation are faced with many challenges that require both careful and strategic planning in order to overcome these obstacles.

The introduction of COVID-19 hit our healthcare system in a way that no one could have predicted. As a radiology administrator, the biggest challenge that many of our institutions faced at that time was employee coverage, or rather employee shortages. It’s no secret that before blood tests, rapid tests and nasal swabs, the first ever created method for COVID-19 diagnosis was through a Chest CT, looking for that distinctive “ground glass” opacity appearance on patient images. During the initial onset, many patients came through the ER with uncertain diagnosis of what appeared to be flu and bronchitis symptoms. At the time, they were positive for COVID-19, but no one knew. We had no idea what we were dealing with or how to handle it. We obviously couldn’t turn patients away, so we had to arm ourselves and do what we signed up for when we chose this profession. Only this time, we were on the front lines fighting an enemy that we knew nothing about.

Radiological technologists are one of the many unsung heroes during the emergence of COVID-19. When isolation was at the precipice of our daily lives and many americans were at home or out of jobs, rad techs were working overtime hours at a rate that would be considered inhumane compared to current labor standards. After excessive hours and continuous exposure, rad techs were getting sick and were diagnosed with COVID-19. Available staff members were decreasing by the week. As a result, there were staff shortages. I can recall a time when staffing was so bad that I was being offered $10,000 per week to come to NY during their COVID-19 crisis. All expenses and accommodations were covered as long as I would agree to at least a four week contract. As good as that might sound, I still had work and family obligations to consider before respectfully declining the offer.

My advice to anyone starting and learning how to navigate this field would be to pick a modality that you love and then pursue a 2nd certification to help you become more marketable.

Dealing with a rising number in patient sickness’ and a growing concern for inadequate staff coverage, we turned to agency and contract staffing to help. Patient care needs were being met and we were able to ensure continuity of all radiology services for the foreseeable future. Even though this seemed like a great plan at the time, there were still a few setbacks. Agency staffing takes quite a bit of time to be approved, as they needed the appropriate clearance checks before being onboarded in our system and it comes at a high cost to the bottom line. I’m sure many administrators can relate to the exuberant costs that were being paid at the time. A large percentage of revenue was lost due to COVID-19, and then having to turn around and pay a high expense for additional staffing hurt our financials in a way that many outside the healthcare field will never understand. It was a balancing act that needed to ensure that our current staff members were being paid their full salaries, without the fear of losing their jobs or the reduction of hours, while simultaneously maintaining a reserve to ensure that additional staffing was a possibility when necessary. I’ll give you an example. If I needed an additional CT tech from an agency, I would have to endure the cost of paying about $200 per hour. What many technologists are not aware of is that a lot of these agencies will sign them up for a contract anywhere from 4 to 16 weeks and pay them at a rate between $60 to $80 per hour or more, which is significantly more than the normal Full-time or PRN rate and consume the rest of the money for their administrative and overhead cost. The trend that was happening during COVID-19 was that many radiological technologists were leaving behind their secure full-time jobs to hop on a bandwagon that seemed to pay out large sums of money. Yes, they would acquire a larger sum of money in a short period of time, but there were no benefits, long-term commitments or guarantees of sustainability. 

Leaving a secure position for an agency is something I strongly advise against. No matter how promising it seems at the moment, I find that the current trend in agency or contract staffing requests are declining as we begin to create ways of normalizing our standard practices in a newly recognized COVID-19 world. I’ve noticed that many technologists that once left their secure roles are trying to find once again a home base to settle down in. The problem is, when they’ve knocked on those employment opportunity doors that were once widely opened, it is now closed. Those positions are now secured by those that chose to stay behind and remain in a secure full-time position. 

My advice to anyone starting and learning how to navigate this field would be to pick a modality that you love and then pursue a 2nd certification to help you become more marketable. Nowadays, directors or hiring managers are looking for team members that can do multi-modality operations. If you have more than one trick up your sleeve, your chance of being hired grows tremendously. Lastly, find a place with a leader that respects and values your contribution to their team. This kind of place will ensure your happiness, give you a sense of purpose and nurture you in your career growth. A great working environment and a positive culture will always beat out a higher paycheck from an unsustainable source.

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In the last several years, my healthcare system has implemented several pieces of AI software in the radiology departments, both across the system and at individual hospitals. We have 13 wholly owned hospitals and six joint venture hospitals with three radiology physician groups reading across the enterprise. Recently, companies and vendors that develop and market AI for radiology have brought many, many software solutions to market. AI software for radiology has been developed for multiple modalities (i.e., CT, MRI, and X-ray, for example) and is able to assess images from specific areas of the body to look for and identify disease states. This is to assist and enhance what a radiology physician would be identifying during their formal read of the study.

AI is not meant to replace the radiologists for their part in patient care. I went to the Radiological Society of North America (RSNA) annual meeting and convention in Chicago at the end of November 2022. There were hundreds of vendors at the meeting representing AI software and platforms for the radiology industry. Most of these software are FDA approved, but some are not. Due to the recent explosion in this area of technology, a focused and structured approach to adopting this technology into a hospital practice is needed, whether it is for one hospital or a larger system.

Visiting many of the AI booths at RSNA, it became apparent that vendors are taking several approaches to market and implement this technology. The first approach is the vendor develops their own AI software. The vendor would market their software in individual software offerings or in package offerings that include several pieces of AI software, directly to end users/facilities. This means they employ or contract with all their own software developers. Most of their offerings are FDA approved, but some may not be. 

A radiology AI implementation committee should be formed to make strategic decisions as to what software modules are most important and then determine how to implement that software.

The second approach vendors use is licensing third-party developers of AI software to market to their customers. Again, this can be marketed as individual software offerings or as package offerings that would assess images of several different areas of the body. Some of these vendors may have their own platforms that could be launched directly from the end user’s current PACS solution.

The third approach vendors use for marketing AI for radiology applications is a hybrid model of the first two. These vendors develop their own software and license 3^rd party software to the market to end users/facilities. This allows the vendors to market software to end users that they would not otherwise have in their offerings.

There are two aspects radiology departments should consider when assessing AI vendors; how the vendor platform interacts with the radiology physicians during image assessment, and how the AI platform real-time interfaces in order to communicate a positive finding to the care team. These two aspects are independent of each other and not all vendors will have either, or both, of these platforms. If the vendor has an interactive platform for the radiology physicians for when they are reading the exams, the way that platform is utilized by the physician is important, as it can greatly affect the physician workflow efficiency. One example of an interface used during the exam reading task is the vendor AI software would send an assessed image with an interactive icon to the facility’s native PACS system. That icon on the image may indicate that the AI software has identified a finding and the physician could click on that icon inside the PACS system which would take the physician to the AI software, opening directly to the image where the positive finding can be found. Once the AI software has identified a positive finding, if the software platform has a results interface, it would then send the findings to the care team that is signed into the platform at the time. For instance, a positive finding for Large Vessel Occlusion (LVO) could be sent to the Neuro Interventionalist, Stroke/Vascular Cath Lab team, radiologist, stroke coordinator, Hospitalist and/or ED physician, and any other clinical team member needing this information. Examples of software that a vendor may carry include intracranial, hemorrhage, LVL, brain aneurysm pneumothorax, aortic dissection, and C spine fracture, just to name a few.

Lastly, in order to determine a strategy on which of the vendor’s specific software modules to purchase and how to implement those modules, a formal process should be implemented. At my health system, we will create a Radiology Artificial Intelligence Summit Committee. This committee will consist of a radiologist from each of our radiology physician reading groups, members of radiology IT, the chair and vice chair of our system radiology directors’ council, and several SMEs from the areas of focus of the software we are assessing. As an example, for LVO, those SMEs could include stroke coordinators and/or neuro interventionalists. These SMEs would be adhoc and different for each software module that would be assessed by the committee.

With so many aspects to consider, adoption of AI in medical imaging can be an overwhelming and arduous project, especially in a large hospital system. Knowing what specific AI software modules are strategically important to your hospital system imaging departments is a key piece of information to determine what details to look for from AI software vendors. This would include pricing based on if the hospital would be purchasing one specific software module, a package of several software modules, and if the vendor has a comprehensive platform and interfaces for radiology exam reading and the ability to communicate acute positive findings to the clinical care team. A radiology AI implementation committee should be formed to make strategic decisions as to what software modules are most important and then determine how to implement that software.

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If you have worked in healthcare for even the smallest of time, you are aware of the nursing shortages, and the movement to travel nursing resulting in much higher wages. This has made the organization profit margins slim, or even fall into the red. What’s not captured in the headlines as much is the shortage of imaging technologists, primarily MRI, CT, X-ray, and mammography. While not as critical as nursing shortages, organizations are scrambling to offer similar sign-on bonuses, higher wages, or better hours in hopes to lure new technologists in, avoiding low staffing, or paying higher traveler cost. However, this comes at a heavy costs both financially and morale. 

Because of a fierce competitive job market, technologist who are unhappy for any reason, including pay, fair treatment, hours, or management treatment can easily find a new job without the need to relocate. Not only does this happen between organizations but often between departments within the same organization. The biggest question is, how do we retain staff at reasonable wages, and hours for both the staff member and the organization? 

Everyone has seen the jokes about management and pizza parties being “the best we can do”, however what employees don’t understand are the high cost and at times low payments for imaging studies. Sitting down with staff during meetings is a great way to improve transparency and bring to light the high cost and number of staff it takes to run a successful imaging department. Many employees have heard of the gross charge for an exam, and associate that with an actual payment which of course is vastly different. Hospitals struggle to collect 25% of what they charge while outpatient centers are better but still around 35-40%. To help simply that, providing an average payment for a particular study can be useful. For example, if a study pays $200, show the staff how far that money goes, not only for their pay, but the pay of the check-in person, the staff who performs prior authorizations, and equipment repair. CT tube, or mammo detector replacements can run over $100,000 easily, not including labor. Not only will staff be thankful for the education and knowledge, but they will also gain respect for the challenges we face as healthcare leaders. 

The biggest question today, how do we retain staff at reasonable wages, and hours for both the staff member and the organization?

Another challenge leader’s face are internal bidding wars, between different facilities inside one large organization. X-ray or other commonly used modalities can often bounce around from hospital to outpatient centers within the same organization and at times receive a pay increase. This is a two-fold issue with the first of losing the staff, and the second being a morale hit to the current department. As many of us know, employees do often communicate their pay to one- another, making it difficult for leaders to keep morale up. Keeping open lines of communication between leaders and having a simple agreement no pay increases for lateral moves can help both keep staffing levels in hospitals sufficient and morale at the desired level for your team. Directors, or VPs should be mindful of these issues and stress a consistent pay practice across the organization. 

While internal transfer do happen, the main concern is losing staff to outside organizations. How to slow down the bidding war to hire staff? Many organizations are already providing internal bonuses, and higher annual raises, but are still seeing employees exit for even more money. While staff mostly cite this as the reason for their departure, it is often deeper than financial reasons. Every employee, even outside healthcare has different needs from their leader. Some love one-on-one time for a meeting, while others may just enjoy a simple coffee every-so often. Leaders must almost keep a diary on their staff, recording what helps motivate them to go “above and beyond.” Knowing how employees like to be appreciated or engaged goes a long ways with staff, and can make them second-guess a move to another organization for a modest pay raise. Using e-cards, emails, or just praising a staff member individually vs. group goes a long ways to help staff feel wanted. Rounding daily but not only by the direct manager but by senior leadership help staff feel more engaged, and enjoy sharing their experiences or concerns with higher level leadership. 

Increasing new grads through technical schools is another way to hire for growth, or staff vacancies. With the work population at a higher age, improving access for students to train has never been more important. Healthcare organizations must work with their local education systems as early as high school to get students interested in imaging, and invest in clinical training for those at a technical school. Going to career fairs, is a great way to show all that imaging has to offer, with so much focus on nursing, imaging departments must show the benefits of becoming a technologist, such as hours, patient mix, and advanced technology. 

Since there is no one solution for every imaging site, leaders must use their best judgement with staff retention. However, continuing to increase pay without regard to fair practice pay, staff morale, or profit margins will place a strain on healthcare systems, limiting capital, or increasing staff volumes. Keeping an open dialogue with current staff members is critical, ensure that employees who do have an offer from another organization look at the “total picture,” including benefits, layoff history of completing organizations, and work/life balance. Sometimes putting things in perspective helps staff see the grass isn’t greener on the other side.

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January 1, 2023 was to be the start of the payment penalty phase of the AUC Mandate, but has been delayed by the CMS. CMS did not provide a date for full implementation. The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a program which was intended to ensure the use of advanced diagnostic imaging services on CMS beneficiaries had been vetted by a practitioner through a CDS Mechanism, (CDSM). CDSMs are electronic portals through which the ordering of an advanced imaging study, such as CT, PET, MRI, or nuclear medicine procedures go through an algorithm to ensure the appropriate use of these imaging exams.

One of the goals of AUC implementation was to ensure these expensive exams were being ordered correctly to avoid ordering an exam that did not provide the required clinical information. Another was to improve the amount of clinical information being provided on an order to ensure the correct exams were indeed being ordered. As an ex-imaging technologist, I cannot count the number of times I received an order for an imaging exam only to have to go out on a reconnaissance mission to interpret exactly what type of exam was needed to give the clinician the information they needed to come to a correct diagnosis to properly care for the patient.

The patient would present to the imaging center and describe their symptoms, illness, pains, and what they were hoping the imaging exam would answer for their clinician. The technologist reviews the order and realizes that the exam ordered, the diagnosis given by the clinician and what the patient is saying is not materializing into the exam that needs to be performed to answer the questions fully. The imaging technologist speaks with their radiologist, who calls the clinician to change the order to a more appropriate order for an exam that needs to be performed to give the clinician the needed information. Meanwhile, there is a much-needed scanner sitting idle while the required information is attained, not to mention, now the 3:00 patient has become the 4:00 patient, the 4:00 patient becomes the 5:00 patient and the 5:00 patient must be rescheduled because the imaging center closes at 5:00.  

In an ideal world, the patient presents each time with what is needed, the technologist performs what is ordered, the radiologist dictates what was performed, the coders code what was dictated in the report, and the payors pay with no rejections or denials. When evaluating an imaging exam that was ordered incorrectly, one must consider the reasons for the incorrect order. Was it human error? Was it a process issue? Once identified, one must explore potential fixes. Sometimes, this includes education or putting new workflows/processes in place. Most important is to view the fix as a benefit to the patient’s care.

One action that can ensure that an order is correctly performed, is to ensure that the ordering provider provide as much information as possible. There are regulatory and accreditation requirements that providers supply documentation to support code assignment. Details needed in an imaging order are the same details captured during a patient visit to their provider. Imaging service providers are not asking for new information, but for what already has been captured during a patient interaction.

Organizations continue to move forward implementing systems/algorithms (tools) built to address the AUC mandate. These tools enhance the quality of care by improving provider and patients satisfaction, track improvement efforts, identify gaps in care to improve health outcomes, and reduce variation in clinical practice. Although CMS has put the penalty phase on hold, it is good to see organizations moving forward with this important tool.

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