Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
Sarah S. Donaldson, MD
Background Published online 10.1148/radiol.14140272 Content code: Radiology 2014; 271:315–319 1
From 875 Blake Wilbur Dr, G226, Stanford, CA 943055847. Received February 5, 2014; revision requested February 6; revision received February 11; final version accepted February 13. Address correspondence to the author (e-mail: [email protected]). Conflicts of interest are listed at the end of this article. RSNA, 2014
q
As recently as the mid-1970s, Surveillance, Epidemiology, and End Results (SEER) data revealed that just over half of children afflicted with cancer survived only 5 years (1,2). In the 1970s, radiation oncology was primitive. Medical linear accelerators were in the early stages of development (3,4). There was no acknowledged discipline called pediatric oncology, as subspecialty certification in pediatric hematology/oncology was not offered by the American
Radiology: Volume 271: Number 2—May 2014 n radiology.rsna.org
Board of Medical Specialties until 1974. In addition, cross-sectional imaging with computed tomography (CT) and magnetic resonance (MR) imaging was not yet clinically available (5–8), so radiology consisted mainly of plain-film radiography. At that time, radiologists were generalists. Radiology training programs were unified as general radiology (9), and we were at the nexus of patient care. Rounds often began in the radiology suite, where, during morning radiology conference, the radiologist demonstrated the many clues to the biology of human disease. Technology developed primarily for warfare was immediately extended to medical applications and use. Radiology quickly expanded to meet the new demands of technology. Radiologists began to subspecialize, and the practice of radiology gradually became less cohesive and less unified. To master this complex new technology, radiology training programs separated, with therapeutic radiology splitting from diagnostic radiology, and gradually radiologists drifted further and further apart. The good news was that within radiation therapy, the new technology improved understanding and accuracy, allowing the use of higher doses of radiation delivered to larger areas of the body, which brought about improved cancer cure rates (10). But ironically, the very treatment that cured cancer also created some new problems. All too soon, the cancer survivors began to show unanticipated and unacceptable radiation injury to normal tissues (11). Radiation oncologists were then challenged to reduce radiation toxicity and still maintain high cure rates for the cancer survivors. To sustain these high cancer cure rates, oncologists learned to cooperate, collaborate, and form multidisciplinary partnerships. It soon became apparent that all oncologists 315
ADDRESS
I
t is an extraordinary privilege to deliver the 2013 Radiological Society of North America (RSNA) President’s Address, to serve the RSNA, and to serve radiology. The annual RSNA meeting gives all of us a chance to renew old friendships, make new friends, and invigorate ourselves and our profession. These are extraordinary times, unsettling times, because we are working in an ever more stressful environment. It is an environment that challenges us to change, yet change is always difficult. However, in the midst of our daily pressures, we must look for opportunities for change, and these are the opportunities upon which we must focus. The Power of Partnerships is a theme that reminds all of us of the incredible power that comes from acting together and working together, as partners, to change the way we practice medicine. Three important and unique opportunities for partnerships deserve our immediate attention: those within radiology, those with others outside of radiology, and those with our patients. Within radiology, my expertise is in radiation oncology, with subspecialty interest in pediatric radiation therapy. Thus, my perspective for opportunities comes from caring for children with cancer.
Reviews and Commentary n PRESIDENT’S
The Power of Partnerships: A Message for All Radiologists1
PRESIDENT’S ADDRESS: The Power of Partnerships
Donaldson
Figure 1
Figure 1: Five-year relative survival figures for children with cancer, 1975–2008. Data are from the SEER Cancer Statistics Review (1).
had to work together effectively to build consensus. This focused multidisciplinary effort resulted in the development of new research programs that created more precise oncologic therapy. These multidisciplinary partnerships produced dramatic results. Pediatric cancer provides a good example of an effective partnership (Fig 1). Today, more than 80% of children with cancer are cured of their disease by using multidisciplinary, risk-adapted therapy (1,2). The goal in pediatric cancer care today is to obtain even higher cure rates, using treatment that is free of toxicity. Within a time frame of just 40 years, we can see the rewards that have come when diverse disciplines collaborate. Caring for children confirms the importance of partnerships. This success story with childhood cancer can help all of us better understand the extraordinary power of partnerships. Today in radiology we face extraordinary challenges on many fronts, challenges that demand a shift in our culture. This is a time that requires us to focus on producing value not volume, outcomes not output. To meet these challenges, to continue to grow and thrive, radiologists must build a new culture, a culture that fosters partnerships with a common focus. We can learn from the words of Sir Winston Churchill, a master of developing alliances and partnerships. His message, “If we are together, 316
nothing is impossible, if we are divided, all will fail,” carries universal applicability (12). Radiologists also need to establish our own powerful alliances and partnerships focused on improving patient care. To meet these enormous challenges, we need to develop partnerships at three levels: internal partnerships within radiology, external partnerships with health care professionals outside of radiology, and partnerships with our patients. However, we need to follow a number of specific steps to build these solid partnerships.
Internal Partnerships within Radiology In the current health care environment, precision—in diagnosis, treatment planning, treatment delivery, and reporting—is essential. To practice precision radiology, radiologic subspecialists must work closely with one another. A good example of such a close working relationship is the partnership involving radiation oncologists, oncologic imagers, and interventional oncologists. Oncologists achieve a delicate balance between killing cancer cells and sparing normal tissue. Their effectiveness is governed by what can be seen and how precisely the image can help target oncologic treatment. To function effectively and cure cancer, oncologists need to know precisely where the
cancer is located so they can precisely target their treatment. To target a tumor, oncologists must integrate images from all sections of radiology. They need to see and measure tumors in every dimension, understand how tumors move, their heterogeneity, their blood supply, and their molecular pathways. More than ever before in the history of radiology, radiation oncologists have an intensely strong interrelationship that already aligns radiologists as partners. Never before have specialists in diagnostic imaging and radiation oncology been so closely united. A builtin, natural partnership already exists. Radiation oncologists rely on anatomic and functional imaging to stage disease, to define response to therapy, and to plan treatment. They use imaging to localize radiation therapy volumes and to determine radiation therapy doses. And they counsel patients about their prognosis based upon the images obtained by specialists in diagnostic imaging. For example, Figure 2 shows how precise imaging permits high doses of radiation to be delivered in a short radiation therapy course for a hepatic lesion in a patient with a known primary colorectal cancer (Fig 2a). But this abnormality was not well-defined with CT and was not felt appropriate for radiofrequency ablation. However, the tumor board recommended stereotactic body radiation therapy, or SBRT, for precisely targeted, high-dose treatment given over a short period of time. SBRT is used in cases not amenable to standard external beam radiation therapy, as in this case, because of hepatic sensitivity to radiation. To deliver this treatment, oncologists need daily, realtime image guidance and tumor tracking, facilitated by fiducials implanted by colleagues with expertise in interventional radiology. At simulation, a positron emission tomography (PET)/ CT scan was obtained to localize this lesion (Fig 2b). Four-dimensional gating techniques confirmed the tumor did not move with respiration, but the PET scan showed a larger hypermetabolic lesion than revealed by CT. After specialists in functional imaging confirmed
radiology.rsna.org n Radiology: Volume 271: Number 2—May 2014
PRESIDENT’S ADDRESS: The Power of Partnerships
Donaldson
Figure 2
Figure 2: Cross-sectional and functional images in patient with a known colorectal primary tumor and an abnormality in liver. (a) Hepatic abnormality is not well visualized with CT. (b) PET/CT scan reveals a larger hypermetabolic lesion than revealed with CT. (c) Radiation therapy treatment volume was enlarged owing to findings from both anatomic and functional images to provide a high-dose radiation therapy plan delivered in a short course for definitive ablative therapy. (Images courtesy of Albert Koong, MD, PhD, and Billy W. Loo, MD, PhD.)
the tumor volume of concern, the radiation oncologists enlarged the treatment target volume (Fig 2c). Without integrated multimodality imaging and close interaction with our colleagues in cross-sectional and functional imaging, the true extent of disease would have been underestimated, resulting in “a marginal miss”—a guarantee of subsequent failure of localized radiation therapy. But the disease in this patient has been controlled and the patient has suffered no hepatic toxicity, a clear example of how important it is for all radiologists to work together to provide optimal patient care. Not only do radiologists use hybrid images to demonstrate both anatomic and functional findings, but hybrid technology also facilitates optimal treatment. Oncologists rely on PET/CT as part of radiation therapy simulation, and soon PET/MR imaging will also be commonplace. A ground swell of integrated activity is rapidly moving radiologists toward precision radiology, and it is predicted to continue. Soon even more emphasis on advanced imaging will create more tailored therapy. Four-dimensional, high-resolution color images will be commonplace. One can imagine that soon radiologists will generate images with molecular pathways already labeled for clinical use. Oncologists anticipate that soon they will be using
not just anatomic and functional imaging to guide treatment but also molecular imaging for gene expression. Most important, this momentum toward precision radiology demands that we cooperate, collaborate, and share responsibility for the care of our patients. Integrated cancer care requires that all radiologists understand tumor and molecular biology to tailor treatment to the individual characteristics of each patient. Increasingly, interactions within radiology will cut across all patient ages, diagnoses, parts of the body, and sections of radiology. Day-to-day common clinical problems are solved by teams of radiologists, not by single individuals. Team-based radiology, in partnership, is essential to the effectiveness of patient care. If radiologists can see these technical advances as opportunities to fine-tune oncologic therapy, then we will successfully meet these challenges for change.
Changes in Radiology Educational Programs Radiologists also need to take a hard look at radiology training and consider how the required curriculum should be modified across subspecialties to meet the modern demands of integrated care, such as collaborative training programs in radiology. A timely example is the subspecialty collaboration beyond
Radiology: Volume 271: Number 2—May 2014 n radiology.rsna.org
the newly approved Interventional Radiology and Diagnostic Radiology pathway initiated by the American Board of Radiology (13). Perhaps radiologists should consider a more enhanced interventional oncology/radiation oncology pathway, one that would include dedicated training in radiation oncology. This approach may sound revolutionary, but this model of integrating interventional oncology and radiation oncology has already been proposed in the United Kingdom and in Australia (14). While the underpinnings of a natural partnership within radiology are already in place, radiologists and radiation oncologists must develop and refine them through new modes of education and training.
External Partnerships with Colleagues Outside of Radiology No matter where on the globe we practice, the enormous emphasis on quality of care and patient outcomes demands team-based care. No longer do we work in individual silos. Multidisciplinary teams are already defined by specific diseases and anatomic sites. We know them as the “head and neck service,” the “lung team,” or the “lymphoma group,” to name only a few. One of the most profound truths in this era of image-based therapy is that radiologists are at the very center of these teams, and the teams do not 317
PRESIDENT’S ADDRESS: The Power of Partnerships
function well without radiologists. So, the partnerships for team-based care are already in place. To achieve the benefits of teambased medicine—better coordination, better cost containment, and better concierge care—we must take some important steps. We must find creative ways to increase our visibility. One way is to get out of the heavily shielded basement and out of the darkened reading room by actively participating in clinics, tumor boards, and multidisciplinary conferences. While it is difficult to send a consultative radiologist to cover every conference and tumor board, the fact is that radiologists cannot afford to be absent from these conferences. To be seen as equal partners in team care, radiologists must be at the conference table. This means all radiologists need to be more visible and need to share in the responsibility for patient care. When radiologists share patient care responsibility, we demonstrate our accountability and enhance our credibility. For the radiologists, this partnership in multidisciplinary team medicine is more than image interpretation and more than rapid communication of a consultation. It requires accepting responsibility for patient care, another excellent way to demonstrate the value of the radiologist as a member of the patient care team. When radiologists teach others about modern imaging and therapy, collaborative programs develop, resulting in an increase in patient referrals. Soon a radiologist is no longer simply an assigned physician but a requested physician. Radiologists avoid being replaced by a computer algorithm. Once again both diagnostic radiologists and radiation oncologists will be seen and valued at the nexus of patient care. Team-based medicine broadens the expertise of practicing physicians, it promotes collaborative research programs, and it builds careers of individual clinicians. The opportunities that cross-disciplinary partnerships afford include the excitement of developing innovative ideas with others, the challenges of building 318
Donaldson
new research programs, and the satisfaction of creating new collegial relationships. These opportunities invigorate radiology and radiation oncology as well as each of us as individual subspecialist radiologists.
Partnership with Our Patients One might ask, what is to be gained by having a direct partnership with a patient? Quite simply, patients want personalized care from their radiologist just as they have from their other physicians. Patients reiterate that they like having their radiologist speak with them and give them a preliminary result at the end of a radiologic procedure. If a patient’s images look good, it is nice to say so. If the images are concerning, then a comment that, as their radiologist, you will be speaking with their referring physician would also be welcome. However, this kind of one-on-one interactive communication is not a common practice today. To establish optimal patient relationships, the patient must know the name of his or her radiologist, just as we know the name of the patient. Moreover, patients who have met their radiologist face to face are more likely to appreciate the expertise and value of their radiologist. We are learning that patients want to partner with their physicians, and as physicians we need to partner with our patients. Whether or not this environment is comfortable for us as radiologists, patient-driven care is the new challenging reality. By accepting this change in culture, we have the opportunity to strengthen direct patient relationships, resulting in relationships that are longer lasting and of greater meaning. As a practicing oncologist, I know how gratifying it is to build meaningful relationships with my own patients. To partner with a patient is to establish a unique and rewarding long-term relationship, one that surely contributes to a rewarding professional life. Partnering with a patient can forge a long-term rewarding friendship, one that confirms that, as radiologists, we have contributed to the health and
well-being of our patients. Bonding with patients provides the greatest satisfaction of the practice of medicine and can give physicians the courage to welcome change, to meet the challenges, and to embrace the opportunities for new partnerships. As radiologists we must commit to these personal partnerships for a simple reason: they are good for our patients. A partnership with a patient defines who we are and how we practice medicine. Dr Francis Peabody offered some sage advice when he said: “…of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” These wise words are as valid and inspiring today as they were 86 years ago, when Dr Peabody lectured to Harvard medical students in 1926 (15).
Expected Consequences from Partnerships This presidential message offers a new vision of interdependence, of partnerships: internally, with other radiologists; externally, with our colleagues outside of radiology; and jointly, with our patients—our most important partners. All radiologists can form these partnerships. But, to do so, all radiologists must meet critical challenges, modify our culture, and invest in our opportunities. The question for all radiologists is, in these extraordinary times, these unsettling times, can radiologists now join together to build the strongest of partnerships for all of radiology? Again, Winston Churchill’s wisdom rings true for all radiologists today: “We make a living by what we get, but we make a life by what we give” (12). As partners, we indeed have much to give. Disclosures of Conflicts of Interest: No relevant conflicts of interest to disclose.
References 1. Altekruse SF, Kosary CL, Krapcho M, et al, eds. Surveillance, epidemiology, and end results cancer statistics review, 1975–2007. Bethesda, Md: National Cancer Institute, 2010.
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PRESIDENT’S ADDRESS: The Power of Partnerships
2. Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin 2011;61(4):212–236. 3. Karzmark CJ, Pering NC. Electron linear accelerators for radiation therapy: history, principles and contemporary developments. Phys Med Biol 1973;18(3):321–354.
Donaldson
Hickey Memorial Lecture. AJR Am J Roentgenol 1976;126(6):1117–1129.
fects on critical normal tissues. Cancer 1976; 37(2 suppl):1186–1200.
7. Damadian R, Goldsmith M, Minkoff L. NMR in cancer: XVI. FONAR image of the live human body. Physiol Chem Phys 1977;9(1): 97–100, 108.
12. Humes JC. The wit and wisdom of Winston Churchill: a treasury of more than 1000 quotations. New York, NY: HarperCollins, 2009.
8. Mansfield P, Maudsley AA. Medical imaging by NMR. Br J Radiol 1977;50(591):188–194.
13. Becker GJ. Interventional radiology and diagnostic radiology primary certificate. The Beam [newsletter] http://library. constantcontact.com/download/get/file/ 1102498794338-376/Becker-IR-DR_final. pdf. Published 2012.
4. Thwaites DI, Tuohy JB. Back to the future: the history and development of the clinical linear accelerator. Phys Med Biol 2006;51(13): R343–R362.
9. Knight N. Training and education. In: Gagliardi RA, Wilson JF, eds. A history of the radiological sciences: radiation oncology. Reston, Va: Radiological Centennial, 1996; 165–184.
5. Baker HL Jr. Computed tomography and neuroradiology: a fortunate primary union. AJR Am J Roentgenol 1976;127(1):101–110.
10. Kaplan HS. On the natural history, treatment, and prognosis of Hodgkin’s disease. Harvey Lect 1968–1969;64:215–259.
14. Kenny LM, Adam A. Radiation oncology and interventional oncology: time for a collaborative approach. Clin Oncol (R Coll Radiol) 2013;25(9):515–518.
6. Evens RG. New frontier for radiology: computed tomography. 40th Annual Preston M.
11. Phillips TL, Fu KK. Quantification of combined radiation therapy and chemotherapy ef-
15. Peabody FW. The care of the patient. JAMA 1927;88(12):877–882.
Radiology: Volume 271: Number 2—May 2014 n radiology.rsna.org
319
Sarah S. Donaldson, MD
Background Published online 10.1148/radiol.14140272 Content code: Radiology 2014; 271:315–319 1
From 875 Blake Wilbur Dr, G226, Stanford, CA 943055847. Received February 5, 2014; revision requested February 6; revision received February 11; final version accepted February 13. Address correspondence to the author (e-mail: [email protected]). Conflicts of interest are listed at the end of this article. RSNA, 2014
q
As recently as the mid-1970s, Surveillance, Epidemiology, and End Results (SEER) data revealed that just over half of children afflicted with cancer survived only 5 years (1,2). In the 1970s, radiation oncology was primitive. Medical linear accelerators were in the early stages of development (3,4). There was no acknowledged discipline called pediatric oncology, as subspecialty certification in pediatric hematology/oncology was not offered by the American
Radiology: Volume 271: Number 2—May 2014 n radiology.rsna.org
Board of Medical Specialties until 1974. In addition, cross-sectional imaging with computed tomography (CT) and magnetic resonance (MR) imaging was not yet clinically available (5–8), so radiology consisted mainly of plain-film radiography. At that time, radiologists were generalists. Radiology training programs were unified as general radiology (9), and we were at the nexus of patient care. Rounds often began in the radiology suite, where, during morning radiology conference, the radiologist demonstrated the many clues to the biology of human disease. Technology developed primarily for warfare was immediately extended to medical applications and use. Radiology quickly expanded to meet the new demands of technology. Radiologists began to subspecialize, and the practice of radiology gradually became less cohesive and less unified. To master this complex new technology, radiology training programs separated, with therapeutic radiology splitting from diagnostic radiology, and gradually radiologists drifted further and further apart. The good news was that within radiation therapy, the new technology improved understanding and accuracy, allowing the use of higher doses of radiation delivered to larger areas of the body, which brought about improved cancer cure rates (10). But ironically, the very treatment that cured cancer also created some new problems. All too soon, the cancer survivors began to show unanticipated and unacceptable radiation injury to normal tissues (11). Radiation oncologists were then challenged to reduce radiation toxicity and still maintain high cure rates for the cancer survivors. To sustain these high cancer cure rates, oncologists learned to cooperate, collaborate, and form multidisciplinary partnerships. It soon became apparent that all oncologists 315
ADDRESS
I
t is an extraordinary privilege to deliver the 2013 Radiological Society of North America (RSNA) President’s Address, to serve the RSNA, and to serve radiology. The annual RSNA meeting gives all of us a chance to renew old friendships, make new friends, and invigorate ourselves and our profession. These are extraordinary times, unsettling times, because we are working in an ever more stressful environment. It is an environment that challenges us to change, yet change is always difficult. However, in the midst of our daily pressures, we must look for opportunities for change, and these are the opportunities upon which we must focus. The Power of Partnerships is a theme that reminds all of us of the incredible power that comes from acting together and working together, as partners, to change the way we practice medicine. Three important and unique opportunities for partnerships deserve our immediate attention: those within radiology, those with others outside of radiology, and those with our patients. Within radiology, my expertise is in radiation oncology, with subspecialty interest in pediatric radiation therapy. Thus, my perspective for opportunities comes from caring for children with cancer.
Reviews and Commentary n PRESIDENT’S
The Power of Partnerships: A Message for All Radiologists1
PRESIDENT’S ADDRESS: The Power of Partnerships
Donaldson
Figure 1
Figure 1: Five-year relative survival figures for children with cancer, 1975–2008. Data are from the SEER Cancer Statistics Review (1).
had to work together effectively to build consensus. This focused multidisciplinary effort resulted in the development of new research programs that created more precise oncologic therapy. These multidisciplinary partnerships produced dramatic results. Pediatric cancer provides a good example of an effective partnership (Fig 1). Today, more than 80% of children with cancer are cured of their disease by using multidisciplinary, risk-adapted therapy (1,2). The goal in pediatric cancer care today is to obtain even higher cure rates, using treatment that is free of toxicity. Within a time frame of just 40 years, we can see the rewards that have come when diverse disciplines collaborate. Caring for children confirms the importance of partnerships. This success story with childhood cancer can help all of us better understand the extraordinary power of partnerships. Today in radiology we face extraordinary challenges on many fronts, challenges that demand a shift in our culture. This is a time that requires us to focus on producing value not volume, outcomes not output. To meet these challenges, to continue to grow and thrive, radiologists must build a new culture, a culture that fosters partnerships with a common focus. We can learn from the words of Sir Winston Churchill, a master of developing alliances and partnerships. His message, “If we are together, 316
nothing is impossible, if we are divided, all will fail,” carries universal applicability (12). Radiologists also need to establish our own powerful alliances and partnerships focused on improving patient care. To meet these enormous challenges, we need to develop partnerships at three levels: internal partnerships within radiology, external partnerships with health care professionals outside of radiology, and partnerships with our patients. However, we need to follow a number of specific steps to build these solid partnerships.
Internal Partnerships within Radiology In the current health care environment, precision—in diagnosis, treatment planning, treatment delivery, and reporting—is essential. To practice precision radiology, radiologic subspecialists must work closely with one another. A good example of such a close working relationship is the partnership involving radiation oncologists, oncologic imagers, and interventional oncologists. Oncologists achieve a delicate balance between killing cancer cells and sparing normal tissue. Their effectiveness is governed by what can be seen and how precisely the image can help target oncologic treatment. To function effectively and cure cancer, oncologists need to know precisely where the
cancer is located so they can precisely target their treatment. To target a tumor, oncologists must integrate images from all sections of radiology. They need to see and measure tumors in every dimension, understand how tumors move, their heterogeneity, their blood supply, and their molecular pathways. More than ever before in the history of radiology, radiation oncologists have an intensely strong interrelationship that already aligns radiologists as partners. Never before have specialists in diagnostic imaging and radiation oncology been so closely united. A builtin, natural partnership already exists. Radiation oncologists rely on anatomic and functional imaging to stage disease, to define response to therapy, and to plan treatment. They use imaging to localize radiation therapy volumes and to determine radiation therapy doses. And they counsel patients about their prognosis based upon the images obtained by specialists in diagnostic imaging. For example, Figure 2 shows how precise imaging permits high doses of radiation to be delivered in a short radiation therapy course for a hepatic lesion in a patient with a known primary colorectal cancer (Fig 2a). But this abnormality was not well-defined with CT and was not felt appropriate for radiofrequency ablation. However, the tumor board recommended stereotactic body radiation therapy, or SBRT, for precisely targeted, high-dose treatment given over a short period of time. SBRT is used in cases not amenable to standard external beam radiation therapy, as in this case, because of hepatic sensitivity to radiation. To deliver this treatment, oncologists need daily, realtime image guidance and tumor tracking, facilitated by fiducials implanted by colleagues with expertise in interventional radiology. At simulation, a positron emission tomography (PET)/ CT scan was obtained to localize this lesion (Fig 2b). Four-dimensional gating techniques confirmed the tumor did not move with respiration, but the PET scan showed a larger hypermetabolic lesion than revealed by CT. After specialists in functional imaging confirmed
radiology.rsna.org n Radiology: Volume 271: Number 2—May 2014
PRESIDENT’S ADDRESS: The Power of Partnerships
Donaldson
Figure 2
Figure 2: Cross-sectional and functional images in patient with a known colorectal primary tumor and an abnormality in liver. (a) Hepatic abnormality is not well visualized with CT. (b) PET/CT scan reveals a larger hypermetabolic lesion than revealed with CT. (c) Radiation therapy treatment volume was enlarged owing to findings from both anatomic and functional images to provide a high-dose radiation therapy plan delivered in a short course for definitive ablative therapy. (Images courtesy of Albert Koong, MD, PhD, and Billy W. Loo, MD, PhD.)
the tumor volume of concern, the radiation oncologists enlarged the treatment target volume (Fig 2c). Without integrated multimodality imaging and close interaction with our colleagues in cross-sectional and functional imaging, the true extent of disease would have been underestimated, resulting in “a marginal miss”—a guarantee of subsequent failure of localized radiation therapy. But the disease in this patient has been controlled and the patient has suffered no hepatic toxicity, a clear example of how important it is for all radiologists to work together to provide optimal patient care. Not only do radiologists use hybrid images to demonstrate both anatomic and functional findings, but hybrid technology also facilitates optimal treatment. Oncologists rely on PET/CT as part of radiation therapy simulation, and soon PET/MR imaging will also be commonplace. A ground swell of integrated activity is rapidly moving radiologists toward precision radiology, and it is predicted to continue. Soon even more emphasis on advanced imaging will create more tailored therapy. Four-dimensional, high-resolution color images will be commonplace. One can imagine that soon radiologists will generate images with molecular pathways already labeled for clinical use. Oncologists anticipate that soon they will be using
not just anatomic and functional imaging to guide treatment but also molecular imaging for gene expression. Most important, this momentum toward precision radiology demands that we cooperate, collaborate, and share responsibility for the care of our patients. Integrated cancer care requires that all radiologists understand tumor and molecular biology to tailor treatment to the individual characteristics of each patient. Increasingly, interactions within radiology will cut across all patient ages, diagnoses, parts of the body, and sections of radiology. Day-to-day common clinical problems are solved by teams of radiologists, not by single individuals. Team-based radiology, in partnership, is essential to the effectiveness of patient care. If radiologists can see these technical advances as opportunities to fine-tune oncologic therapy, then we will successfully meet these challenges for change.
Changes in Radiology Educational Programs Radiologists also need to take a hard look at radiology training and consider how the required curriculum should be modified across subspecialties to meet the modern demands of integrated care, such as collaborative training programs in radiology. A timely example is the subspecialty collaboration beyond
Radiology: Volume 271: Number 2—May 2014 n radiology.rsna.org
the newly approved Interventional Radiology and Diagnostic Radiology pathway initiated by the American Board of Radiology (13). Perhaps radiologists should consider a more enhanced interventional oncology/radiation oncology pathway, one that would include dedicated training in radiation oncology. This approach may sound revolutionary, but this model of integrating interventional oncology and radiation oncology has already been proposed in the United Kingdom and in Australia (14). While the underpinnings of a natural partnership within radiology are already in place, radiologists and radiation oncologists must develop and refine them through new modes of education and training.
External Partnerships with Colleagues Outside of Radiology No matter where on the globe we practice, the enormous emphasis on quality of care and patient outcomes demands team-based care. No longer do we work in individual silos. Multidisciplinary teams are already defined by specific diseases and anatomic sites. We know them as the “head and neck service,” the “lung team,” or the “lymphoma group,” to name only a few. One of the most profound truths in this era of image-based therapy is that radiologists are at the very center of these teams, and the teams do not 317
PRESIDENT’S ADDRESS: The Power of Partnerships
function well without radiologists. So, the partnerships for team-based care are already in place. To achieve the benefits of teambased medicine—better coordination, better cost containment, and better concierge care—we must take some important steps. We must find creative ways to increase our visibility. One way is to get out of the heavily shielded basement and out of the darkened reading room by actively participating in clinics, tumor boards, and multidisciplinary conferences. While it is difficult to send a consultative radiologist to cover every conference and tumor board, the fact is that radiologists cannot afford to be absent from these conferences. To be seen as equal partners in team care, radiologists must be at the conference table. This means all radiologists need to be more visible and need to share in the responsibility for patient care. When radiologists share patient care responsibility, we demonstrate our accountability and enhance our credibility. For the radiologists, this partnership in multidisciplinary team medicine is more than image interpretation and more than rapid communication of a consultation. It requires accepting responsibility for patient care, another excellent way to demonstrate the value of the radiologist as a member of the patient care team. When radiologists teach others about modern imaging and therapy, collaborative programs develop, resulting in an increase in patient referrals. Soon a radiologist is no longer simply an assigned physician but a requested physician. Radiologists avoid being replaced by a computer algorithm. Once again both diagnostic radiologists and radiation oncologists will be seen and valued at the nexus of patient care. Team-based medicine broadens the expertise of practicing physicians, it promotes collaborative research programs, and it builds careers of individual clinicians. The opportunities that cross-disciplinary partnerships afford include the excitement of developing innovative ideas with others, the challenges of building 318
Donaldson
new research programs, and the satisfaction of creating new collegial relationships. These opportunities invigorate radiology and radiation oncology as well as each of us as individual subspecialist radiologists.
Partnership with Our Patients One might ask, what is to be gained by having a direct partnership with a patient? Quite simply, patients want personalized care from their radiologist just as they have from their other physicians. Patients reiterate that they like having their radiologist speak with them and give them a preliminary result at the end of a radiologic procedure. If a patient’s images look good, it is nice to say so. If the images are concerning, then a comment that, as their radiologist, you will be speaking with their referring physician would also be welcome. However, this kind of one-on-one interactive communication is not a common practice today. To establish optimal patient relationships, the patient must know the name of his or her radiologist, just as we know the name of the patient. Moreover, patients who have met their radiologist face to face are more likely to appreciate the expertise and value of their radiologist. We are learning that patients want to partner with their physicians, and as physicians we need to partner with our patients. Whether or not this environment is comfortable for us as radiologists, patient-driven care is the new challenging reality. By accepting this change in culture, we have the opportunity to strengthen direct patient relationships, resulting in relationships that are longer lasting and of greater meaning. As a practicing oncologist, I know how gratifying it is to build meaningful relationships with my own patients. To partner with a patient is to establish a unique and rewarding long-term relationship, one that surely contributes to a rewarding professional life. Partnering with a patient can forge a long-term rewarding friendship, one that confirms that, as radiologists, we have contributed to the health and
well-being of our patients. Bonding with patients provides the greatest satisfaction of the practice of medicine and can give physicians the courage to welcome change, to meet the challenges, and to embrace the opportunities for new partnerships. As radiologists we must commit to these personal partnerships for a simple reason: they are good for our patients. A partnership with a patient defines who we are and how we practice medicine. Dr Francis Peabody offered some sage advice when he said: “…of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” These wise words are as valid and inspiring today as they were 86 years ago, when Dr Peabody lectured to Harvard medical students in 1926 (15).
Expected Consequences from Partnerships This presidential message offers a new vision of interdependence, of partnerships: internally, with other radiologists; externally, with our colleagues outside of radiology; and jointly, with our patients—our most important partners. All radiologists can form these partnerships. But, to do so, all radiologists must meet critical challenges, modify our culture, and invest in our opportunities. The question for all radiologists is, in these extraordinary times, these unsettling times, can radiologists now join together to build the strongest of partnerships for all of radiology? Again, Winston Churchill’s wisdom rings true for all radiologists today: “We make a living by what we get, but we make a life by what we give” (12). As partners, we indeed have much to give. Disclosures of Conflicts of Interest: No relevant conflicts of interest to disclose.
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