Radiology

Introduction to Clinical Medicine

Francis Neuffer M.D.

Asso Professor/Radiology U.S.C. School of Medicine

Radiology
E-mail: x-ray@med.sc.edu Radiology Website: http://radiology.med.sc.edu Radiology Department: Basement of Library 733-3295

GOALS

Radiologists and radiology departments Residency Ordering studies Reading reports Issues

GOALS

Understand exams and indications Strengths and weakness Interpretation Work-up for diseases Resources

What is Radiology?
Supervises and interprets imaging studies Reports findings to referring physicians

ANATOMY vs. PATHOLOGY LOCATION & EXTENT DIAGNOSIS & DIFFERENTIAL

RADIOLOGY TRAINING
Medical School Radiology Residency 4 years 4 years (1 year clinical) 4 years 4 years

Nuclear Medicine Radiation Therapy (Oncology) After Residency: Subspecialty Fellowship Research

1 year 1 year

RADIOLOGY SERVICES IN THE UNITED STATES

260 - 330 million procedures 1990 400 million procedures 2005 55% performed in office 19 -20 billion dollars 65-75 billion dollars 85-95 billion dollars 1990 2000 2005
Sunshine, AJR 157, September 1990 Rothenberg JACR May 2005

DIAGNOSTIC IMAGING IN OFFICE PRACTICE

Frequency and Cost
Frequency Cost 4 - 4.5 times greater for self referring physician 4.4 - 7.5 times higher mean imaging costs per episode of care
NEJM: 323:23,1990 Hillman

DIAGNOSTIC IMAGING CENTERS

PHYSICIAN ENTREPENEURSHIP

DIAGNOSTIC IMAGING CENTERS

PHYSICIAN ENTREPENEURSHIP
Frequency Cost 47% greater for self referring physician Increases cost $2.7billion

Fletcher JACR May2005 WALL ST.J. May 2 2005

Mean Professional Liability Premiums per Self-Employed Physician

ANNUAL PREMIUMS (in thousands of dollars)
1994 10.2 8.6 22.3 7.6 37.4 11.2 9.4 1996 8.4 8.9 21.7 8.3 35.2 11.3 5.2 1998 10.9 16.5 22.8 9.0 35.8 12.3 5.4 2000 13.8 13.7 23.6 11.5 39.2 19.3 12.9 Family Practice Internal Medicine Surgery Pediatrics OB/GYN Radiology Psychiatry

AMA, Socioeconomic Characteristic of Medical Practice 2003

RADIOLOGY PRACTICE
Positive
1. Intellectually exciting 2. Good Income a. low overhead b. collectible charges 3.Limited Responsibility a. reduced patient contact b. predictable hours

Negative
Geographically limited Little Control

Clinical Perception

PROBLEMS WITH RADIOLOGY

Planning the diagnostic workup
Too many available choices create confusion and anxiety

The radiology report

Disorganized and imprecise document that can rarely be taken seriously by clinicians

Heilman, NEJM Vol.306, No.8, 1992d

?
NUCLEAR MEDICINE ULTRASOUND

CT

BARIUM

MRI

ANGIOGRAM

What next?

How to decide. . .

1. Cost 2. Effectiveness (efficacy) 3. Risk 4. Availability

American College Radiology APPROPRIATENESS CRITERIA USC RADIOLOGY DEPT WEB PAGE

THE X-RAY REPORT

Prominent Engorged Congested Accentuated Interstitial edema Increased interstitial markings Early failure CHF

RADIOLOGY TOOLS

X- RAY COMPUTED TOMOGRAPHY NUCLEAR MEDICINE ULTRASOUND MAGNETIC RESONANCE

WHOLE BODY PROJECTION SECTIONAL TOMOGRAPHIC

X- RAY
HIGH ENERGY PHOTON IONIZING RADIATION EXPOSES FILM

PA & Lateral Chest X-ray

4 BASIC DENSITIES VISUALIZED

BONE SOFT TISSUE FAT AIR

X- RAY
BONE SOFT TISSUE FAT AIR

Upper GI
oral barium contrast

Barium Enema
rectal barium/air contrast

Intravenous Pyelogram (IVP)

Intravenous Iodine contrast

Arteriogram
Intraarterial Iodine contrast

TOMOGRAPHY

COMPUTED TOMOGRAPHY
HIGH ENERGY PHOTON IONIZING RADIATION EXPOSES DETECTOR DIGITAL DATA

NUCLEAR MEDICINE

INJECTION OF RADIOPHARMACEUTICAL HIGH ENERGY PHOTON IONIZING RADIATION EXPOSES DETECTOR DIGITAL DATA

EXAMPLES

BONE

HIDA

RENAL

ULTRASOUND

SOUND WAVE NO IONIZING RADIATION REFLECTED TO DETECTOR DIGITAL DATA

EXAMPLES

GALLBLADDER KIDNEY OB

MAGNETIC RESONANCE

HYDROGEN PROTONS ALIGN IN MAGNETIC FIELD RADIO FREQUENCY SIGNAL TRANSMISSION INTENSITY OF SIGNAL RELATES TO TISSUE NO IONIZING RADIATION

MAGNETIC RESONANCE

BRAIN SPINE JOINT

THE PRODUCTION and MEDICAL USE of X-RAY

X- RAY
HIGH ENERGY PHOTON IONIZING RADIATION EXPOSES FILM

KV

GRID

MAS

SCREEN

TISSUE OF INTEREST DETAIL REQUIRED EXPOSURE PATIENT -AGE/SEX TARGET ORGAN BENEFIT/RISK

KV

GRID

MAS

SCREEN

SCREEN

TISSUE OF INTEREST DETAIL REQUIRED EXPOSURE PATIENT -AGE/SEX TARGET ORGAN BENEFIT/RISK

COLLIMATION

KV MAS GRID SCREEN COLLIMATION