Transitioning to Practice: Getting up to Speed in Efficiency and Accuracy

Abstract

The transition from trainee to breast radiologist is challenging. The many new responsibilities that breast radiologists acquire while establishing themselves as clinicians may increase stress and anxiety. Taking inventory of existing knowledge and skills and addressing deficits toward the end of one’s training can be beneficial. New breast radiologists should expect to be slower and gain proficiency in the first several years out of training. Having realistic expectations for oneself with respect to screening mammography interpretation and following up on the subsequent diagnostic imaging workup of screening callback examinations can increase competence and confidence. Familiarity with the available literature to guide management in the diagnostic setting can increase efficiency. Planning ahead for localizations and biopsies also allows for efficiency while alleviating anxiety. Ultimately, adapting to a new work environment using a collaborative approach with primary healthcare providers, pathologists, and surgeons while remembering to have mentors within and beyond the field of radiology allows for a more successful transition.

Key Messages.

• Taking inventory and addressing potential knowledge gaps during training allows breast radiologists to better prepare for the transition from training to practice.

• Radiologists new to practice can expect lower efficiency in the screening, diagnostic, and procedural settings; obtaining and incorporating feedback from colleagues and subsequent diagnostic evaluation and biopsy outcomes improves accuracy and, ultimately, confidence.

• Establishing mentors, remembering that multiple mentors, including those outside of radiology or one’s own peers, is beneficial.

Introduction

The transition from trainee to an independently practicing breast radiologist occurs overnight, quite literally. While a graduating trainee has spent the past five to six years ensuring that the appropriate knowledge and skills are in place, multiple additional factors come into play at the time of transition to an independently practicing breast radiologist. These factors include anxiety related to becoming the final authority, increased workloads, navigating different health care systems, and adopting new professional roles and responsibilities (1–3).

Multiple new challenges may result in new breast radiologists practicing with decreased accuracy and efficiency. One such challenge is the need to balance sensitivity and specificity. One study demonstrated that there is a learning curve in screening mammography interpretation among community radiologists without fellowship training in breast imaging and that the learning curve is steepest in the first three years of clinical practice and continuing into a radiologist’s career (4). The same study showed that there is no such learning curve for fellowship-trained breast radiologists (4). Further, another study demonstrated that although fellowship-trained breast radiologists detected more cancers than radiologists without specialized training, they also had a higher false positive rate (5). It is important to note that not all radiologists interpreting breast studies are fellowship-trained. In fact, the majority of mammograms in the United States are interpreted by general radiologists (5,6). This article identifies key points to assist radiologists in increasing efficiency and accuracy as they transition from trainee to practicing breast radiologist.

Taking Inventory

A key component of transitioning from trainee to an independently practicing breast radiologist is understanding one’s limitations in knowledge and acquired skills. Although almost all radiology residency programs and breast imaging fellowships provide training in multiple aspects of breast imaging (interpretation of screening and diagnostic mammography, ultrasound, and MRI; procedural skills; and multidisciplinary teamwork), there is variation in the volume of each of these components (7). Additionally, trainees may receive limited education on image quality analysis, positioning, the technical aspects of mammography, quality control, and the medical audit (7). In some instances, they may receive limited exposure to radiation oncology, medical oncology, surgery, and pathology (7). Taking inventory of these factors toward the end of one’s training and actively filling the gaps makes the transition to breast imaging practice less anxiety-provoking.

Providing the final word on reports and workups can be one of the most challenging aspects of transitioning to independent practice (1). In a nationwide survey of senior radiology residents’ attitudes toward breast imaging, higher levels of stress were reported with interpretation of mammographic examinations compared to abdominal CT scans, with 81% of residents reporting higher levels of stress due to fear of misdiagnosis on mammography (8). For those completing a breast imaging fellowship, using the second half of the year (after the basic skills are acquired) to gain as much independence as possible is beneficial. For example, fellows should take the lead in the workup of a case and present their suggested management plan to the attending radiologist, allowing for discussion should their strategies differ. The goal is for the trainee to develop confidence in independently interpreting breast imaging studies.

Breast imaging fellowships, which are not accredited by the Accreditation Council of Graduate Medical Education (9), may appoint fellows as instructors (or an equivalent title), and if the fellows are appropriately licensed and credentialed, they can perform work independently, including performing procedures, reading screening mammograms, and evaluating diagnostic patients. The amount of independence can increase over the fellowship year as the fellow gains competence. This approach can significantly increase the fellow’s confidence in transitioning to practice, including the ability to recover from an error or an unexpected complication (10). For those who have not completed dedicated training in breast imaging or those who require additional exposure to certain modalities, the American College of Radiology (ACR) Breast Imaging Bootcamp with Tomosynthesis (11) and Breast MRI (12) courses provide training in mammography, including tomosynthesis, and breast MRI.

Establishing Oneself as a Clinician

Although the completion of residency and fellowship may signify the end of formal training, learning does not stop the day training is completed. New breast radiologists can expect to gain knowledge and procedural proficiency in the first several years out of training. In the clinical setting, mental preparation is the key to success. Most new breast radiologists should expect to be slower than more experienced colleagues and should expect to stay in the clinic later on most days (1). Balancing slower speed while keeping up with the clinical workflow can pose a challenge. Limiting the number of technologists in the reading room at one time can help to decrease pressure and distractions.

Screening Setting

A common situation leading to slower speed in the screening setting is concern regarding the medical audit—specifically, the screening mammography recall rate (13,14). A new breast radiologist should expect to have a higher screening recall rate and learn from it. As previously mentioned, Miglioretti et al (2009) found that radiologists without fellowship training in breast imaging significantly improved in their interpretation of screening mammograms as they gained clinical experience, especially during the first three years after residency (4). Furthermore, for radiologists without fellowship training in breast imaging, false-positive rates decreased sharply within the first three years of clinical practice, without evidence of an associated decrease in sensitivity (4). More specifically, for non-fellowship-trained radiologists, the number of women recalled per breast cancer detected dropped from 33 for radiologists in their first year of practice to 24 for radiologists with three years of practice to 19 for radiologists with 20 years of practice (4). In comparison, for radiologists with fellowship training in breast imaging, no such learning curve in their clinical practice was shown (4). In an article about variability in interpretive performance at screening mammography, Elmore et al (2009) showed that the only characteristic significantly associated with greater sensitivity in cancer diagnosis and higher overall accuracy was fellowship training in breast imaging (5). However, as previously discussed, these fellowship-trained radiologists also had significantly higher false-positive rates compared to radiologists without specialized training (5).

As recent research has noted, a higher screening recall rate may be acceptable if associated with an increased cancer detection rate (15). Ways to reduce recall rates include performing personal follow-up on one’s own screening callback examinations or asking senior colleagues for feedback on screening callbacks and workups (4). While most audits are performed on a yearly basis, more frequent auditing for self-assessment purposes can facilitate increased scrutiny of a new breast radiologist’s screening callbacks to identify areas that need attention (4). The addition of second opinions (official second readers or verbal consultations) also assists in decreasing screening recall rates (16). Ultimately, following every patient’s imaging course from screening to surgery increases confidence (17).

Several hands-on courses are also available allowing access to hundreds of screening mammograms with immediate feedback on recalls. In a community-based practice study evaluating internal mammography interpretation audit data, attendance at dedicated mammography courses was shown to improve radiologists’ performance and even alter imaging approaches (18). For any courses attended, establishing a method to keep track of continuing medical education credits (including specialty, modality, risk management, ethics, and self-assessment modules) helps in future audits and accreditation processes.

Diagnostic Setting

A common situation leading to slower speed in the diagnostic setting is uncertainty regarding the workup of complex cases. Most residents and fellows will be familiar with the “Quick Reference” table provided by the ACR Breast Imaging Reporting and Data System (BI-RADS) Atlas (11). The BI-RADS Atlas also provides specific guidance for questions that may arise (11). Spending time reviewing each section as well as frequently asked questions builds knowledge in application of these algorithms to diagnostic patients. Additionally, having a low threshold for examining and talking with patients and personally performing the ultrasound for patients builds knowledge in optimizing US images and direct correlation with physical exam findings. In complex cases, discussing the case with the referring clinician prior to finalizing the imaging report may be helpful. Getting advice from radiologist colleagues is typically welcomed and viewed as a positive rather than a weakness or lack of knowledge. This excellent habit of asking for other opinions builds a collegial working environment. For nonemergent cases, waiting and reviewing the case later in the day or on the subsequent day may also be beneficial. Ultimately, following the guidelines set forth by the ACR, including ACR Practice Parameters (19) and ACR Appropriateness Criteria (20), will help breast radiologists answer potential questions that arise and troubleshoot difficult questions (21).

Procedural Setting

Difficult procedures, including biopsies and preoperative localizations, can also cause anxiety and may lead to slower performance. As much as possible, preparing ahead of time and having second or third options ready when a procedure becomes challenging can alleviate anxiety (22). Attending hands-on courses may assist radiologists as they familiarize themselves with new biopsy devices and techniques. It has been shown that a combination of online learning and face-to-face education produces the best results when compared to one method alone (23). Many breast imaging review courses include dedicated procedural workshops. Additionally, utilizing support services provided by specific vendors for biopsy devices and programs, including requesting in-person assistance on the day of the procedure, may be helpful. During a procedure involving a difficult patient, biopsy, or localization, stepping away for several minutes to reassess the situation can decrease stress. Giving a break to all members of the team (the radiologist, the technologist, and the patient) eases the tension and may lead to a successful outcome. Getting another opinion from a more experienced colleague can expand the options in a difficult case. Compartmentalizing the past and putting a challenging patient or case on the shelf after completion is then required for the breast radiologist to continue functioning effectively throughout the day.

Additional Pearls

Although the acquisition of clinical knowledge is relatively consistent across institutions, practice styles may vary. Accepting the need to adapt to a new environment is key. Technologists are an excellent resource because they are aware of the local culture of the radiology department and the referring clinicians (24). Additionally, formal introductions to referring clinicians help to pave the way for subsequent verbal discussions on interesting or challenging cases (25). The age-old adage, “the pathologist is one’s best friend” is even more true when starting independent practice. Reviewing challenging cases with the pathologist, particularly when there is questionable imaging-pathology concordance or a possible need for excision, may lead to a change in diagnosis and improved patient outcomes (26). These efforts will be appreciated by the referring clinicians as well. Attending tumor boards and local radiology and medical society meetings assists on a broader level and increases a new breast radiologist’s exposure.

Breast imaging has more patient interaction than most other radiology subspecialties. This requires radiologists to develop effective communication skills and strategies for managing difficult encounters. Breast radiologists often discuss the need for additional imaging or the need for biopsy and communicate positive pathology findings to patients, thereby making communication skills as important as screening, diagnostic, and procedural skills (27). However, previous studies have demonstrated that radiologists receive little training on effective communication strategies (28). A specific source of anxiety for both the breast radiologist and the patient may include delivering bad news. Harvey et al (2007) in the Journal of the American College of Radiology specifically outlines steps to communicating bad news and provides specific phrases to improve communication in this setting (29). As with other specialties in medicine, breast radiologists may experience difficult patient encounters due to the stress and anxiety associated with breast imaging, particularly in the diagnostic setting, resulting in a variety of emotional responses from the patient (29,30). Understanding the patient’s perspective and acknowledging the patient’s feelings in an empathetic manner is an important component in managing such encounters (27,29,30). Ultimately, despite effective communication strategies, assistance of a patient advocacy or patient care department at the hospital may be required in difficult patient encounters (29).

Role of Mentors

It is natural for new breast radiologists to have many questions in the screening, diagnostic, and procedural settings. There are many situations that may not have been encountered as a trainee that come up during the early years in practice. Ultimately, having a “go-to” source or mentor is necessary (2). This is especially true for breast radiologists practicing in isolation or in a situation where they may be the sole individual scheduled in a clinic. Numerous studies have demonstrated the positive effects of mentorship, including providing feedback and decreasing the stress level (3). The mentorship process requires ongoing communication and regular meetings, with high satisfaction seen in true mentoring programs (31). It important to seek a good fit between the mentor and the mentee. And while one mentor may be designated, more than one mentor may be needed. For example, a clinical mentor may differ from a research mentor, who may differ from a leadership mentor. Looking beyond the world of radiology to referring clinicians and administrators to serve as mentors may be required as new roles are acquired (25). As a new breast radiologist, identifying those who excel at each of these individual areas will assist in selecting the appropriate mentor whose behavior may be emulated.

Mentorship need not always occur between senior and junior colleagues. Peer mentors can also provide invaluable guidance in the transition period from trainee to breast radiologist (32). Most breast radiologists undergoing the transition period with another junior colleague know what challenges are frequently being encountered. Having ongoing discussions, even formal weekly meetings, during this transition phase decreases the sense of isolation and anxiety (32).

Conclusion

The transition from training to practice is one of the most challenging stages in a new breast radiologist’s career. Recognizing one’s own limitations in clinical knowledge and skills and filling those gaps during and immediately after training can assist in alleviating anxiety during the transition. Awareness of the new expected roles and responsibilities are key to successful preparation. Increasing efficiency and accuracy in the screening, diagnostic, and procedural setting will improve over time. Mentors of varying types, including peer-to-peer mentors, mentors within the field of breast imaging, and even mentors from other departments will be invaluable in this new career phase.

Funding

This work was supported by the National Institutes of Health/National Cancer Institute Cancer Center Award Grant under award number P30 CA016672.

Conflict of Interest Statement

None declared.