Imaging is everything

Dr. James H. Thrall, Radiologist-in-Chief at the Department of Radiology of the Massachusetts General Hospital provides a picture of the institution’s work.

These days, departments of radiology in the United States are enormous enterprises and that at Massachusetts General Hospital is no exception. With 110 faculty level radiologists, a further 100 people training to be radiologists, 175 PhD level scientists working on approximately 650,000 imaging studies on the clinical side of operations and a research budget in the range of $65 million per year, it is no wonder that the department has gained recognition and acclaim for its work.

Mass General’s radiology department is world-renowned, with roots dating back to 1896 and the making of one of the first X-rays in the United States. Today, it is again leading the way by bringing imaging excellence into the community with the establishment of Mass General Imaging-Chelsea and Mass General West Imaging in Waltham.

James Thrall, Radiologist-in-Chief, is justifiably proud of the department, which has gained distinction for its subspecialty expertise in thoracic imaging, neuroradiology, musculoskeletal radiology, gastrointestinal and genitourinary imaging, interventional radiology, pediatric radiology, emergency radiology, breast imaging and nuclear medicine.

Having worked in radiology for more than 40 years, Dr Thrall has been at the forefront as the discipline has developed. “The world of medical imaging has expanded incredibly rapidly over the last 30 years. Medical imaging is now the guiding hand of medicine. It’s really astonishing for me to have watched it go from an ancillary service to a service that is on the critical pathway of just about every major disease or condition that might come into a hospital.”

One recent advance is the department’s effort in informatics, where it continues to be a leader in reinventing radiology in the digital age. “The radiology order entry (ROE) system, developed under the direction of Dr. Daniel I. Rosenthal, has been extended and expanded to include point-of-care decision support (DS) capability,” says Thrall. “This has streamlined scheduling of examinations and facilitated obtaining the prior approvals required for  performing high-cost imaging procedures.

“The MGH Informatics Group, under the direction of Keith Dreyer, has supported the ROE and ROE DS efforts and has added a creative online analytic processing capability to generate management reports and provide data mining tools to exploit our databases of radiology reports and images. Much of the information systems technology developed in the Department has been licensed for commercial sale.”

Change and expansion
Thrall describes how his predecessor at the hospital, former Chairman Dr. Juan Tavares, was one of the leaders in developing the subspecialty structure for radiology.“Sub-specialization is something that has become very important in radiology, particularly at academic medical centers. We now have a separate group of people with special expertise for each organ system, along with some technology areas such as nuclear medicine.

“Pediatrics is a special area because it is designated by the age of the patients rather than either the technology or body part. Therefore, the level of specialization allows us to match up in a much better way with expert clinicians. Let’s take neuroradiology as an example: the neuroradiologists who spend two years in fellowship training after they have received their basic board certification in radiology develop a very strong information and knowledge base in neuroscience and neurological disease.

“As a result, they are not only very capable of interpreting the examinations, they can also discuss the clinical aspects of the case in a very intelligent way with a neurologist or a neurosurgeon. This is the kind of expertise that neurosurgeons and neurologists in academic centers expect. The same construct applies in the other specialty areas as well.”

The department continues to expand its clinical activities with a renewed emphasis on quality and safety, embracing new MGH internal and external imperatives. One such initiative is the decision to use wristbands for all outpatients, in the same way they are currently used for inpatients and patients from the emergency department, to help ensure that each person is identified correctly and matched to the proper examination.

Thrall recalls how historically quality was held to be a matter of professional commitment on the part of doctors, nurses and other caregivers. “Quality was a matter of trust,” he explains.  “Patients trusted their caregivers and providers to deliver services at a high quality.  Today, quality is still a matter of trust, but it is also a matter of measurement. We have made a commitment institutionally and departmentally to try to identify the key factors that contributes to the highest quality of care and systematically measure our performance relative to those factors.”

An indication of how important quality is to the institution comes from the agenda of the hospital’s General Executive Committee meetings. Thrall notes that in the past these meetings typically began with a discussion of financial results – a report on operating margin and other key indicators such as number of admissions. “Today, each meeting begins with a discussion of quality and safety lead by the President of the hospital who does it personally to demonstrate his own commitment to these important issues. Everyone involved sees that we can always do better and there is an opportunity to transform healthcare delivery through implementation of better systems and by measuring performance. We have the same commitment and outlook departmentally.”

Each section of the MGH Radiology Department undertakes a ‘Failure Mode and Effects Analysis’ of an issue felt to represent a potential risk to patient safety. “By empowering rank and file employees to help redesign a better way to care for patients we mobilize far more brain power and creativity than from management alone.”

Continual learning
An important philosophy held by the department is that everyone should be continuously learning and that the team should keep growing both personally and professionally. A perfect example of this is the fact that the department is set to begin an initiative in learning medical Spanish. Spanish is the largest second language spoken in the department, and many patients speak it as a first language.

“If we can teach people in the department even an entry-level amount of Spanish, it can break down some barriers and reduce some of the anxiety of patients who come into our department as Spanish speakers themselves,” enthuses Thrall. “It’s a way of breaking the ice, greeting people and welcoming them into our department in a more personal way. Beyond that, it’s an opportunity for people to grow in their own lives. Learning a foreign language requires a certain discipline, and success brings with it satisfaction.”

Achieving this aim has involved asking a committee chaired by a native Spanish-speaking radiologist to design a curriculum for the department. Following this, an educational organization was invited to carry out a pilot project, which has now been completed. The pilot involved 20 of the department’s receptionists – the people on the front line of greeting patients – to go through a five-week program. The department is now evaluating the results of the pilot and hopes to expand it to a wider group of staff.

The department is also now offering an introductory course in basic cardiac life support to all staff members, regardless of their roles. Any staff member may be a first responder. and Thrall sees this as a wonderful opportunity for the hospital’s cardiac life support instructors to share their knowledge with colleagues who work in non-clinical roles.

Professional contributions
Thrall recently received an award from the New England Roentgen Ray Society, which is headquartered in Massachusetts. “There were three people from Massachusetts who in the same year came up for important national recognition in the United States,” he explains. “I was recognized for my contributions to radiology professional organizations. One of my colleagues here at Mass General, Dr. Theresa McLoud, serves as the President of the Radiological Society of North America; and the third individual, Dr. Herbert Kressel of the Beth Israel Deaconess Medical Center, was just named as Editor of the Journal of Radiology. The Roentgen Ray Society took the opportunity to celebrate these accomplishments of is members.”

Other current honors for Dr. Thrall include the gold medal of the American Roentgen Ray Society (ARRS), presented last spring, and the gold medal of the Radiological Society of North America (RSNA), presented at the 2007 annual meeting in November.

This month, Thrall will become the Chairman of the Board of Chancellors of the American College of Radiology (ACR). The ACR is the largest radiology organization in the United States, devoted to socioeconomic issues on behalf of radiologists. As Thrall explains, “We have approximately 32,000 members, and our first and most important agenda priority is working on behalf of these professionals in bringing their point of view – our point of view – in front of the Congress in the political process and taking that same agenda to the Centers for Medicare and Medicaid Services – the CMS – which is the organization that administrates the government insurance program. Dealing with new laws and the rules and regulations that are derived from those laws is the principal function of the college.

“In addition to that, we have extensive programs in quality of care: we provide quality of care accreditation to imaging centers and in particular to breast imaging centers throughout the country. We are deemed by the FDA for the latter purpose, and we also have extensive educational and research programs.”

All in all, the radiology department at Massachusetts General is looking at a bright future. As Thrall summarizes, “I am delighted to be able to say that the department continues to progress in all areas of its mission. Participation in departmental initiatives is at an all-time high, and as much as we are proud to look back on recent accomplishments, we are equally excited looking forward.

“None of this would be possible without the extraordinary group of people who come together every day to take care of patients and to participate in educational activities and in creating new knowledge. We now have nearly 2000 people associated with the department in one way or another, and each one of them makes the department stronger by the knowledge, skills and dedication that they bring to their respective roles.”

Dr. James H. Thrall serves as Radiologist-in-Chief at the Department of Radiology of the Massachusetts General Hospital. He also holds the title of Professor of Radiology at Harvard Medical School. He has an undergraduate degree in mathematics and trained in radiology and nuclear medicine at the Walter Reed Army Medical Center in Washington, DC. For the past 20 years he has been Departmental Chairman at the Massachusetts General Hospital.