We all know the market that Hallmark has on this special day. So why don't we take advantage of this month in the medical area and market our breast centers, inviting all women to get a mammogram? I can't think of a better gift to give a mother, sister, aunt--and whoever that special "like-a-mother someone" is to you--than a mammogram.

Years ago when I was a manager of a breast center we did exactly that: encouraged our community to support the women in their lives on Mother's Day to get a mammogram as a gift. We gave discounts to people who couldn't afford it, and also created special funding for those who had no insurance at all for the entire month of May. We had a local florist donate flowers and miniature plants to the breast center to distribute to the women who had their mammogram-a gesture to say "thank you."

We also made our education department available to women and their guests, inviting them to take time to visit and ask questions of a nurse or mammographer and read brochures and literature. (This would be a terrific idea if you have digital or are planning it soon to educate and interest patients on the new technology!)

Patients responded favorably to the services we provided that month and encouraged us to do it the following year--and we did, for several! We took the time to show we care and dedicated it to women...not just in the breast cancer awareness month of October but May also. (This really should be every month; the disease doesn't pick a month.)

I invite all of you to make this Mother's Day a special one for you community at your breast center. Let the women know you care and how important a mammogram is. It may provide early detection of breast cancer, allowing many more Mother's Days to follow. What better way to show you care!

Have you had a mammogram? The pink ribbon at birth is the pink ribbon of hope for the future.

The article continues with the experience of a patient, who also happens to be a mammographer working with digital technology in her breast center. She describes her anxiety and thoughts of what her family would have to endure.

What brought me to blog about this article, were the comments/blog posts on the site itself. Oh my goodness ...what are we doing? The entries were from a mixed audience, but the ones that disturbed me the most were from the mammographers! Patients' comments about what technologists are doing and what they perceive about the procedure were also quite disturbing.

The mammographer that commented was uneducated about digital technology and radiation exposure, nor did she have respect for the interpreting radiologist. These grabbed my attention: "each time a woman has a repeat study, she is exposed to additional radiation," and "if the radiologist that you are going to has to call back patients for his learning curve go to another facility--this excuse is inexcusable--either they are qualified to read your films or study or they are not."

This is so disturbing to read from a radiologic technologist and dedicated mammographer. How can she make these comments about the "extra radiation" dose? We all know that radiation exposure exists but now with digital, there is a dose reduction. She needs to talk with her physicist. And even more upsetting is the comment about the radiologists. We all hear about respect for each other, although it seems she is lacking it. To say that it's inexcusable for the radiologist to call back a patient translates to a lack of mammography knowledge in general--not only digital but also analog.

To state it simply, we all know that the mammogram cannot be its best unless the positioning is the best; and where does that come from....? The mammographer! Radiologists rely on our expertise. I could continue, but it all comes back to my very first blog post about educating our staff of mammographers on digital so they can, in turn, educate and care for the patients. For the radiologists who are reading this, I acknowledge and respect your dedication to mammography and I (we) want to work together as a team.  Otherwise, we'll continue to see this mass confusion on the transition. We need to carry the message of truth: Awareness of breast cancer detection-- and the mammogram-- is our best screening tool to save lives!   

The major challenge of breast MRI lies in the fact that it has been accepted as the gold standard in breast diagnostics without a great deal of reality testing. Please don't take this as a disavowal of the evidence establishing the benefits of breast MRI. On the contrary, I fully recognize the benefits of breast MRI. My quarrel is with the selection of MRI as the only alternative to mammography for adjuvant imaging of the breast.

In any health care paradigm, physicians have a responsibility to choose the imaging technology that is most appropriate for the patient, given the relative risk of disease, the relative "quality" of different available technologies, and the cost of those technologies. Just because MRI will "work," doesn't mean that's why it should be selected.

Let's look at a real life example, a patient whose only known risk factor is dense breast tissue, and whose mammogram, though difficult to interpret, is objectively normal. Adjuvant breast ultrasound is certainly far less expensive than MRI, and should provide both sensitivity and specificity, when used with the mammogram, that will compare favorably with an adjuvant MRI. If the ultrasound was ambiguous, an MRI might be ordered, however breast specific gamma imaging is an alternative, and lower cost, modality that will yield approximately the same results.

In the title I refer to "Unnatural Selection," because the natural tendency is--in my opinion--to move too quickly to the "ultimate" imaging modality, rather than select modalities, and the progression from one modality to another, based on personal preference (rather than the dictates of patient care). This is the easy pathway, but it's not intellectually honest. And, it doesn't address the matter of health care expenditure increases that are outstripping both the inflation rate and the ability of this nation to meet its health care costs. The latter must be the responsibility of each of us, or our power to make these important decisions will be taken from us.

What I really want to tell all who are listening-administrators, managers, radiologists-your technologists want digital! (By the way, I'm not trying to promote my business with this blog! I want you to encourage the decision makers at your hospitals/clinics to make the transition to digital.) Do it soon and involve your mammographers!

I've presented several seminars in various locations these past few weeks-from the sunny panhandle of Florida to the snow covered grounds of Ohio to many in between-with attendances over 100. Wow! It's amazing to see and hear their reactions to my "ABCs of digital mammography" seminars. The majority of the audiences are still analog, with a significant percentage of digitals present (this was great, plus CR mammo)! I always ask those in the audience who are digital what type of training they had, and if they were part of the digital transition in their department. It's always a disappointment to hear the comments and see the reaction. A few may have had some limited say in the decision of digital, but they really want to understand the "whys" and "hows"-not to mention the "what now?" They want to know it all!

Unfortunately, they're not experiencing that opportunity. They're still under the impression that they need to image those 10 patients an hour that digital promises. They're not realizing it's not 10 per mammographer. They're expecting it to work faster yet perceive it's taking longer, not understanding the anatomy of digital regarding workflow/PACS and the rest of the digital world!

Not every technologist can be part of the decision making, but hey, have you even asked us? It's important for the directors and managers of mammography departments to discuss changes with personnel. Ask for their input, and also support the transition of the essentially new modality of digital. Make necessary changes in the schedule to accommodate training for a new modality and educate staff before the change with seminars and workshops, making it possible for all techs to participate. Staff meetings are a great start. Yes, I understand the time demands in scheduling and preparing. But it's all about the patient, and if you don't have a staff that's comfortable or cognizant of why you have digital, then you won't have the customer satisfaction you expect from the new digital technology.

It's interesting, a few of my accounts who requested my services made the comment, "I'm not sure you should talk only on digital; not everyone is digital or interested." Well, they were wrong. With high attendance in my last few seminars-as well as evaluation feedback-they want to know! They are now understanding the "whys" and "hows" and those who are getting ready for the change have more accurate expectations. Your technologists have a voice-listen to them; they want to learn and change. Education is a great resource for significant paybacks.

In the early ‘90s Congress mandated mammography for payment by Medicare, and the requirement of coverage gradually came to apply to most health insurers. Few will remember today, but crucial testimony in this process came from Richard Bird, MD, a Carolina breast radiologist who had developed the workflow system to allow the delivery of a mammogram at a price of $35. Congress would never have mandated coverage, had the economics not been satisfactorily addressed.

In April of 2007 the American Cancer Society issued recommendations for the use of adjuvant breast MRI for screening certain classes of high-risk patients. Specifically excluded from those recommendations were women with dense breast tissue, and the reason was that the weight of the evidence was not yet great enough to support MRI for this use. It's clear, however, that evidence in support of this use is mounting, but therein lays a very big Catch-22.

Even though a very small percentage of women can be classified at very high risk within the meaning of the ACR recommendations, pushback from third-party payers has been immediate and strong. Onerous precertification processes, lack of uniformity in acceptance criteria, limitation to one MRI per year (biopsy?), and routine denial for lack of medical necessity are plaguing the provider community. Breast MRI is becoming a real challenge from the reimbursement side.

Imagine what will happen when MRI is found to have specific value for patients with dense tissue. By various estimates the number with dense breast tissue ranges from 8 to 40 percent of the screening population, depending upon which density criteria one includes (extremely and/or heterogeneously dense). The financial impact would be on the order of $2.5 to $12 billion in additional screening expense. While the technology may be valuable, the simple fact is that cost increases of this magnitude are not acceptable. Consider the fact that, at Medicare rates, 30 million women can be given a digital screening mammogram, including CAD, for under $4.5 billion.

What should we do? The ultimate risk of expansion of the recommendation for breast MRI would be a dramatic repricing of the study to levels that are closer to the level of payment for a diagnostic mammogram. It should be obvious that this alternative would not be an economic possibility for the technology, especially as it now exists.

The answer to this quandary may be found in a new way of looking at technology that I will explore in my next blog--stay tuned.

In the last blog we discussed cancers that are missed by breast imaging, and the emotional impact on the patient of a cancer. We tend to look at the impact on the physician as "merely" the risk of malpractice, but the facts go much deeper. Physicians, and particularly breast physicians, are emotionally affected by a missed cancer as well. Even though a "miss" may be explainable, every breast physician has a personal commitment to detecting cancers as early as possible.

Breast imagers measure their performance through the mammography audit. In the mammography audit the imager's recall rate, cancer detection rate, tumor size at discovery and other statistics are measured and compared with benchmarks. An important part of the mammography audit is also the reconciliation of all patients with findings other than a normal finding, other than those who are placed on a short interval follow-up. These patients (BIRADS 0,4,5) should be followed through biopsy and, preferably through surgery and the surgical pathology report to correlate the imaging findings.

Another important part of the mammography audit is a thorough review of all missed cancers (false negatives). Centers of excellence will typically subject the imaging studies involved to review by one or more independent breast imagers to determine whether the false negative was a "simple" miss, or a very difficult case that others would be expected to miss as well. This review process helps to ensure that correctable situations receive the attention they deserve.

Not everything about a missed cancer is bad. True breast imagers are among the most dedicated of physicians. Even the "misses" that cannot be avoided because they were not visible on imaging create a rededication of effort on the part of these physicians. The reality that we cannot find all breast cancers through imaging typically creates a level of humility in breast imagers that helps them to empathize with their patients. We see this as a passion for care that is unusual in medicine these days, but welcome to the women who are anxious about their breast health. This level of care is not universal, but it is available at centers of excellence in many towns and cities across the nation. Demand it!

You all have heard this saying…well I’m in Las Vegas and I’m talking! Oh yes, it’s the city with all the glitz and shows—from Blue Man to Bette. But the biggest hit this week is the NCBC, the 18^th Annual National Interdisciplinary Breast Conference of National Consortium of Breast Centers Inc.

This year’s conference brought together 800 attendees of medical professionals involved with breast health to exchange ideas and learn about advances and new techniques in providing care to patients. I’ve definitely been impacted by the different levels of professionals present. There are administrators and managers of breast centers, nurses, radiologists, oncologists, surgeons and, of course, technologists. All of us, together, learning and sharing the most we can about breast health during this four-day conference.

The speakers have been inspiring; they’ve let the technologists know they are appreciated and that their passion needs to be contagious—passed on to younger techs. We’re learning more about pathology and how important the field is in diagnosing the level of breast cancer and discovering the genetic formation. To me, pathologists have always been the silent partner in breast health. What incredible work they are doing!

We’ve been talking about having a navigator in the breast center. No, not a modern-day Columbus, but a navigator that would personally counsel the breast cancer patient. She’d have someone to assist in all her decisions and help her understand the medical decisions she may need to make for herself and her family. If every breast center could incorporate a patient navigator program, it would provide immense emotional support.

The hot topic of digital mammo is definitely being discussed here at NCBC: the transition of going digital, the reimbursement, economics and coding of digital—thanks to my blog partner, Gerry—and the future step of tomosynthesis. Get ready! Amazing results demonstrate that the death rate of breast cancer is down…Great! While we don’t have a cure, but the message we are communicating to get a mammogram—and early—is working. But, we all need to continue to get that message out there: get a mammogram. It’s the best method of detection.

I highly recommend this conference. I’m not their marketing director nor do I receive kick-backs! I’ve attended a few conferences in my 30 years in the mammography field and this really is a grand spice rack of speakers! They have grand expertise and are eager to share this information from all over the world. If you are looking for the best conference to get educated and understand what it takes to become a better, this is it. As a mammographer, it impressed me to see nurses who are breast center directors sitting in on technologist lectures. When I asked them why, they said they wanted to understand the challenges we face and be aware of techs’ responsibilities. Thank you!

At the end of the day, the most intriguing lecture was a selective panel discussing the interdisciplinary approach to the diagnosis and treatment to breast cancer. It was intense and quite controversial at times, but in the end the main focus was the patient. What can we do to provide the best breast care to the patient? Yes, we need to show care, empathy. It’s early detection of breast cancer and we are working together to get the message to the patient.

If every radiologist who had missed a mammographically-detected cancer were to quit reading mammograms tomorrow, there would be no more mammography. The truth is that the breast is a very complex organ to image, and there are a number of benign conditions that mimic the appearance of cancers. Unfortunately, the public’s perception is that a “normal” mammogram means that there is no cancer, and this misconception, coupled with the prevalent idea that, somehow, the physician is responsible for bad health outcomes, leads to many lawsuits being filed over cancers in which the interpreting physician had very little likelihood of affecting the ultimate result.

What can be done about this unfortunate situation? My next few blogs will address a few different approaches to the missed cancer—from prevention to attitude—in an attempt to make these occasions less frequent, more understandable, and less emotionally traumatic when they occur. I will attempt to address the subject from both the patient and physician perspectives in an attempt to develop better understanding among all those who are concerned.

Mammography is an excellent technology, but it’s limited in its ability to present information to the radiologist. The limitations of mammography are largely the result of the variability of the tissue that comprises the breasts of individual patients, and how that tissue presents on an X-ray image. Basically, X-rays go through fat cells easily, allowing cancers to appear in stark contrast to the surrounding tissue. Glandular tissue, on the other hand, appears white and can hide—or obscure altogether—cancers that may be in the breast. This is particularly true for small, early stage cancers.

As a cancer grows it will become more evident, even in dense glandular tissue, and it may even reach the size where it can be felt. In these cases, when the radiologist—knowing where the cancer is in the breast—looks back to prior mammograms, he or she can see the cancer in the maze of glandular densities. This is not a miss, for the cancer is only identifiable in hindsight. This case may be very “defensible” from a legal perspective, but it does not alter the fact that the patient has a cancer, or that she had that cancer at a time when she thought she was “normal."

Cancer news is always bad news for the patient. Emotions run high and it is very easy for the patient to transfer her anger about the disease to her physician. This is especially true when he fails to communicate with the patient either because the subject is unpleasant or he is afraid to discuss a subject that could end in litigation. In most cases the patient is looking for understanding, but failure to communicate and to share the patient’s pain sends the message that something went wrong. This is never a good outcome.

Your reception area--your waiting room--is the entry area for your patients. They’ve come to have their scheduled mammogram. This first encounter, the surroundings and the greeting from behind the desk, sets the entire mood at your imaging center.

The same--if not more--should be expected at the medical level. As I travel with my consulting business, I experience the nature of the reception area. As a patient approaches the desk, many times she shows nervousness or hesitation on what to do or who to approach. This is where and why the atmosphere should be “welcoming”—give visual cues of instruction and acknowledgement. A warm, kind, knowledgeable professional should ease the arrival. Unfortunately I’ve seen many a wondering patient because a receptionist doesn’t take the time to assist or listen. One of the areas that disturbs me (in both the medical world and social situations) is a lack of human respect. Often just the tone of voice and mannerisms can make a huge impact. If a patient gets disturbed or annoyed before her exam, her interaction with the technologist/mammographer won’t likely be a positive one…not a good scenario for your business!

The other issue I’ve recognized is “chatter” that goes on behind the desk--not good. Medical reports, family stories, personal problems--is this what we want patients to hear?

Patient care and customer satisfaction are they really not the same but should go hand in hand…for a successful practice, focus on both. Start at the beginning, the entry area. THANK YOU... :)

In my last blog, I introduced the challenge of commoditization of the screening mammogram. This edition will address some of the proactive efforts that centers can make to fight this trend.

The tendency in breast centers for the number of diagnostic patients to be disproportionate to the screening base is a natural phenomenon that is a reflection of market differentiation. In other words, your expertise is recognized by referring physicians so they refer their “problems” to the center. Rather than view this as positive recognition, however, I would suggest that material disproportionality should serve as a red flag warning of a problem.

We have found that the problem has two basic dimensions. The first of these comes from some of the referring physicians themselves who have implemented the delivery of mammography in their practices as a revenue item, and then bid out interpretation to the low bidder. The second--but more important in terms of numbers--is a combination of misunderstanding and lack of attention on the part of physicians who refer diagnostic patients to our centers.

The answer to the first of these is to initally make the difference in quality between center-based breast imaging and low bidder radiology very clear to these physicians and practices. When you get a diagnostic from them in which a cancer is visible on a prior, do not hesitate, physician-to-physician, to point out the missed lesion, perhaps even hinting at their place in the medical-legal liability chain. You need also to go directly after their patients. Women are allowed to self-refer for mammography and should be encouraged to be proactive in selecting this aspect of their care.

The second instance is actually much easier, and will probably provide a greater net yield in terms of screening volume. Here you need to track the source of all diagnostic patients back through the screening exam. If the screening exam for a given patient is an outside exam, then look carefully at the referral patterns of the referring physician and, if you find a pattern of non-referral for screening, you need to dig deeper and determine why you aren’t getting the screening referrals. At the end of this process you’ll probably need to have face-to-face meetings between physicians, and an evidence-based discussion of the importance of excellence in screening mammography.

Yes, this process can be tedious, but your future--not to mention the future of your patients--depends on how successful you resist commoditization in your community. The stakes are very high.

As I watched the big game this past Sunday--the Superbowl--I thought about the blog. All the hype these past few weeks has made people want to be part of the action, even if they're not even sports fans. WHY?...it's the excitement, the atmosphere, the advertising, the star players and what really makes them a team. Our breast centers need to be a team sport!  

I say this because I believe our breast centers need to get all the players involved. This starts at the top with administrators and managers and works its way down to the day-to-day operations of the technologists. We all have different personalities and unique skills (just like football players), and every week we need to get out there and play together as a team. As breast centers grow rapidly with a focus on patient care and new digital technologies, how much information is communicated to your staff of technologists? So many times, a center makes changes to improve technology or advance patient care but falters in communicating plans to their staff.

What about that one technologist (the MVP player) who has a suggestion or idea that can really be the powerful "play" to make your breast center thrive? For example, perhaps you're having issues with the schedule or productivity. Why not ask the techs their opinions on the issue and their expectations as they relate to day-to-day operations? This is really where I see the team working together. Your staff of technologists--on up to managers and administrators--working together as a team can benefit everyone...meaning not only the breast center but most importantly, the patient. Patient care is what it's all about! Just like in the Superbowl we wanted the players to perform at their best so the Giants' and Patriots' fans could be the winners--and they did!

Take the time to involve your staff in decision making. Keep them informed with monthly meetings and have them voice their opinions or suggestions. Consider even having an MVP technologist for a month All staff members are part of the team and their opinions and ideas can make a difference for a better breast center You'll be amazed at the response you'll receive once everyone realizes they're part of a real team. The Superbowl can happen every week in your breast center.

Let me begin by stating, unequivocally, that the screening mammogram is the most important study in breast cancer. I know, it doesn't pay enough, is "boring," carries a large medical legal risk, and isn't very "high tech," but none of that alters its importance to women, or to anyone in the chain of care for breast disease.

All cancers are biologic processes, meaning that they grow over time. Screening mammography allows us to intercept breast cancers while they are pre-clinical in size, and the evidence is clear that, where breast cancer is concerned, smaller is better. In fact, most of the decrease in mortality rate from breast cancer has been attributed to screening mammography for this reason.

There is, however, an interesting phenomenon that one observes with most good comprehensive breast centers, and that is a disproportionate number of diagnostic patients when contrasted with the "native" screening population. Even after discounting for clinical referrals and short interval follow-up patients, the number of diagnostic patients exceeds the number of screening recalls by a substantial percentage. Unfortunately, if you dig deeper, you will find that that this body of patients tends to have larger cancers and even cancers that are apparent on the screening priors that the patient brings with her.

What we are seeing here is the effect of the commoditization of the screening mammogram, and it is dangerous. Commoditization reflects the erroneous perception by both third party payers, and by many of our referring physicians that all mammograms are equal, when nothing could be further from the truth. Unfortunately the consequence of this misperception is costly, both in terms of pure economics, and in the delayed diagnosis of treatable cancers.

What to do? If you are a woman, choose wisely and well. Pick your breast radiologist with care, from subspecialists who focus on breast imaging, who interpret large numbers of mammograms each year, and who keep up and improve their skills by regularly attending professional meetings and seminars devoted to breast imaging. If you are a center that is facing the commoditization challenge, stay tuned for the next edition of this blog.

Over the holidays, we hear all about upgrading our televisions to high-definition (HD)...so why don't we hear more about the medical industry--especially mammography--upgrading? We need to educate the community about digital mammography and the dramatic changes the technology has brought to women's health.

This week I encountered a female patient--over 40 years old--who had not yet had a baseline mammogram. She was confused about what type of mammogram was "best" (analog vs. digital), what type of breast tissue she had (not to mention what that meant), as well as what technologies local facilities were offering. A rare patient breed, she took matters into her own hands and started calling area facilities. The nearest mammography facility that provided digital technology was over 50 miles away from her home. When she asked the other facilities why they didn't offer digital services, many responded, "We're waiting for the technology to get better." No wonder this woman--and many like her--hadn't yet managed to go for her first mammogram.

Patients deserve more than a mixed message. Contingent, of course, on the technologies you offer, what type of information does your facility provide to inquisitive patients when they ask about analog, digital...even breast MR or ultrasound? What's your role in educating patients--today's health care consumer? Do you invite your front office /receptionists and the other personnel at your breast centers to staff meetings and/or educate them on the services you have to offer? After all, they are your front line!

Fortunately, this woman did have her mammogram and made the trip to the digital center. She asked us about whether digital was really better than analog--and if so, why more facilities don't have it. We explained the difference but also reassured her that if digital was not available in her area, that an analog mammogram was more advantageous than not having a mammogram at all. I used the analogy of an HD TV compared to a basic tube TV, which gave her the reassurance that a mammogram is needed--even analog--with the knowledge that digital is the more superior technology. She now can share this information with family and friends who may also need a mammogram but are unsure about what to do. She was so appreciative that we took the time to explain the difference. This eased her anxiety about the initial mammogram and also subsequent yearly visits.

Regardless of the technology we offer, we must take responsibility and reach out to our communities on women's health issues and services--they are too important to go unheard. We need to start within our own facilities so women hear us!