iRADiX

For it matters not how small the beginning may seem to be:

what is once well done is done forever.

Henry Thoreau, Civil Disobedience

The G7-G8 group of countries named “Lifelong learning” as a main strategy against unemployment. Having worked in the international “Global-work place” in a private corporate set-up and seen many “corporate-cruelties” in the name of “nothing-personal-just-business” one of the survival strategies is to have dedicated working groups.

A performance agreement

I will try to make you a technologist, and not remain a technician all your life.

As a new technician, S.K.Prasanth Abburi (SKP) joined the department fresh from Yashoda hospitals, Hyderabad, India, eager to show me the strong points in his Imaging department we set up this performance agreement. The following blog article shows the components of this “Performance Agreement” between us.

Hopefully, over the months, we will review our journey together and report to the community. I hope some radiographers also join in and have similar performance agreements in their imaging departments and share their experiences so that the process can become richer.

Strategies against Unemployment

In response to the article “Day One” http://www.iradix.in/277-Day-One.html a senior department manager in an international setting had asked why technicians are not called Radiographers or Radiology Technologists.

In articles http://www.iradix.in/504-How-does-one-set-the-protocol.html

and http://www.iradix.in/506-I-initially-missed-out-on-this-case.html

we started examining some issues related to MRI protocols and approach to different diseases by trying to form “Special Focus Groups”.

The debate has been rife in IRADIX regarding general radiologist versus subspecialty interests. I have some very interesting straight-from-the-heart letters regarding this issue and hopefully the authors will put them into blog form so that all in the Radiology community will benefit by reading these reflections and also re-examining their own positions.

Personally, I feel it is a question of survival. Without forming special focus groups I think we will become redundant.

The G7-G8 group of countries named “Lifelong learning” as a main strategy against unemployment. Having worked in the international “Global-work place” in a private corporate set-up and seen many “corporate-cruelties” in the name of “nothing-personal-just-business” one of the survival strategies is to have dedicated working groups.

Apart from Line Diagrams, (http://www.iradix.in/290-Line-diagrams.html)

another interesting theme is to go for graphs. In MRI one can try to see the Spectroscopy and fat saturation techniques and try to draw some graphs to guide our practice. What are the other graphs which one can try to form as a baseline?

We can examine these in greater detail in coming articles.

Performance Management

Performance management is the essence of every manager’s role.

A Radiology department manager may have to have performance agreements with several different professionals, which sets out what is expected in any particular role or job.

We interact with many specialties. Our role may involve developing logic to guide radiology test ordering? How does one play this complex game? Are there rules agreed upon before hand? Or is it a power-might decides milieu in which you work?

(See articles

http://www.iradix.in/427-Radiology-Utilization-Committee.html

http://www.iradix.in/432-Puppets-in-a-Puppet-Show.html

It may involve http://www.iradix.in/415-Dealing-with-The-Internet-Armed.html

or Revisiting disease processes

(See articles

http://www.iradix.in/406-Revisiting-Chiari.html

http://www.iradix.in/417-Fluid-pockets-and-line-diagrams.html

These management roles may be formal or informal, with or without a defined hiearchy.

The Beginning:

Performance management begins with a performance agreement, which sets out what is expected in a particular role or job.

The process begins with induction and training and then continues through formal and informal planning, monitoring and reviewing processes.

As stated in the opening line of this article we saw our joint effort to help in evolving the MR professional from being a mechanical technician to a technologist.

“I will try to make you a technologist, and not remain a technician all your life.”

Performance management will be more effective if you formalize it with a written agreement of commitment. Both parties involved should be clear about their obligations and attain a full understanding of the processes involved.

The components of our performance agreement are

Objectives:

A senior MR professional is not expected to just mechanically keep doing the routine cases. He will have to monitor and improve on-site protocols, train the other technicians and liason with other departments to seek like-minded professionals and create ‘community-of-learners’ who will try to do things other than the mundane routine.

Activities:

(I)We will jointly review the weak points in our imaging subsystems.

For that we have divided the MR section into four components

(a) Abdomen (b) Musculoskeletal system (c) Spine (d) Brain

We will identify areas where there is scope of improvement.

This activity may involve coordinating with other departments as with small private non-teaching hospitals (like ours) we may not have all the latest software.However, nothing stops us from being aware of the latest innovations and directions.(especially in this age of Information technology)

(II) Teaching the less experienced staff.

Design a course on

1. Safety procedures (Time frame-in 1 week)

(ii) Checklists for a MR-CT site (Time frame-2^nd week)

(iii)Give talks on basic sequences, advanced sequences.(3^rd, 4^th weeks)

1. Create portfolios of Interesting cases from the technical perspective.

( In a Time frame of 2 months, they will present 10 cases each highlighting a technical aspect.)

Achievement Criteria

How is progress measured? For abdomen imaging Artefact reduction and Chemical shift imaging were the two criteria we set forward. In the initial two weeks we jogged down some of the company protocols and modified our on-site protocols.

Problems that uniquely affect abdominal MR imaging include motion artifact (from respiratory, cardiac, gastroinstestinal, and voluntary movement), susceptibility artifact , conductive and dielectric effects and wraparound artifact

Techniques to minimize artifacts often need to be addressed within the time constraints of a single breath hold. Acquisition time is minimized by obtaining fewer phase-encoding steps, decreasing repetition time, and increasing efficiency with use of parallel imaging and multiecho acquisitions(3)

***

Plain and post contrast axial images: Left lobe of liver complex cystic lesion-most likely Hydatid etiology. The technical issue here was the use of Fast SPGR sequences. (FSPGR-GE, Turbo FLASH-Siemens, TFE/FFE-Phillips). Gradient recalled echo (GRE) techniques achieve their speed by using a low flip angle and gradient reversal resulting in a short TR. The shortening of TR values from seconds in conventional SE or IR sequences to tens of milliseconds in gradient echo sequences greatly reduces scan times.

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Ghosting: False impression of intrahepatic lesion

Ghosting

***

Repetitive motion (eg: respiration and pulsatile arterial flow) manifests as distinct ‘ghosts’ with regular periodicity across the phase encoding axis. This may lead to false impression of an intrahepatic lesion . Another cause of such false impressions may be due to Wrap around artifacts. These occur when the FOV is smaller than the imaged object in the phase encoding direction. These are generally accepted if it occurs over the abdomainla wall but can be problematic when it obscures organs of interest.

( 1,2)

For abdomen imaging Artefact reduction and Chemical shift imaging were the two criteria we set forward. For these we considered issues relating to motion and possibilities of reducing these by reducing scan times by using FSPGR sequences.

Chemical Shift imaging is another part of our joint exploration. The term Chemical shift refers to the difference in precessional (or resonance) frequency between two proton MR signals, expresses in parts per million of the resonance frequency of the static magnetic field (B0). Diffuse signal intensity loss throughout a lesion on the out-of-phase image compared to the in-phase image indicates a fat water admixture. Conversely absence of signal intensity loss suggests that the tissue is composed predominantly of a single proton species, either water only or fat only. Most commonly this technique is used for adrenal adenoma (incidentaloma) where demonstration of loss of signal intensity in out-of-phase compared to in-phase image indicates presence of fat-water admixture. Other examples of this technique may be applied to differentiating focal fat deposit versus neoplasm in pancreas, or focal fat deposits mimicking metastasis in patients with breast cancer.

(3)

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In-Phase(b), Out-Phase (c) images: Absence of signal intensity loss suggests that the tissue is composed predominantly of a single proton species, either water only or fat only.Coronal T2 images (a) show hypointense lesion, hypoenhancing (d) on FSPGR T1 Wpost contrast images.As there is no signal loss in out-of-phase images,neoplasm is likely.

Qualitative versus Quantitative Imaging.

In the article " Learning to Count", http://www.iradix.in/424-Learning-to-count.html

we recalled the words of Philolaus of Tarentum

“ Actually everything that can be known has a Number;For it is impossible to grasp anything with the mind or to recognize it without this (Number)”.

While my friend SKP was happy that he had reduced the artifacts using the fast imaging techniques and also helped characterise some lesions by chemical shift techniques I asked him about his experience in quantifying lesions.

The quantification of fat is not relevant for extrahepatic fatty lesions. Although fat detection may suffice to suggest the diagnosis of fatty liver, fat quantification is required to determine the severity of steatosis, actively monitor patients over time, and assess response to therapeutic intervention. Regardless of the MR imaging technique used, the key step is to break down the net MR signal into fat signal and water signal. If this is done corretly, the proportion of fat signal to the net signal can be quantified as the fat signal fraction (FSF)

FSF = S (fat)/ S (water) + S (Fat)

The strength of fat signal relative of the water signal (FSF) can be quantified by measuring the signal in colocalized regions of interest on the in-phase and out-of-phase images and then applying the following equation.

FSF = S (fat)/ S (water) + S (fat) = S (IP) – S (OP)/ 2 S (IP)

(3)

We have limited experience in quantification. I hope some people with more experience may enlighten us of their experiences and pitfalls.

Meanwhile I have given SKP the task of finding out the numbers involved in changing T1 weighting.

Duration:Time scale involved.

The performance agreement has objectives, activities, measurement criteria which should be implemented in a time frame.
The process begins with induction and training and then continues through formal and informal planning, monitoring and reviewing processes. As part of the induction, we started going through the already existing sequences, and reviewed studies of the abdomen. As part of training (trying to make him a technologist rather than remain a technician) we tried to go through some numbers and how they apply to our cases.

Teaching folders: Going beyond doing routine. The senior technician has identified areas where the juniors are hesitant. Areas like searching for the undescended testis (a,b) or the dilineation of fistulas (c,d)In a Time frame of 2 months, they will present 10 cases each highlighting a technical aspect.

***

In the article http://www.iradix.in/484-Communities-of-Practice-A-Broad-Church.html

we went through the many facets of a Radiology department and I had hoped that one of our Technical managers could start a blog on these aspects. Lifelong learning as part of strategy against redundancy and unemployment is the way forward. This article is our small beginning together in a process to look at some aspects of our radiology imaging practice which made us remember the words of T.S.Eliot

We shall not cease from exploration. And the end of all our exploring will be to arrive where we started and know the place for the first time.

Hopefully some technical managers and more experienced body imaging professionals from larger academic settings will join in so that we can re-learn and reflect on our work. ***

Notes and suggested further reading:

1. Yang et al, Optimizing Abdominal MR Imaging: Approaches to Common problems.

Radiographics 2010:20:185-199

1. Stadler A et al, Artifacts in Body MR imaging: Their appearances and how to eliminate them. Eur Radiol. 2007; 17(5): 1242-1255.

1. Hughes Cassidy et al: Fatty liver disease: MR imaging techniques for the detection and quantification of liver steatosis. Radiographics 2009; 29:231-260.