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NYPH-Columbia University Medical Center New York, NY
WEB—This is a Web exclusive article.
Although analyzing a system with a goal of not impeding access to an excellent screening tool, the article does not appear to take into account that the system currently could be broken. In calculating numbers, the report states that if the "volume requirements were increased (> 2,000), the actual work load required would reflect the need for mammography to be more specialized." However, it is precisely this current lack of specialization that is the thorn in the side of the superior screening examination and that has resulted in screening mammography being the primary cause for medical mal practice cases in the United States.
There is no suggestion offered for the possibility of implementing mammographic specialization, which is currently present in other areas of radiology and is present in mammography in several European countries. The article mentions possible solutions, specifically for rural areas: telemammography, mobile digital vans, and centralization of interpretation.
As the necessity for screening continues to grow, digital mammography and telemammography have become realities. Telemammography is much more involved than teleradiology because it requires the transmission of more information and greater technical and quality assurance requirements, but the results are dramatic and, significantly, are not just applicable to rural situations but can be applied to suburban and urban areas as well. The formation of centralized telemammography centers with fewer, yet specialized, mammographers could potentially eliminate or substantially diminish access problems, yield more accurate interpretations resulting in a probable decrease in malpractice, and remove the burden from low-volume practices and rural areas.
Another potential benefit to private practices as well as hospital scenarios, given the unavailability of a specialist in most private practices, would be to alleviate the burden of screening from most practices in which a mammography specialist is not always in the office on a daily basis. The practice or hospital would retain the diagnostic workups, sonography examinations, MRIs, and biopsies and could subsequently allocate resources more efficiently. These specialized screening mammographers would undergo continuous review as they do in Europe and be subject to quality and visually oriented examinations to maintain their qualifications. Insurance companies and malpractice carriers might also consider better reimbursement of the professional fee for these mammographers because the number of diagnostic workups, sonography examinations, and missed lesions would be reduced.
As a case in point, we began use of this system at a major academic center in New York City over the past 3 years. Although there is improvement of the allocation of radiologists (mammographers) working within the facility, telemammography has been used for the majority of screening. Relationships have developed in which the telemammographer (operating from a remote reading site) can communicate with other hospital-based mammographers on a specific case for an additional opinion before issuing a final report. This has changed accessibility in a positive mode. Before starting dedicated screening telemammography, screening backlogs in the facility were more than 6 months (with 1–6 months not uncommon in a significant number of practices) [3, 4]. The backlog has been reduced to currently < 3 days.
As digital machines increase their market penetration, this scenario becomes more feasible. For instance, we currently have an increased volume of cases interpreted by more-qualified specialists who, working in an undisturbed environment, can easily interpret > 12,000 cases per year. This would result in an actual improvement to access (regardless of location), reduce backlogs, improve access to the underserved or working women who because of their situation cannot make an appointment at a facility, diminish recalls in a batch interpretation system (which has been shown to be more accurate), and probably result in a decrease in malpractice cases without having to immediately address the need of increasing the number of current mammography fellowships. There are currently a significant number of excellent mammographers who are partially retired or newly trained who may not want to work a full regular work week. This flexibility may also alter the attitude of radiology residents regarding entering the field of mammography [5]. With the use of telemammography, work schedules are significantly more accommodating to interpreters.
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