Not Your Typical Day
A recent fellow provides a snapshot of a day in the life of a breast imager.
“Part of my enjoyment in practicing breast imaging is that there is rarely a typical day,” says Ann L. Brown, MD, who completed her breast imaging fellowship at Beth Israel Deaconess Medical Center in Boston this summer.
For Brown, the mix of screening, diagnostic imaging, and interventional procedures adds variety to her workday.
Brown was drawn to breast imaging by the potential for collaboration with other specialties and for long-term relationships with patients. “Breast imaging stood out to me as a unique subspecialty of radiology dedicated to saving lives,” says Brown. “We see patients at pivotal moments, and in these moments we can make a real difference. The breast radiologist plays an integral role in patient care not only at the outset of diagnosis, but through treatment and for years to follow. We are, essentially, primary care for the breast.”
For Brown, most days are about 75 percent scheduled, leaving the rest of the time for patient-care tasks as they arise. “We have incorrect orders that need clarification from clinicians. We have no-shows and we have add-ons. If there is a patient who is particularly anxious or who has findings concerning for cancer or infection, we do our best to fit them in the same-day,” says Brown. All of this requires flexibility to be built into the radiologists’ schedule.
Brown walked the Bulletin through a typically atypical day in the life of a breast imager, interacting with patients, reading exams, and supporting referring colleagues.
7:30 a.m.: Depending on the week’s rotation, I use the first 30–45 minutes of the day to review and plan my approach for any scheduled procedures. As a fellow, I typically perform between two and six procedures or 10–12 diagnostic exams in a morning.
8:00 a.m.: A full diagnostic day is truly full: I see a patient approximately every 20 minutes. If an ultrasound is necessary, I examine and scan each patient after the technologist. Before the patient leaves the department, I review the case with my attending and make a final recommendation, which is communicated to the patient.
8:30 a.m.: I meet with Ms. Z, a 65-year-old Chinese woman with an appointment for stereotactic core biopsy to evaluate calcifications. She is reticent about the biopsy, and her daughter says that she had to convince her mother to come today. Through an interpreter, I explain the suspicious appearance of these calcifications and our concern for an early stage malignancy. Ms. Z ultimately agrees to the biopsy, which is performed successfully.
9:15 a.m.: Mrs. M is a 52-year-old woman with an appointment for wire localization prior to partial mastectomy. She has a 2.5 cm mass, and the order calls for a single wire. However, I know that the patient’s surgeon prefers bracketing wires for masses greater than 2 cm. A phone call clarifies the order, and with the patient’s consent two wires are placed.
Noon: After additional cases throughout the morning, I break for lunch. One or two days a week, I present imaging for patients being seen in multidisciplinary breast cancer clinics or tumor boards. This purpose is to review each patient’s case in detail with the clinical team, which includes breast surgery, medical oncology, radiation oncology, breast pathology, genetics, and social work.
1:00 p.m.: Back in action, I call the doctor’s office of Ms. P, a 45-year-old woman with a breast mass that has come back positive for cancer. For any positive result, I make it a point to call and speak directly to the referring provider to discuss next steps. In the case of Ms. P, she is young and has dense breasts, so I recommend a diagnostic breast MRI for staging. Improving breast cancer detection in women with dense breasts remains a top challenge facing the next generation of breast imagers.
1:10 p.m.: A nurse practitioner calls, asking if we can make time to see Ms. R, a 36-year-old woman with a palpable breast lump. The patient is understandably anxious, as her mother had breast cancer at a young age. I notify the supervising technologist that we will need to fit in a clinic patient.
1:35 p.m.: I find Ms. R waiting nervously in the ultrasound suite. As soon as I walk in, I let her know that so far I see nothing to worry about on today’s imaging. I ask her to point out the lump. When scanning the area, I find the same simple cyst imaged by the sonographer, and I explain that all is well.
5:00 p.m.: Following a busy afternoon of additional scans and procedures, I finish my day by reviewing orders for breast MRI and MR-guided biopsies for the next day. It is my responsibility to protocol these studies appropriately. When I encounter incorrect or inappropriate orders, I reach out to the referring physician for clarification or correction and frame the conversation around radiation safety, cost, workflow, and diagnostic accuracy.
Each day, breast imagers are on the front lines of value-based imaging care through our close collaboration with patients and referring clinicians. We add value to radiology practices by building relationships with referring physicians, but we also prioritize patient engagement. We take time to interact with patients, give them results in person, and answer their questions.
As I continue my career as a breast imager and assistant professor of radiology at the University of Cincinnati, I look forward to advances that will transform our subspecialty and the ways we care for our patients. Medicine is headed toward more individualized and precision-based methods of caring for patients. For us in the breast imaging world, this process is well underway, with therapies tailored to a patient’s specific cancer and strategies to individualize surveillance.
As patient care shifts, we as physicians will have to adapt to increasing transparency in patient outcomes and public ratings along with increasing demands from consumers, who are our patients. The best way to succeed in this new paradigm is to strengthen our relationships and focus on the value we bring to our patients and referring physicians.