The specialty of women’s health care has experienced tremendous growth ever since the medical community began recognizing that women have different health care needs than men. As a result, many health care providers during the past 2 decades have packaged medical services specifically to appeal to female consumers. This trend is expected to continue as the population’s life expectancy increases and the need for comprehensive health care for women beyond the reproductive years intensifies. As women’s health centers spring up around the country, the subspecialty of women’s imaging is destined to grow.
“As the concept of comprehensive health care centers for women continues to gain popularity, radiologists will play a critical role as the primary providers of women’s imaging services,” predicts Terisita Angtuaco, MD, professor of radiology, University of Arkansas Hospital for Medical Sciences in Little Rock and women’s imager at the University Hospital of Arkansas. “This is largely due to the fact that imaging services are usually at the core of activity in a women’s health center.”
Although Angtuaco’s women’s center is currently limited to oncology services, plans are under way to add comprehensive care, particularly internal medicine and obstetrics and gynecology services. One of the challenges the University of Arkansas Hospital for Medical Sciences faces is that its current women’s center is located in a very tight space within the hospital. “My advice to individuals interested in starting a women’s health center is to develop a comprehensive plan prior to starting the service that will address growth issues,” Angtuaco says. “It is imperative to have commitment from the powers to be that the center will be for all types of women, not just specific types of women.”
A HISTORICAL PERSPECTIVE
According to Angtuaco, the movement for better women’s health care was spurred by a 1990 government report that highlighted several inequities in women’s health care, including the failure to adequately involve women in research studies, inadequate attention to gender differences in research and clinical services, as well as lack of funding for women’s health concerns and the lack of education on women’s health issues, both for the public and among health care professionals.1 “This report revealed that these inequities existed because of the prevailing assumption that the causes, treatment, and prevention of diseases are similar for both sexes,” Angtuaco says. Several studies conducted by cardiologists in the 1990s confirmed these incidents of gender inequity.(2)
The federal government responded to the 1990 report by authorizing the development of centers of excellence in women’s health care through the Public Health Service Office on Women’s Health. These centers were designed to serve as model programs in the area of comprehensive women’s health care. “With a focus on one-stop shopping, these centers were established to meet the unique needs of women in their communities,” Angtuaco says. Since 1996, 18 centers of excellence in women’s health care have been designated by the Public Health Service Office on Women’s Health: Allegheny University Health Sciences, Philadelphia; Magee Women’s Hospital, Pittsburgh; Ohio State University, Columbus; University of California, San Francisco; University of Pennsylvania, Philadelphia; Yale University, New Haven, Conn; Boston University Medical Center; Indiana University Medical Center, Indianapolis; University of California Los Angeles; University of Maryland at Baltimore; University of Michigan Medical Center, Ann Arbor; Wake Forest University, Winston-Salem, NC; Harvard University, Boston; Tulane/Xavier University, New Orleans; University of Illinois, Chicago; University of Puerto Rico, San Juan; University of Washington, Seattle; and University of Wisconsin, Madison.
Angtuaco points out that in addition to the establishment of these centers of excellence, the government also designated Department of Defense funds to be earmarked for breast and ovarian cancer research. Congress then passed the Mammography Quality Standards Act (MQSA) in 1992, which went into effect in 1994. The MQSA requires that all facilities performing mammography must function at a basic or standard level of quality, which is rigorously enforced through annual reviews and inspections.(3) “This initiative had a tremendous impact on the health care industry and continues to be an example by which other certification procedures are compared,” Angtuaco notes.
THE PUBLIC’S RESPONSE
As the government began supporting women’s health care issues, female health consumers also started demanding changes to the way they receive medical care. Public surveys found that women desire providers who can offer a full range of services as well as physicians who have specialty training in women’s health care. In addition, women stressed the importance of convenient hours, an attractive ambience within the center, alternative therapies, female physicians on staff, and community education.
These were the types of issues that a community advisory council, composed of female leaders from the business and professional community, brought to the attention of administrators of the Richmond-based Medical College of Virginia in the early 1990s. From their input, the MCV Women’s Healthcare Center at Stony Point was created in 1993. Designed as a one-stop shopping center for the delivery of women’s health services, the MCV Women’s Healthcare Center includes a team of physicians (obstetrics, gynecology, radiology, internal medicine, psychiatry, plastic and breast surgery, and genetics), women’s health and adult nurse practitioners, clinical nurse specialists, nurses, nutritionists, ultrasound and bone densitometry technicians, mammographers, social workers, and genetic counselors.
“We have been successful in offering comprehensive services because we are able to still retain our own department lines, but at the same time we are working together to support our mission, which is patient-focused,” says Ellen Shawde Paredes, MD, section chief, Department of Radiology at the Medical College of Virginia and a radiologist with the MCV Women’s Healthcare Center.
“We have never experienced the turf battles that many professionals fear when setting up such a program,” she adds.
With more than 20,000 annual patient visits, the MCV Women’s Healthcare Center has received praise nationally for its specialty in women’s health care. In 1998, it was awarded the National Excellence Award for Outstanding Comprehensive Health Services by the Washington, DC-based National Association of Professionals in Women’s Health.
According to Paredes, one of the reasons the center has been so successful is that every discipline was actively involved in the planning process. In addition, the public was represented through the advisory council, which continues to meet periodically to provide current feedback to the center’s administrators. “It is important to incorporate not just what you think is important, but also what patients feel is important,” Paredes says. The advisory council currently has a diverse group of female members, including a 30-year-old attorney and a senior citizens’ advocate in her 80s.
The other component that is essential in setting up a comprehensive women’s health center is to hire the appropriate people who can coordinate administrative matters, particularly managing schedules for the different disciplines.
TECHNOLOGY ACQUISITION
In offering comprehensive services for women, radiologists agree that a full range of imaging technology is needed on-site. Mammography and breast ultrasound are essential, along with breast interventional procedures, such as stereotactic breast biopsy, cyst aspiration, fine-needle aspiration biopsy, ultrasound-guided core biopsy, galactography, and needle localization. In addition to breast imaging, many women’s health centers offer general radiography, bone densitometry, general ultrasonography, CT, MRI, and hysterosalpingography.
In the ideal setting, patients with mammographically detected abnormalities that require percutaneous biopsy are informed of the findings that day and are immediately scheduled for the procedure. Concurrently, the referring physician is consulted regarding the recommendation. Then the results of the biopsy are conveyed by the radiologist directly to the patient as well as to her physician. Patients with malignant diagnoses should be told the results in person instead of being called on the phone. The radiologist explains the next step and in some instances may set up an appointment with the surgical oncologist for patients who require surgical consultation. “The rapid response to the patient with an abnormality greatly expedites her care and alleviates much of the anxiety associated with waiting for the various steps in the process,” Angtuaco says.
In offering different imaging procedures, Ellen Mendelsohn, MD, chief of mammography and women’s imaging and director of the Breast Diagnostic Imaging Center, Western Pennsylvania Hospital in Pittsburgh, is quick to point out that a center offering comprehensive services must retain the appropriate clinicians who can quickly address issues as they arise. “It is important to have a close working relationship with gynecologists so that if you define a polypoid lesion in the endometrium, you can consult with them regarding its location,” Mendelsohn says.
In terms of obstetrics and gynecology, Mendelsohn stresses that in order to perform pelvic studies, ultrasound is an integral part of the practice. “The practice’s expertise has to include not only transabdominal studies, but also transvaginal ultrasound,” she says.
Even practices that do not provide a full range of services, but still offer comprehensive breast health care, should obtain the best state-of-the-art equipment possible. The Columbia-based South Carolina Comprehensive Breast Center is one such practice that has grown significantly, largely because the appropriate imaging equipment was acquired early on to provide its large patient base with diagnostic and interventional procedures.
“We have been able to grow our practice by about 20% to 30% each year for the past 4 years mainly because of our successful utilization of ultrasound and upright digital stereotaxy within our center,” says Tommy Cupples, MD, director of mammography services, South Carolina Comprehensive Breast Center. By bringing this equipment directly into the center, which is located in a separate building from Palmetto Highland Memorial Hospital, Cupples was able to perform both biopsies of solid lumps as well as calcification within the confines of his practice. In the past, biopsies involving calcification had to be performed in the hospital, which was not convenient for patients or Cupples. “Now women needing either type of biopsy can have it done on the same day the abnormality is detected and histologic pathology results can come back to me and the patient’s physician by the following morning,” Cupples says.
TARGETING TECHNOLOGY
In selecting the appropriate imaging equipment to acquire when launching a women’s health center, research must be conducted to determine which companies have the best reputation for performance and service. According to Angtuaco, final decisions should be made only after consultation with other radiologists and technologists about their experiences. “You cannot always rely on company reference lists, since they are not usually objective: only satisfied customers are kept on those lists,” Angtuaco says.
Angtuaco points out that another factor in selecting the right equipment is anticipated technological advancements in the next 5 years. She stresses that since digital mammography is expected to have a prominent role in screening, it may be worth spending more for a machine that can be upgraded to digital capability. Administrators also need to investigate the benefits and disadvantages of leasing versus purchasing equipment. Usual lease options include a straight lease or buyout options involving varying percentages. If capital is available, it usually is more cost-effective to purchase the equipment outright. Accountants should be consulted for these decisions since there are significant tax ramifications.
Most women’s centers use a computerized database for reporting mammography results for the medical audit required by the MQSA. The computerized database is useful in generating recall letters to patients. The use of such reminders has been proven beneficial in improving the rate of routine mammography among women.
The radiology staff within the women’s center plays an important role in making patients feel satisfied with the treatment they receive. Technologists should teach patients breast self-examination on request and also should provide explanations of procedures. “Within this supportive environment, it is important to make the patient feel that she is not being rushed through, that her questions are being answered, and that she is being provided with the quality of services that she seeks and deserves,” Angtuaco says.
MULTIPLE BENEFITS
Most medical professionals who have gone from working in a traditional practice to working in a comprehensive women’s health center agree that one of the greatest values of this one-stop shopping is that it promotes efficiency. Most centers are designed so patients who are seen for routine gynecologic examinations can also be scheduled on that same day to go to the radiology area for an annual mammogram. If a palpable lesion is found during the physical examination, they can go immediately to the radiology area for breast imaging. The hallways are usually contiguous, which allows gowned patients to easily go from one area to the next without redressing.
Abnormal results from mammography may lead the radiologist to obtain spot compression views, followed by ultrasound to evaluate a suspected solid mass, and then image-guided biopsy. The entire process may take only 30 minutes, with the histologic results usually available the next day. In addition, women with abnormal uterine bleeding can be scheduled for both pelvic ultrasound and sonohysterography on the same day, if needed.
Another major benefit of most successful women’s health centers is that they are designed to accommodate most women’s needs. Convenience is an important attribute for most female patients, so the location and operating hours of the center should be carefully determined. “It would be a perfect situation if a center could offer day care so that women could have their children watched while they have a 15-minute mammographic examination,” Angtuaco says.
The atmosphere of the center is equally important to most women. Successful women’s health centers need to offer a variety of intangibles, such as supportive and compassionate staff and environments that respect women’s privacy and make them feel comfortable. “Women have a different set of requirements when it comes to health care,” Angtuaco says. “Nice music, padded examination tables, and pleasant decorations all make a difference for most women health care consumers.”
In today’s health care market, women also want more than just routine examinations and diagnostic tests. They also seek services that focus on health maintenance and disease prevention. To make services appealing to today’s women, practitioners need to offer alternative therapies, fitness programs, genetic risk counseling, nutrition counseling, and stress management classes.
PREPARING FOR THE FUTURE
To meet the growing demand for women’s health specialists, a women’s imaging fellowship has been developed to train radiologists in this specialty. In late 1998, the Society for the Advancement of Women’s Imaging (SAWI) recommended guidelines for fellowship training in this area. Among the requirements are a board-certified radiologist as the program director; interdisciplinary conferences in obstetrics, gynecology, and breast disease; access to a variety of imaging devices for women; and familiarity with other modalities such as hysterosalpingography and bone densitometry. “More and more radiologists are seeking to obtain this training because people in private practice have begun to favor hiring radiologists with special expertise in this area,” Angtuaco says. “If a person is identified within the practice as a woman’s imager, he or she can coordinate all the imaging studies in the proper sequence, which ends up being more cost-effective for the practice and better for the patient.”
As women continue to play a decisive role in health care decision-making, radiologists who specialize in women’s imaging will find many job opportunities. Angtuaco stresses that as the population of women in midlife increases, there will be a growing need for high-quality women’s health care services that provide comprehensive, efficient care in a single setting. “Since the radiologist holds a key position in the world of women’s health care, we will continue to see considerable growth for women’s imagers,” Angtuaco says. “It is an excellent and exciting field for physicians who enjoy working closely with different medical subspecialists.”
Carol Daus is a contributing writer for Decisions in Axis Imaging News.
References:
- Angtuaco AL. Women’s health care centers and the women’s imaging subspecialty: emerging frontiers in radiology. Radiographics. 1999;19:S3-S10.
- Johnson LL. Sex specific issues relating to nuclear cardiology. J Nucl Cardiol. 1995; 2:339-348.
- 21 CFR ?900: Mammography facility: requirements for accrediting bodies and quality standards and certification requirement sinterim rules. Federal Register. 1993; 58(243): 67558-67572.
