Moyad: Here is the quote that's used throughout the literature. Are you ready?
Margolis: Yeah.
Moyad: I think you actually use this in one of your papers.
Margolis: Maybe.
Moyad: The learning curve for reading these MRIs is steep and long. Let me repeat that.
The learning curve is steep and long, so before you answer,
not only does that make sense to me; it makes me think, why in the h-e double toothpicks am
I going to have someone read it that doesn't read a ton of these things? This, you know,
we argue all day long the surgeons got to do so many radicals, radiation oncologists has got to do
so many radiation treatments to be considered an expert, a pathologist has to read so many slides
to be an expert. Why aren't we arguing this about the radiologists and MRIs? What am I missing?
Margolis: I... No, that that's exactly the right question to ask so
when you are looking for a surgeon; you don't simply say, "Do you do surgery?"
Right? You want to know how much prostate surgery do you do right?
Moyad: Right
Margolis: And there are some really good surgeons that do kidney stones and do some prostates
and some bladders and, you know, the full gamut and probably a skilled surgeon
would do an adequate job, but you want to optimize the likelihood that you will get a good surgeon
so you want her or him to have done a number of prostate surgeries and ideally with the latest
technology—so robotic or laparoscopic or um whatever technique they're planning to use—and
to specialize in prostate surgery so that they're not doing stones all day long every day,
and at most larger institutions they have some the urologists that do primarily prostate and
then they have other urologists for things like female pelvic floor disorders, and kidneys, and
kidney stones, and other things. Similarly, there are a number of radiology groups where everybody
reads everything. I was that guy for a year and a half, and I was better at some things than others,
but this is when we weren't doing Prostate MR. Now, I will mention that I did not do procedures
because those stakes are high enough that you want somebody that's focused on that,
and while I did read mammograms, they were deciding whether or not I should continue. So,
I was fresh out of training; I was trained to read mammograms, but only a small number
of the radiologists read mammograms because you have to—legally have to—read a certain
number every year, and what we are planning to do for prostate MRI is the site accreditation
for excellence in body MRI will have a component for prostate MRI that will look at the quality of
the scan. So, these sites will have to supply a certain number of prostate clinical studies that
have been de-identified or anonymized, but also show that their radiologists have read a certain
number of prostate MRI scans and for a lot of the radiologists coming out of fellowship training,
if they specialize in abdominal and pelvic imaging—you know,
as I was saying we do somewhere between two and five prostate MRs a day—so if you do that for a
few months you've seen a lot of prostate MRs, and you're training with people that only read
abdominal pelvic MR, and so you're training with people that are specialized in it,
and so the good news is if you find somebody who's fellowship trained and focused in it,
that person is probably adequately trained and the American College of Radiology has done a very good
job of providing training for radiologists not only nationwide but even for radiologists from
we've had patients—our students rather—from Colombia (the country of Columbia, not my
fellow campus to the north) and Australia and they have a program where they read 150 prostate MRs
in a day and a half which is a very grueling day and a half, and at that point they're more or
less ready, and then by the time they've read, you know, a couple dozen more, they're good to go. So,
it's important to ask the person that will read the prostate MRI, "How many scans has she read?"
Moyad: Yeah.
Margolis: And how many does she read in a week?
Moyad: Yeah,
and what's the answer I want besides if it's zero, of course, I'm running for the hills, right?
Margolis: Right.
Moyad: What am I looking for in terms of some kind of clarity that this person is somewhat competent?
Margolis: Uh, at least 200 scans in her lifetime.
Moyad: In a lifetime?
Margolis: Yeah, and ideally 500, but 200 is generally enough if they're focused
in that area, and you want them to be reading at least two or three a week
because at a lot of sites that's about the volume that they get,
and for for those of us that focus on abdominal and pelvic imaging that's about what we do.
Moyad: So, let's say I don't get that and I go—I mean, I'm entitled to that information, right? So,
a lot of people watching this right now have thought I didn't think to ask that,
or if I get one of these I didn't think to ask. It's perfectly logical;
can you please tell people that are watching to ask that question before you proceed?
Margolis: Yes, your radiologist is a medical specialist just like your surgeon
and your medical oncologist and she or he should be trained in what they're doing,
so like, I don't read mammograms anymore because I haven't read them in a long time and and I don't
trust myself to read mammograms and I shouldn't, and so at most groups that do prostate imaging
they will pick a small number of their radiologists to focus on that
whereas there's a lot of things that are so common and so straightforward like a
CT scan to rule out appendicitis or to look for a stroke, those we do dozens a day and so everybody
has read tons of those and is not going to miss a significant finding.
Moyad: Right it's like acute diverticulitis, right? I could pinpoint that with my finger
and that's probably the only thing I could pinpoint on one of those scans, I mean...
Margolis: Yes, but prostate MR, you need to leave it to the experts.
Moyad: That really makes my day that you gave us an actual quantifiable number that people can
work with; ideally 200 scans would be nice, 500 ideally, two to three a week; I wrote those down.