Mina S. Makary, MD

A radiologist is more than a name on a report. That’s what Mina S. Makary, MD, director of Interventional Radiology Inpatient Service in the Department of Radiology at the Ohio State University Wexner Medical Center, wants patients to understand.

“When I tell people I’m a radiologist, most people think I’m the one running the machine,” he says. “They have no idea radiologists go to medical school, have residency training, and diagnose and treat diseases. We’re a critical part of their care, but they have no idea.”

How to solve that problem? Provide patients with direct access to their radiologist. Nearly three years ago, Makary began laying plans for the Clinical Interventional Radiology (IR) Inpatient Service, which places radiologists and their staffers front and center for each service referred to the department. 

“I was looking around at ways we could improve our department, thinking about improved communication and reduced turnaround time,” Makary says. “I realized one way to do that would be if we took ownership of the entire process, from initial consultation to evaluation and planning to intervention and finally follow-up.”

Taking Ownership

The clinical radiology service collaborates and consults with referring providers and patients from beginning to end. When the department receives a request for service, staff members discuss the case directly with the referring physician and determine whether it is appropriate. They also schedule appointments with the patient to provide pre- and post-procedure education. Patients see either the radiologist or a radiology nurse practitioner, depending on their needs. 

“It’s just like a consultation with other clinical physicians,” Makary explains. “We take a look at what the procedure is, document the plan moving forward and make sure we communicate that with both the referring physician and the patient.” 

Taking this extra step has helped improve communication and relationships with both referring physicians and patients, and it also has helped with quality improvement. “For example, there are certain procedures that are complicated by the presence of certain blood thinners or other medications, and referring physicians may not know to tell patients they need to stop taking the medication several days beforehand,” Makary says. “That means the patient gets there, is still taking blood thinners and can’t undergo the procedure. Consultations ensure we can tell both the patients and the primary care physicians what they need to ensure everything goes well.”

They have no idea radiologists go to medical school, have residency training, and diagnose and treat diseases. We're a critical part of their care, but they have no idea.

Although most of Makary’s patients are in the inpatient setting, the radiology department provides consultation and evaluation services to outpatients as well via a clinic set up within the department. 

Inpatient rounding, which is completed by either the radiologist or other radiology practitioners in the department, is another part of the service. “Previously, I’d simply perform a procedure and then other hospital teams would take care of the patient afterward,” Makary says. “That’s not ideal, because if I do a procedure on a patient, I want to be able to see how they’re doing the next day and answer any questions they have. And I should be the one doing that since I’m the physician who just performed the procedure and am most equipped to deal with their needs.” 

Rounding also gives radiology residents more opportunities to learn — not just about the procedures being done, but about patient management and follow-up practices. 

Patients admitted for certain procedures are admitted specifically under the radiology department’s care, rather than under another department. “We want to take ownership of our process and ultimately give patients a better experience, so it’s important we take charge of it rather than handing them off to another team who may not have the same expertise we do,” Makary says. 

Makary notes most of this work was already being done, but it wasn’t being documented or billed for because the radiology team didn’t interact as much with patients. 

“Radiologists already oversee the procedures and make recommendations for care, but since we don’t work with the patients directly, we can’t bill for it — it’s another note in their chart,” he says. “By adding these services and streamlining our process, we’re both making sure we do our jobs more thoroughly by improving quality of care and also that we’re getting credit for our work.”

Creating a Plan

Once Makary recognized the need for the clinical radiology service, he spent about a year developing a business plan. He joined forces with a colleague, Daniel Boulter, MD, who provided additional perspective from the diagnostic radiology side of the department. Together, they took the idea to the department leader and chair. 

With their approval, Makary and his department proposed the idea to the hospital leadership. Following this, they used data from a pilot to help show how the plan could ultimately pay for itself in the long-term. 

In the pilot, Makary had existing department nurse practitioners work with patients directly and begin testing some of the consultations the service would provide. He then worked with the billing department to understand how many consultations the department would need to perform to pay for the extra staff — nurse practitioners and physician’s assistants who could take on the additional patient-facing and documentation work needed. 

“I was able to see how much time and how much we’d be able to bill for each level of visit so I could say, ‘If we perform this many consults, we can pay for the staffing required without the workload becoming unreasonable,’” Makary says.

He also spent a great deal of time ensuring he had internal buy-in. “Several of our colleagues were worried we’d be taking on additional work,” he says. “We were able to explain to them not only could we bill for our services, but we’d actually be giving ourselves less work by improving our workflows and making our process more efficient. We’d get interrupted less by calls because by having the consultations, we’d already answer a lot of referring physician questions on the front end. With some tasks provided by the nurse practitioners independently as well, we’d be working smarter, not harder.” 

Once the plan was approved, they hired five extra staff members — advanced practice providers. Makary would manage the services provided by interventional radiology and inpatient services, and Boulter would manage diagnostic radiology needs and the outpatient services.  Following Boulter subsequently assuming other leadership roles in the department, Makary now manages the entire service. 

New staff spent two to three months rotating and rounding with different parts of the radiology department to better learn about radiology as a whole. These team members would not only see how procedures were done or interpreted, but they’d also visit patients with radiologists to answer questions afterward. 

“I wanted them to understand about all the different parts of radiology, but also more specifically the kinds of things we’re looking for as we do procedures and what kinds of things we worry about,” Makary says.  The new system has helped them better understand what to document, as well as anticipate what questions or needs a patient might have.

Once the extra staffers were ready, the service began in earnest — about three years after Makary’s initial idea. 

Finding Success

The clinical radiology service has had many positive outcomes. “We’ve seen vast improvements in turnaround time and internal quality metrics,” Makary says. This is because all communication regarding the patient is happening between the radiology department and the referring physician as well as with patients themselves, so it’s more streamlined. 

Patient satisfaction has also improved. “Patients want to know who their doctors are, and we’re showing them radiologists are their doctors the same way surgeons, for example, get to know their patients before surgery,” Makary says. “They see us as one of their primary providers rather than ancillary team members.” 

He recalls prescribing blood thinners for a patient following a vascular procedure. Makary had seen the patient several times before and after for evaluation consultations and follow-up. When the patient was admitted to a different hospital out-of-state a year later, local providers recommended they halt the blood thinners. 

“Then I got a call from that hospital,” Makary says. “They told me the patient wouldn’t let them stop their blood thinners without talking to their doctor first — me. Even though they had a hematologist and other clinical experts there, they wanted my advice as their doctor. I had earned their trust, which meant a lot to me, and the only way I was able to do it and have that type of doctor-patient relationship was through having the opportunity to develop a relationship with them through our program.”

Just as important, the service has also led to increased job satisfaction in the department. Hannah Emerine, MSN, APRN-CRP, says, “We’ve gone from a purely procedural team to one that improves safety and prioritizes multidisciplinary collaboration. Our work relies on great camaraderie as a team, and I love that as an advanced practice provider, I get to work alongside the team on a daily basis. We learn from them and feel heard at the same time.”

According to Makary, the collaboration is grounding for radiologists, too. “In medicine, we spend so much time on process and metrics, we sometimes lose sight of why we’re here,” he says. “Working directly with patients reminds us all why we went to medical school in the first place: to make a difference. The entire hospital knows and appreciates who we are and what we do, and that’s incredibly rewarding.”