Rethink Imaging

EP 46 • June 11, 2026

Medical Physics in Rural Hospitals: Higher Dose, Lower Resources, Bigger Stakes

Featured Guest

Jill Shuman, DMP, DABR

Board-Certified Diagnostic Medical Physicist; Section Head, Medical Physics, Radiation & Laser Safety • Marshfield Clinic Health System

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Jill Shuman oversees imaging safety and quality across a network of rural hospitals in Wisconsin and Michigan, covering a two-hour radius herself while two colleagues handle sites three and four hours out. For nearly four years her system ran on a break-fix budget, meaning equipment got replaced only when it could no longer be repaired. The result: older CT scanners with higher doses, more downtime, and more repair calls. She drives past a shuttered hospital every day on her way to work, one that handled 900 births a year and housed one of only two ICUs in the region, and it shapes how she thinks about what rural imaging is actually protecting.

Chris and Jill get into the workforce problem behind the budget problem. One of her sites, staffed entirely by travelers, generated image quality complaints from radiologists within days of a brand-new install, and the causes were fundamentals like patient centering and size-appropriate protocols.

They also dig into the catch-22 of the CMS CT dose quality measure: older equipment produces higher doses, higher doses threaten reimbursement, and lost reimbursement blocks the equipment purchases that would fix the doses. Jill’s counterpoint is blunt. An older CT in a rural town still diagnoses strokes, and a shutdown hospital saves no one.

Host

Chris St. John

Host, Rethink Imaging • Imalogix

Featured Guest

Jill Shuman, DMP, DABR

Board-Certified Diagnostic Medical Physicist; Section Head, Medical Physics, Radiation & Laser Safety • Marshfield Clinic Health System

Watch the Episode

Key Takeaways

Jill’s system spent close to four years on a break-fix budget, replacing equipment only when it was beyond repair. The direct costs showed up as higher CT doses than newer scanners would deliver, plus more downtime and more repairs.
A newly equipped site staffed entirely by travelers triggered image quality complaints from radiologists almost immediately. The equipment tested fine; the problems were fundamentals like CT centering and size-appropriate portable protocols that any registered technologist should know.
The CMS CT dose quality measure creates a catch-22 for rural systems: older equipment runs higher doses, higher doses risk reimbursement penalties, and reduced reimbursement makes replacing that equipment even harder.
Two hospitals closed in Jill’s community within the last few years. One was the region’s primary source of mental health and addiction care, one of only two ICUs in the area, and handled 900 births a year. Those patients did not disappear; the remaining hospitals absorb them.
Marshfield became the first hospital in Wisconsin to adopt contrast-enhanced mammography, which offers cancer detection comparable to MRI at lower patient cost, opening access for patients with claustrophobia, larger body habitus, or MR-unsafe implants.

Full Transcript

[00:00:00] Jill Shuman: You know what can’t save lives? A shutdown hospital. Within my own community, in the last couple of years, we had two hospitals shut down. I pass by one of them every single day on my way to work, and it kinda reminds me of the precariousness that we all live in in rural health care.

[00:00:18] Chris St. John: Welcome to Frame by Frame, Rethink Imaging, a podcast by Imalogix. Here, we explore the intricate world of medical imaging, aiming to dissect the field and inspire both professionals and curious minds alike. I’m your host, Chris St. John. Welcome back to Rethink Imaging.

My guest today is Jill Shuman. Jill’s a board-certified diagnostic medical physicist with the Marshfield Clinic where she oversees imaging safety and quality across a broad network of rural hospitals in Wisconsin and Michigan. Jill holds a DMP in medical physics, is certified by the American Board of Radiology, and plays a key role in regulatory compliance, accreditation, and equipment evaluation across underserved regions. Known for her practical, solutions-driven mindset, she brings both technical expertise and a deep commitment to patient-centered care. Today, she joins us to share what it really takes to keep rural imaging going in a system that isn’t necessarily built for smaller towns.

I’ve been trying to get Jill on the show for a while now, and part of the reason why is that we spend so much time just in this sphere. But even on this podcast, talking to people involved in research or at big academic institutions with bigger budgets or bigger teams, but it’s just not the whole picture. Jill covers a several-hour radius of multiple facilities, has spent many years on break-fix budgets, and drives past a shuttered hospital every single day on her way to work that still has a brand-new CT scanner sitting in it. We talk about what happens when your sites are staffed by travelers, why reimbursement penalties hit rural facilities the hardest, and more. Enjoy the episode. Welcome back to Rethink Imaging. I am so excited to be talking today with Jill Shuman from the Marshfield Clinic. Jill, it’s great to have you here today. Welcome.

[00:02:03] Jill Shuman: Thanks so much for having me. Really appreciate you taking the time to chat with me.

[00:02:07] Chris St. John: Absolutely. We met at RSNA, I wanna say, a couple of years ago, and I have been hunting you down relentlessly since that day just because I think a lot of times on this show, we have a tendency to talk to various folks who might have—I wanna be very careful with my words. I am not trying to undersell the value of more rural facilities, but I think very often, we’re talking to people in massive, largely funded academic institutions, which is just such a disservice, I feel like, to the imaging community as a whole. I’m serious because we have all of these different pockets, all of these different groups, all doing their best out here to provide imaging for the US. So I appreciate you coming on the show and talking for the folks that maybe do not get as much public attention as I think they should get.

[00:03:01] Jill Shuman: There’s a lot of us out here. A lot of rural physicists, a lot of consultants. We’re all kinda facing the same struggles. And the academic physicists definitely get a little bit more of the airtime, so to speak. So I extra appreciate having this opportunity.

[00:03:18] Chris St. John: Not to throw a curveball at you immediately off the bat, but since you did say some of these struggles, do you mind just painting a bit of a picture for us about what your day-to-day looks like as a medical physicist in a more rural facility?

[00:03:34] Jill Shuman: My day-to-day is probably really similar to any other diagnostic physicist. I think each day is a little bit different from one day to the next. The primary difference between me and a non-rural physicist is probably just the number of hats I wear and the amount I have to switch between those hats at a moment’s notice. I like to say that a third of my job is equipment testing and travel. A third of my job is protocols, policies, compliance, and then the final third is detective work and creative thinking, whether that be an artifact, a radiologist asking for a new protocol, new technology I’m unfamiliar with, or some mystery equipment issue. The joys.

[00:04:21] Chris St. John: Love that. From an objective standpoint, I’m like, yeah, that sounds like pretty cookie-cutter, cut-and-dry for a medical physicist. Let’s dig into the challenges a little bit. What is something you handle that folks outside of rural health care systems wouldn’t expect?

[00:04:39] Jill Shuman: At my current job, I handle mostly things that folks would expect. I maybe work a little more closely with biomed when it comes to troubleshooting and diagnosing equipment issues. I really enjoy collaborating with service engineers to try to get equipment back up and running. But I will say at my prior job, something that I think will definitely surprise folks is that I worked really closely with CT techs daily to personalize cardiac CT scans at the scanner for patients who were slated to get transcatheter aortic valve replacements. Most of that work was spending time listening to the interventional cardiologist and what he needed, working with the technologists to understand their challenges, and eventually getting to the point of training those technologists to do that work themselves. One of the joys of rural medicine is you’re never quite sure what someone is going to need help with. I try to be flexible, and if I see a problem that my team can potentially help with, I try to step up, lend a hand wherever I can.

[00:05:42] Chris St. John: That is very cool. I didn’t realize that you had been doing work like that.

[00:05:47] Jill Shuman: It was definitely different. You don’t hear about too many physicists doing something like that, but I really enjoyed it. It really gave me a great experience with the technologists. And I feel like I had a much greater appreciation sitting at the CT console day in and day out for what the CT techs were doing. Now, a lot of CT techs at my current job, when I talk to them, they’re like, “Were you a CT tech before ?” I’m like, no, but I was doing an awful lot with the CT techs at my last job.

[00:06:18] Chris St. John: That’s so interesting to me because it’s almost counterintuitive to what I would expect, right? When I hear that, it’s very in line with the Medical Physics 3.0 approach, medical physics for every patient—that level of detail and attention specific to the procedure, specific to the patient, etcetera. Stereotypically, in a more rural setting, I would not guess that that would be the level of care being provided. Maybe that’s my own shortsightedness, to be frank.

[00:06:52] Jill Shuman: I don’t think you’re wrong. I think there is definitely that misconception. Within my own experience, it’s a lot of being willing to step up and do that 3.0 work. If someone says something—like, I’m in a hallway with a bunch of different radiologists, and they’ll just plop on down to my office and say, “Hey, Jill, can you help out with this?”—I’ll be like, I don’t know, but I’ll take a look. It’s that being here in person, and not even just in person, just having relationship building with folks. That’s something in rural medicine I’m really able to do. I’m able to form these relationships pretty easily with these physicians to try and provide better care in all these outlying facilities. We can do this kind of work; it just sometimes takes a little more time than maybe I have.

[00:07:46] Chris St. John: Absolutely. Is that part of what drew you potentially to working in more rural facilities? Are you from the area where you’re working?

[00:07:57] Jill Shuman: I don’t think I was drawn into rural health care. I’m just here. I got the job in it, but it’s grown on me; it has for sure grown on me. I love working in a rural setting. I feel like I can make a really big difference within this space. While it’s not often, there are definitely times I clearly—like with that cardiac work—see that my work has a direct impact on patient care in a positive way, and that’s something that’s really important to me. I know patients we treat could easily be my friend, my neighbor, a family member, so I always do my best to ensure anything I’m doing will positively impact my community’s lives even if it’s in the small and quiet way that a physicist so easily can do. It’s sneaky.

[00:08:45] Chris St. John: I have to ask it. Like I said at the beginning, I’ve been hunting you down for a while now because I think you’re smart, you’re competent, capable, and have a great voice that people need to hear. But your initial reaction when I first approached you was that there was a bit of trepidation on your part, I think, whether or not you were comparing yourself to previous academics that we have had. I’m curious, not to turn this into a therapy session, but what do you think it is about folks in nonacademic settings that makes them potentially just feel a bit overlooked?

[00:09:20] Jill Shuman: A big part of it is I often don’t feel like I’m on the cutting edge of medicine. I’m very clinically oriented. My goals are much more focused on ensuring access to safe, quality images for the patients that we serve. I care about the patients that are coming to my hospital today and ensuring they receive the best imaging possible with the tools I have available. When I’m at these conferences when I met you, there’s so many shiny new pieces of equipment and new technologies and techniques being presented, but I often feel disconnected from those because I know it’s unlikely I’ll see some of that for five, ten years, if ever. And so I’m out at these conferences just trying to look to increase access for patients, trying to get the best bang for my buck on equipment. A lot of the more academic folks have more resources, more dedicated time for things like presenting, research, and things that the fancy people do, like podcasts.

[00:10:25] Chris St. John: Fair. Nobody would argue that they have access to more full-time employees, newer scanners, newer technology, software—all of this stuff that is all very helpful in delivering high-quality imaging. From where you’re sitting, what is the hardest part of maintaining high-quality imaging within your setting?

[00:10:49] Jill Shuman: It’s interesting; I’ve worked at a couple places now. I worked in Kansas, and now I’m in Wisconsin. There’s a couple of barriers that are really common between most rural radiology centers.

Number one, not gonna be a big surprise here: budget, finances. We do the best we can with the budget we have, but there’s really only so much we can do. We really have to weigh all of the different options that a piece of equipment can offer and if those options are gonna have high impact. At some of our more rural facilities, we have to balance between lower patient volumes and providing much-needed access for that community at a price that won’t put us out of business. So often, we have to pick more budget-friendly machines that may not have all the bells and whistles, but can provide a broad range of life-saving services.

And then number two, I wanna make sure I mention here, is training. Training is a big one that’s a struggle in rural facilities because we have a lot of travelers, agency techs, locums. That’s not unique to us; a lot of folks are having more and more travelers. And while I do the best I can to contribute to staff education, oftentimes travelers are the ones who are gonna fall through the cracks because they’re just here for a short time. We absolutely need them to be able to provide care, but the cost of that labor plus combined with the lack of that individual’s personal investment in our community can serve as a double-edged sword. I’ve certainly worked with plenty of really excellent traveler techs; I don’t wanna undermine traveler techs, but I’d be naive to say that there aren’t drawbacks to using travelers.

[00:12:31] Chris St. John: Are there specific moments or cases or something where you kind of felt that the most that you can talk about?

[00:12:39] Jill Shuman: I’ve got one example, I think, probably for each here. I’ll start off with budget because I’ve been on break-fix for the past four years, just about. What that means is, for the most part, we can only replace a piece of equipment if it’s no longer repairable. In radiology, this does start to have these unintended consequences, such as higher doses in CT compared to, say, newer equipment, and then we also have the increased downtime and increased repairs. Technology evolves rapidly, and in an ideal world, we’d be able to replace them sooner. Last year, when we finally were able to come off of break-fix and prioritize replacing some of that older equipment, it’s resulted in me being a lot, lot busier, but for the best reasons.

And then for training, I had a location that recently installed new equipment, and they were staffed 100% by travelers. These techs did get to do applications training prior to imaging any patients. But shortly after they started, radiologists started reaching out to me saying they had some kind of major image quality concerns almost immediately. My team had tested the equipment—personally tested the CT—so I was like, I’m pretty sure this equipment is okay, it’s brand new, what’s going on? After I reviewed the images, most of the quality issues were simple things like centering in CT or using size-appropriate protocols on a portable. Fortunately, we caught these problems early thanks to great engagement by our radiologists. It’s just really frustrating because many of these issues should be common knowledge for any registered technologist. Once again, I’m not trying to dunk on travelers. Travelers have to be able to adapt to new places, new technology, new workflows—it’s a lot to take in—but I do worry sometimes that some of these fundamentals start to get missed because of all of these changes they have to do.

[00:14:40] Chris St. John: Absolutely. It also makes me wonder, right, like some of the new machines are helping with centering. If they spend a certain amount of time on a machine that just does it for them, all of a sudden travels somewhere else, gotta do something new, there’s gonna be fall-through.

[00:14:57] Jill Shuman: Absolutely, there is. It’s hard, but I really appreciate that the radiologists clocked it like that. They were on top of it, and they reached out to me, and I was like, oh, easy, I know the answers. Good engagement with radiologists really helps situations like that where we can get the appropriate training when we need it. The struggle is real with some of these travelers.

[00:15:19] Chris St. John: Are you primarily based in one facility, or do you have a couple of locations that you bounce around to?

[00:15:27] Jill Shuman: I travel over my whole system. I personally have a solid, like, two-hour radius, but up to three or four hours with some of our other facilities. We have three physicists within my system, and so we’re kinda located in different locations. They travel to some of the further away ones from me. I get the ones closer to me, and it kinda works out.

[00:15:49] Chris St. John: To flip to the other side of that, I’m curious about patient access to imaging equipment. Obviously, you don’t have a running log of how far every patient is driving. But I am curious what your patient access to getting a scan actually looks like when it comes to scheduling, traveling, insurance.

[00:16:12] Jill Shuman: Travel is a huge challenge here, and I don’t think I realized when I came specifically to this facility how huge of a challenge it would be. In the majority of my region, there isn’t rideshare—no Uber, no Lyft. There’s limited access to public transportation in a lot of these areas. Getting patients to and from appointments can be a huge challenge. Then there’s the added difficulty of how far are they from their nearest medical center to begin with? Then to add on one more layer to that: specialized care. It kinda stacks on stacks on stacks within these rural settings of getting people to hear. One of the coolest parts about Marshfield is that for some of the more specialized care, we do provide some patients and families housing in the area—places like Cattails Place, Cattails Cottage, Ronald McDonald House.

[00:17:08] Chris St. John: And that’s to come for appointments, there’s housing options, or you’re talking about permanent housing?

[00:17:13] Jill Shuman: No, it’s more like ongoing. Cancer care, we have a children’s hospital. If your kiddo is in the hospital, Ronald McDonald helps with that. Cattails Place is if it’s an unexpected surgery and you just need a place to spend the night, that can be kinda nice. They each kinda have their own place. Slowly but surely, some of those things help with access. But all in all, there’s only so much you can do to help mitigate travel concerns.

[00:17:41] Chris St. John: Absolutely. Especially, y’all have enough on your plate just trying to provide the services that you provide, let alone anything else that is required to show up for said services.

[00:17:54] Jill Shuman: Yeah.

[00:17:55] Chris St. John: What about patients who have to travel who are coming back for multiple CTs?

[00:18:01] Jill Shuman: I don’t know if I have an answer to the traveling, but I can certainly speak to high CT utilizers. High utilizers is gonna be a problem everywhere; this isn’t just gonna be rural. Everyone’s dealing with high utilizers, and so I’ll get pinged on some of these cases where a patient has, quote, unquote, “received too much dose from CT”. I’ll do a review, and sometimes every single scan was warranted because the patient is medically complex and requires interval follow-up. Other times, this patient has had a medical trauma where, historically, that CT answered their question, it saved their life. And so now whenever they have a similar issue, they’re like, “Oh, I need a CT right now, this is going to fix my problem,” and then the ER obliges. Even for other patients, it may be that they’re a frequent ED utilizer because they don’t have insurance, because they don’t have housing, or perhaps there’s an unaddressed mental illness, and therefore they’re not getting more chronic conditions treated in a primary care setting. These problems slowly get worse over time, leading to more ER visits, leading to the “donut of truth” CT.

[00:19:17] Chris St. John: I have never heard that term before: donut of truth?

[00:19:20] Jill Shuman: You’ve never heard the donut of truth?

[00:19:22] Chris St. John: I am farther out. You know, I was just talking to my boss about the Dunning-Kruger effect—the more you know, the more you realize you don’t know. Here I am, I feel like I’m really starting to pick up quite a bit on what’s going on in the world of imaging, but then you miss fun things like donut of truth.

[00:19:37] Jill Shuman: Then you miss the fun donut of truth. You’re getting the technicals; you’re missing the fun side.

[00:19:43] Chris St. John: So wait, okay, I can’t not ask additional questions about the donut of truth. Is this a colloquialism that is regional? Is this something that you heard in school? Where does this come from?

[00:19:55] Jill Shuman: Oh, I think in the rise of the internet, it’s just folks like to call it the donut of truth. It’s the magical donut that lets you see inside. Okay.

[00:20:06] Chris St. John: So this is potentially medical imaging internet meme speak?

[00:20:12] Jill Shuman: Oh, yeah. This is internet meme speak for sure. I am of a certain generation that I live on meme speak to some degree.

[00:20:20] Chris St. John: Where are the internet circles where folks are making reference to the donut of truth, and where are younger medical imaging professionals hanging? Seriously, especially for you being somebody who’s kind of further removed physically from major cities and all of this, where are you connecting with other medical imaging professionals online?

[00:20:47] Jill Shuman: Oh, I’d be in, I think, the same place anyone my age is looking at things: TikTok, Instagram, Reddit, what have you. I mean, there’s a Reddit for just about everything.

[00:20:58] Chris St. John: Oh, I’ve been in the medical physics subreddit. I just didn’t think it was that active.

[00:21:02] Jill Shuman: Oh, it’s not. This is mostly a TikTok thing.

[00:21:06] Chris St. John: Okay, cool. And so is there like a serious, physicist-specific contingent? I’ve seen radiology tech TikTok—I’m not on TikTok myself, well, the podcast is, but I’m not. And so, I’ve seen some techs here or there, and then there’s the occasional, “AI is gonna steal your radiologist job,” which everybody sees. But I’m curious, specific to physics, is there like a little community on there?

[00:21:32] Jill Shuman: No, not specifically. I know there are definitely physicists out there on TikTok, and I’ve seen some fun videos. More so I see them on YouTube than I do on TikTok. And so when I find them, they’re fun little gems, but it’s mostly technologists that are out there that are on social media. The few radiologists, I seek them out and slowly, but algorithmically, they come to me.

[00:21:55] Chris St. John: Right, of course. It’s the power of our lord and savior, the algorithm.

[00:22:09] Jill Shuman: Yes.

[00:22:00] Chris St. John: I joke.

[00:22:00] Jill Shuman: I feel that deep in my soul. Yeah.

[00:22:02] Chris St. John: I live to escape the algorithm, always running away.

[00:22:05] Jill Shuman: Same.

[00:22:06] Chris St. John: Now that we’ve had that fun little non sequitur, but I could not help myself, let’s get back a little bit towards equipment. You were talking about break-fix as kind of your status quo. I’m curious, when you were in that specific time, were scanners going down, like, with semi-regularity, and how was it affecting scheduling and access, or not that big of a deal?

[00:22:32] Jill Shuman: I think for the most part, like, there are certainly ebbs and flows with times of the year. Sometimes I don’t know if it’s like a barometric pressure wave comes through, but we’ll have a month where, like, four or five pieces of equipment across the system—fortunately, it’s not all in one location, I’m gonna knock on wood for that—goes down at the same time, but we’ll have one go down here, one go down there. That keeps me busy when it does happen.

For patients when that happens, if there’s more than one scanner—so let’s say it’s a CT scanner that goes down—we prioritize the ER patients, and then outpatients who live closer are gonna be the ones who get canceled first. We do take into account that distance that we were talking about. If they live far away and they’re already on their way, we’re gonna try to squeeze them in. Now if we only have one CT at a site, then we gotta go on diversion. If we think that piece of equipment is gonna be down for a while, then maybe we’ll get a mobile. But that’s kind of few and far between. Most of the time, we’re down for less than twenty-four hours. Biomed gets it back up and running. We get it tested if we need to, and that’s the end of it.

[00:23:45] Chris St. John: Hell, yeah. That’s fantastic to hear. We’ve talked a bit about equipment going down. We’ve talked a bit about lack of access to the shiny, bright donuts of truth that are out there—maybe you’re hanging with some slightly older ones, CT scanners for those who just jumped in the middle of the episode. I’m curious about how financial pressures, reimbursement rates, etcetera, impact the imaging services that y’all are able to offer.

[00:24:11] Jill Shuman: There’s this catch-22 that exists in rural areas where you need reimbursement to function and buy new equipment, but then because you have dated equipment, your reimbursement is negatively impacted and you struggle to buy new equipment that can then get you better reimbursement. I got a couple examples here.

I’ve got an older example from 2018 when reimbursement for computed radiography was cut. Many hospitals were forced to convert from computed radiography to digital radiography, and that costs like 20 to $50,000 per unit. There’s a lot of radiography units out there. Fortunately, it was kind of a slow reimbursement cut that slowly increased over time, but that type of change does disproportionately impact rural hospitals that often operate on thinner margins and have a smaller patient population to over time kinda get that 20 to 50k back.

And then the more modern example, the less direct—and you’ve talked about it a bunch on your podcast—is the CMS CT dose quality measure. Being from a rural system, one of the things you’ve discussed that’s really my primary concern is that older equipment is more likely to have higher doses, and therefore is gonna be more likely to struggle with this metric. In the future, if this does go into place, then it could reduce our reimbursement. And I, as a physicist, I’ve already done as much in my power to get doses as low as diagnostically achievable. If my hospital is unable to purchase new equipment because there’s just not simply enough money because there’s just not simply enough reimbursement, then I found myself in a catch-22.

My potentially controversial take here is that a CT in a rural location, even if it’s older, with potentially higher doses, is saving lives. Like everything, it’s a risk-benefit analysis, and often the benefit of a CT in a rural setting can be life-changing. If you’re having a stroke, you wanna get to the closest hospital you can and have that CT that’s able to diagnose that stroke so we can intervene quickly because time is brain. You know what can’t save lives? A shutdown hospital. Within my own community, in the last couple of years, we had two hospitals shut down. I pass by one of them every single day on my way to work, and it kinda reminds me of the precariousness that we all live in in rural health care. One of these hospitals was the primary source of mental health care and addiction and recovery in my region. It was also one of only two ICUs in the area; it handled 900 births for a year. These patients don’t disappear when these hospitals close. For the most part, my hospital and the other hospital in town do our best to absorb those patients, but it’s inevitable that some of these patients face gaps. If we can do anything to improve reimbursement, these kinda sticks to reduce reimbursement because of higher dose really harm our rural facilities much more than I think folks really realize, especially, I hate to say it, some of the more academic folks because it’s just not on the brain as much.

[00:27:25] Chris St. John: Absolutely. Rather than continuing to harp on challenges, especially with that eloquent soapbox moment, I wanna hear about the other side of the coin. What makes you proud to be working in these more rural facilities? What brings you joy about it?

[00:27:44] Jill Shuman: There are so, so many things that bring me joy about working in these rural facilities. Like, my cousin had to come get a CT for something recently, and he came to my facility. I was like, yeah, I know that you’re gonna get a safe scan because I designed the protocol for the thing that you got. Whenever we are able to purchase new equipment, it’s a huge win for us. Every single piece of equipment that we install is just this giant win.

One of the things I really wanna highlight here is last year, we were the first hospital in Wisconsin to adopt contrast-enhanced mammography. I’ll chalk that win more up to our chief breast radiologist, Doctor Sarah Nielsen, but really being able to add these new technologies when we can, the contrast-enhanced mammography is able to have similar cancer detection to MRI. Patients who can’t get MRI due to claustrophobia, size, or if they have an MR-unsafe implant, then they can now get this instead. So we’re increasing access. Every time we get a new piece of equipment that can increase access or provide additional care that maybe we weren’t able to provide before, that’s a huge win. Especially with the contrast-enhanced mammography, the cost to the patient is much lower than an MRI, and so it’s a win-win-win for everyone.

[00:29:08] Chris St. John: That’s awesome. I clearly had some misunderstandings, right? I think there’s an inclination to make assumptions about rural facilities that do not have debatably the same level of access as academic ones. I’m curious what you think maybe is misunderstood or any misconceptions.

[00:29:29] Jill Shuman: I don’t think there’s any one specific misconception here that I have in mind, but I do understand. Like, there are certainly misconceptions, I think, even amongst patients. Patients think if I come to this rural facility, my care will be less than, say, if I go to the very big fancy hospital down the road that’s three, four hours away in the big city. And, yes, there are going to be certain tools that places in the big city have that we don’t. But in rural medicine, there are people here fighting for your access. There are people here that want to get the best images because we do. Like I was saying, we know that these are our neighbors, our friends, our family members, and so we have a lot of personal investment in making sure that care is quality. This misconception that if you go to a rural facility, you’re gonna get chucked out back in this rinky-dink CT that’s 30 years old and, like, no.

[00:30:34] Chris St. John: It’s got, like, a pull-start engine.

[00:30:39] Jill Shuman: We gotta kick the fan on. That’s not what it is. We do keep up with things, I swear. Sometimes things are a little tight, but we’re doing the best with what we can, and we always are making sure that images for patients are as good as they can. Our radiologists, our physicians, we’re all fighting for our patients. That’s the beauty of rural medicine is that we all want what’s best for patients here and I suppose everyone does. I don’t wanna say, “No, those academic physicists, they don’t care about that”. No, it’s just there is a personal aspect to being in some of these smaller communities and someone walks in. I was talking to a manager the other day, and she was training someone in mammo. The person she was training, she’s like, “Do you know everyone who comes in to get a mammo?” and she was like, “Well, I know a lot of them, but sometimes it’s just knowing how to talk to folks”. I just had to laugh. I was like, yeah, you probably do know most of them, though.

[00:31:36] Chris St. John: Well, and it’s such an interesting and such a different dynamic from any big—like, I’m several hours north of New York City, but I think about New York City, and everyone there is anonymous, right? There’s millions and millions and millions and millions of people, but they’re dehumanized into the sea of people that make up the city, right? There’s something powerful to me.

[00:32:03] Jill Shuman: It’s a different kind of personalized medicine. We all talk about personalized medicine. It’s a different kind of personalized medicine and realizing that behind every image there is a patient, and forming those communal bonds and being out in the community. The area I’m in, I’ll be honest, is a bit bigger of a city within my system, but going to all of these rural centers, you start to kinda see it.

[00:32:29] Chris St. John: Absolutely. And I think to some degree, when I talk to folks, the term patient itself can very often begin to be slightly dehumanized in a way, right? Like, when patients become statistics, there’s a bit of a separation that happens there, which is nice to hear about that gap not always existing.

[00:32:54] Jill Shuman: Absolutely. I think that’s 100% correct. And that does happen when I’m reviewing CT doses and I’m looking at hundreds of patients or thousands of scans. But I always try to ground myself back in every image is a patient, and any patient could be a family or a friend. Keeping that level of “we’re here for patients, that is the point,” always keeps me grounded in what I’m doing.

[00:33:21] Chris St. John: Hell, yeah. What sort of changes—big changes, small changes—do you think would really start to make a difference in your community and in these types of facilities?

[00:33:36] Jill Shuman: Resources. If I could shout it from the rooftop: resources. No more cuts to reimbursement. Less expensive equipment. Like, these cuts to reimbursement, they’re not helping us. Like I was talking about with that CR-to-DR example, we need incentives, we need grants, we need coupons. I don’t think coupons are an option here, but reducing the price of some of the more modern equipment would have such a huge impact in rural areas. Recently, my hope is that the rural health transformation program is gonna help with some of that financial infusion, but I personally need it to go to like radiology training programs. I need it to go to imaging technology. And so I have my own kind of horse in that race of things I want money to go to, but healthcare is especially rural healthcare is always going to be needing more. Technology is always going to be advancing, and we’re always gonna need more resources.

Even from the academic side, sometimes I’m out here trying to reinvent the wheel that I know other physicists have done. I’ll reach out to a colleague and say, “Hey, can you help me with this protocol?” and they’re unable to due to legal concerns. They can’t share that with me because there’s a legal potential liability issue. So, oftentimes, I am looking to like the ACR, the AAPM for resources, but some of those resources for just physicists are also out of date. So like CT protocols on the AAPM used to be a really, really good resource for me because it had all the different makes and models. But now that resource is about ten years old, there’s new makes and models. And I always use that as my jumping-off point of like, okay, these are protocols, the AAPM has reviewed them, I have confidence that these are okay. Now I’m just out here trying to navigate these waters on my own with limited support from applications if I can get it. And so just more resources. I can’t harp on it enough from anyone out there who’s listening. It’s more resources, more funding, more money, coupons… I’ll take it all.

[00:35:56] Chris St. John: Hell, yeah. Well, honestly, Jill, I mean, I feel like that’s a beautiful place to kind of wrap things up today.

[00:36:03] Jill Shuman: Absolutely.

[00:36:04] Chris St. John: Jill Shuman is a diagnostic medical physicist with the Marshfield Clinic. Jill, it has been so much fun having you here today. Thank you so much for joining us.

[00:36:12] Jill Shuman: Thanks so much for having me. This has been a real joy getting to chat with you. I appreciate your time.

[00:36:17] Chris St. John: And we’ll talk soon.

[00:36:18] Jill Shuman: Awesome. Thanks.

[00:36:20] Chris St. John: Frame by frame, Rethink Imaging is brought to you by Imalogix. Here, you’ll find engaging interviews with thought leaders, experts, and patients sharing stories that showcase the transformative power of medical imaging. To discover how Imalogix is rethinking imaging in health care, visit or wherever you listen. And from all of us here at Imalogix, thanks for tuning in.

Questions from This Episode

Why does older imaging equipment threaten rural hospital reimbursement?
Older CT scanners tend to deliver higher doses than current models, and measures like the CMS CT dose quality metric tie reimbursement to dose performance. Jill has already pushed doses as low as diagnostically achievable on her existing fleet, so the remaining gap can only close with new equipment. If penalties cut the revenue that would fund those purchases, the hospital is stuck in a loop it cannot buy its way out of.
Are traveler technologists a risk to image quality?
They can be. Jill saw a fully traveler-staffed site produce quality problems on brand-new, physicist-tested equipment within days of go-live, with root causes as basic as patient centering. She is careful to say many travelers are excellent, but constant changes in sites, scanners, and workflows mean fundamentals slip, and short-stay staff tend to fall through the cracks of local training programs.
Is imaging at a rural hospital worse than at a big academic center?
Jill pushes back hard on that assumption. Big-city hospitals do have tools rural sites lack, but her teams design protocols knowing the patient on the table could be a neighbor, a cousin, or a friend, and radiologists and physicists fight for quality on every install. Her broader point: an older CT that diagnoses a stroke in minutes beats a newer one that is three hours away, because time is brain.