Rethink Imaging

EP 30 • October 23, 2025

The Six Pillars of Quality in Medical Imaging

Featured Guest

Dr. Summer Kaplan, MD

Associate Professor of Clinical Radiology, University of Pennsylvania School of Medicine; Pediatric Radiologist, Children's Hospital of Philadelphia • Children's Hospital of Philadelphia

Listen Now38 min

Also on:

Let's Talk

Beyond dose

Ask us what your imaging data can actually show you.

Start a Conversation

Share This Episode

Subscribe to Rethink Imaging

Dr. Summer Kaplan returns to Rethink Imaging to walk through the six pillars of quality the Institute of Medicine defined more than twenty years ago: care that is safe, timely, effective, efficient, patient-centered, and equitable. She explains why safety in radiology goes well beyond radiation dose, from MRI projectile risks that put anyone near the magnet in immediate danger to confirming the right body part gets scanned. She also breaks down how radiation risk actually works: the dose a machine produces, the fraction a patient absorbs, and the individual genetics that decide whether damaged cells repair themselves or become a problem years later, which is why children get extra caution.

The conversation gets candid about what departments can and cannot measure. Turnaround times and dose are easy to track, so they get tracked. Patient-centeredness gets measured through surveys that mostly angry people answer. Equity shows up in research like the ER study that found white children received head CTs for headaches more often than Black or Latino children. And effectiveness, the pillar Kaplan calls radiology’s biggest struggle, depends on orders radiologists do not control. Her advice for referring clinicians: name the diagnosis you are worried about, not just the symptom, so the right study gets done the first time.

Host

Chris St. John

Host, Rethink Imaging • Imalogix

Featured Guest

Dr. Summer Kaplan, MD

Associate Professor of Clinical Radiology, University of Pennsylvania School of Medicine; Pediatric Radiologist, Children's Hospital of Philadelphia • Children's Hospital of Philadelphia

Watch the Episode

Key Takeaways

The six pillars come from an Institute of Medicine group in the early 2000s: quality care should be safe, timely, effective, efficient, patient-centered, and equitable. Departments default to tracking safety and timeliness because those are the easiest to measure.
MRI safety is a right-now risk, unlike radiation’s long-term cancer risk. Kaplan cites real events: hospital beds pulled across the room into the magnet, and a loaded gun that made it into a scan environment, discharged, and shot its carrier in the foot.
A single diagnostic scan poses close to negligible risk to an individual patient. Risk climbs with repeat imaging and is higher in children, whose active cell replication and longer lifespans give radiation more opportunity to cause harm.
Imaging volumes are growing an estimated 6 to 8 percent a year without matching staff growth, which makes radiologists the bottleneck and turns maximum efficiency into a recipe for burnout and errors.
An ER study found white children with headaches received head CTs more often than Black or Latino children, the kind of inequity that stays invisible unless someone looks for it.

Full Transcript

Summer Kaplan Transcript

[00:00:00] Chris St John: When I think about health care, there’s health and there’s care, and care is not efficient. You take time with people. And if you engineer your system for maximum efficiency, you’re not taking care of people. You’re not pausing to give somebody a little extra time when they need it on the patient side. On the radiologist side, if you’re being super efficient, you’re reading studies as fast as you can, and that’s a recipe for burnout. That’s a recipe for making errors. So I think efficiency is a little bit of a Goldilocks measure where you don’t want too much, you don’t want too little. You gotta find just the right spot where you’re not wasting time, but you’re also not rushing.

[00:00:40] Summer Kaplan: Welcome to Frame by Frame Rethink Imaging, a podcast by Imologix. 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 Frame by Frame Rethink Imaging. We are thrilled to welcome today, once again, doctor Somer Caplan. Doctor Caplan is an associate professor of clinical radiology at the University of Pennsylvania School of Medicine and a practicing pediatric radiologist at the Children’s Hospital of Philadelphia. She has over a decade of experience in pediatric imaging with a focus on quality improvement, and she’s become a key voice in advancing safer, smarter imaging practices. Doctor Kaplan previously came on an episode to talk to us about gonadal shielding in X-ray, but then we did a follow-up episode with doctor Asanshameh where we were talking about, like, quantification of quality, which led to a conversation between the the benefit of imaging. And I’m curious, like, to you, what is the most important lens? Is there a most important lens to evaluate the benefit of imaging today?

[00:02:01] Chris St John: Yeah. Thanks, Chris. It’s great to be back with you. So I think that the benefit of imaging is is tremendous. I mean, it’s a huge benefit to patients, to clinicians who are trying to find answers for diseases, conditions. I mean, I think that the huge growth in the use of imaging in the past thirty years, forty years, hundred years, like that speaks for itself as to how much people value being able to use medical imaging. We’re visual creatures. We like to literally see what’s going on. So having a picture that shows the inside of the body is super valuable for patients, for clinicians. So I think the growth in just the use of imaging speaks to its benefit.

[00:02:42] Summer Kaplan: And, like, what is the lens that you think about that benefit? Like, is there a particular framework when you’re thinking about it?

[00:02:50] Chris St John: Yeah. I mean, so you really think about what does it add to patient care. Patients come to see the doctor, to the ER with a problem, a question, and it’s a job and the goal of the care team to provide answers and then to provide help for whatever’s troubling the patient. So, you know, in diagnostic radiology, we’re a huge part of providing answers. Is there pneumonia or not? Is there appendicitis or not? Is there cancer or not? You know, and having a picture proves one way or the other in many cases, whether the problem is there or not. And so the benefit to peace of mind if you can rule out a cancer, the benefit to helping patients get better if you can diagnose an appendicitis and then send them on for appropriate treatment. So really how does imaging help the patient either be put their mind at ease or get better? That’s really kind of the lens that you think about in terms of how to say what the benefit of imaging is.

[00:03:49] Summer Kaplan: Right. And so I was, like, far be it for me to jump in and get ahead of you. And are we saying pillars of quality? Is that the terminology you like to use?

[00:03:57] Chris St John: Yeah. So the pillars of quality, which I didn’t make up, I wish I could take credit for it, but it was developed in the early two thousands, over twenty years ago now, by the Institute of Medicine, which is a large group of doctors and policymakers thinking about how to improve health care. Health care is always in crisis of some kind or another. And so at that point in time, it was really how do we migrate to a digital world? How do we provide the best care for the most people with limited resources? You know, like, in The United States, we have more resources than most places, but it’s always limited. There’s always, you know, a limit to what you can do. So the this focus group at the Institute of Medicine came up with these six pillars of quality. So quality care should be timely. It should be effective. It should be efficient. It should be safe. It should be patient centered, and it should be equitable. So those are lofty goals, and we all want that. And so the question is that we’ve been struggling with for the past twenty years since these pillars were sort of established and taken up by the medical community is how do we do that? How do you actually make something patient centered? How do you, I mean, making things safe and timely is often what we focus on because it’s easier to measure. Measuring effectiveness is super hard. So these pillars are sort of, like, guiding principles that we use, but how to put them into practice is is challenging.

[00:05:23] Summer Kaplan: Absolutely. I mean, I would love to just briefly touch on all six pillars if that’s okay.

[00:05:28] Chris St John: Well, yeah. Yeah.

[00:05:29] Summer Kaplan: So, I mean, like, let’s start off with those which are easier to measure and quantify. So they say safety first. So safety first. You know, I know we track dose, and we have all of these things that we measure that theoretically point back to safety. But I’m curious specifically, like, beyond dose, how should we be thinking about safety?

[00:05:53] Chris St John: So I think you’re right to mention dose because that’s the first thing to people’s mind when you think about safety and medical imaging is the radiation. And you’ve had several podcasts about radiation and those are there in the record. Really, when you’re thinking about a safety system in radiology, it should be ideally completely invisible to patients. Right? They should never know that there’s a safety system in place because they should never have events that are unsafe. So this is something that a medical practice, a radiology practice wants to have running constantly to prevent any safety events. So in radiation, we do things like dose tracking. We have the equipment for CT, for x-ray, for fluoroscopy has a lot of safety mechanisms built into it. So the the vendors have helped us out a lot with how to maintain low doses and prevent accidental high doses. But outside of radiation, the other big safety concern in radiology is around MRI safety. And so MRI is magnetic resonance imaging. It’s super powerful for seeing what’s going on inside the body, especially in the brain or in the skeletal system, but it’s a super powerful magnet.

[00:07:00] Summer Kaplan: Oh, yeah. There was a horror story recently. Yeah.

[00:07:03] Chris St John: Yeah. Occasionally, there’s huge safety issues, right, that pop up that they’re so egregious and so scary. They make the news where you see a hospital bed flying across the room pulled into the magnet. Anything becomes a projectile around the magnet, anything ferromagnetic. I mean, there was an event where someone somehow got into the scan environment with a loaded gun, which discharged and shot them in the foot. So that should never happen. That’s an example of a safety event in MR, and it it no patient was harmed, but the person carrying the weapon was harmed. So around MR, it’s a completely different safety environment in part because you’re worrying about real time right now problems. Like, is there a projectile that could fly into the magnet and harm a patient? Resid radiation, it’s all long term. Like, could this scan now lead to a higher risk of cancer fifteen years from now? Like, it’s very removed. But MR, it’s like right now is could there be harm to a patient? And it’s the nature of radiology that there’s so many people coming in and out of our imaging environment. It’s patients, it’s hospital staff, it’s radiology staff. And so making sure that everybody knows how to be safe in the MR environment, it’s a big task that we struggle with. So it’s MR safety, and then I think the other safety issue is around just making sure that patient information is kept confidential, making sure that you’re doing the right body part, wanna scan someone and find out, oh, that was actually the left leg we meant to scan. So scanning the wrong body part is a safety issue as well.

[00:08:32] Summer Kaplan: It’s funny. It makes me think this is a non sequitur, but there’s a joke in the TV show 30 Rock where there’s a kidney transplant happening, and the doctor writes it wrong on the sheet. It’s like, oh, no. No. No. I’m not giving him the kidney. He’s giving me the kidney. And he pulls out the form, and he goes, no. No. No. No. I don’t need to change it. I’ll just remember it’s the opposite. And he looks at the form, and he goes, opposite. Opposite. And later in on the episode, they’re like, no. No. No. He’s giving me the kidney. And he’s like, that’s not what this form says. It’s That’s

[00:09:01] Chris St John: Fantastic show.

[00:09:02] Summer Kaplan: Yeah. So good.

[00:09:03] Chris St John: Doctor Spojeman. Right?

[00:09:04] Summer Kaplan: Yes. Exactly. One of, like, the best doctor characters in my opinion.

[00:09:09] Chris St John: Yeah. So don’t do that. That’s an example of unsafe practice.

[00:09:12] Summer Kaplan: Yes. Not being a doctor’s pajama.

[00:09:14] Chris St John: Yeah. And

[00:09:15] Summer Kaplan: I I know we kind of glossed over Dosh, but I wanna touch a little bit on, like we talk about cancer risk as this long term statistical hypothetical, however you wanna phrase it, whoever you are, whatever your views on it are, like, how do you weigh the safety trade offs between over imaging, under imaging, especially in, like, a pediatric setting?

[00:09:36] Chris St John: That’s a great question. And some of your other speakers probably have gone into this a little bit, but there’s really two different types of radiation risk. There’s the long term cancer risk, which is what people worry about. That’s what makes the news. But there’s also a more immediate risk if at extremely high doses delivered. You can get radiation burns. You can get cataracts. So there are some things that are a little bit more immediate with radiation. And in diagnostic imaging, we we’re like a 100 times, a thousand times below the levels that cause that kind of harm. So when you think about how to balance the risk and the benefit to each individual patient, the risk of a single scan for diagnostic purposes, you know, you have headache, like, do you have a brain tumor, a scan, a head CT for that purpose? The poses almost negligible risk to an individual person. I think we start to worry when a person gets many scans. You know, if you are getting a head CT every day for two months, you know, your risk is gonna increase. But then you balance that against, well, maybe you’re in the ICU with traumatic brain injury and those scans are keeping you alive because they’re checking to make sure that your intracranial pressure and anatomy is normal or or is as normal as it can be. So I think that for each individual patient, it’s kind of a different a different calculus of how the benefit outweighs the risks.

[00:11:03] Summer Kaplan: Yeah. And I’m trying to decide if I wanted to ask a question about, like, measuring that, but, I mean, it feels incredibly nuanced.

[00:11:10] Chris St John: I think yeah. Doctor Sameh, who you had on earlier, uh, gave such a great, like, analogy of measuring radiation, and it really doesn’t give you a sense of the value of the scan. Right? Like he spoke about measuring calories doesn’t tell you how good your food is. And so measuring radiation doesn’t tell you how valuable the scan is. Measuring radiation is tricky because you can measure how much the machine is producing, but how much of that the patient receives, like they don’t receive all of the radiation, right? There’s some that falls around them. So they receive a fraction of what the machine produces. And then only a fraction of that radiation is going to cause the kind of cellular reaction that could predispose to cancer. So of the radiation that reaches the body, only a fraction of that may pose a cancer risk. And then the other, like, wild card is each individual person has different genetics, different risks for cancer. And so in one person, you get, say, five of these cellular reactions and they can’t repair them and they go on to develop cancer. And somebody else, their body eliminates those cells and they don’t develop cancer. So it depends on individual genetics. It depends on the body part being irradiated. Right? So some body parts are more sensitive. Typically, those with higher cell turnover, like, your gut lining is fairly sensitive because the gut lining is always being replaced. There’s always new cells coming in. And that’s similar to why we worry in children because children are growing, so they’re always making new cells and their cells and their genetic replication systems are just a lot more active. And when you have genetic replication, that’s where the radiation can potentially cause harm. So that’s why we worry more in children. And also because children have a longer lifetime over which to develop a cancer. If you give radiation to an 85 year old, there’s a good chance they might die of something else before they would develop a radiation really good cancer. But if you give that same radiation to a five year old, theoretically, they have eighty more years of which to develop the cancer.

[00:13:13] Summer Kaplan: Right. Which, like, I do not believe that is what you mean by timeliness, but I feel like that feels like a really good moment to transition to the next pillar where we talk about timeliness, which, like, to some degree, feels self evident and self explanatory. Like, you know, get the work done. But I’m trying to even figure out, like, the best way to ask a question about timeliness as a pillar of quality.

[00:13:39] Chris St John: I can tell you some of the challenges we face with timeliness, and also it depends on whose perspective. Right? So for patients, when you talk about timeliness, you want to arrive at your appointment and be seen at the time of your appointment. You don’t wanna be waiting around for an hour when you were supposed to be seen an hour ago. And then you also want your results to be timely. Right? So you get your mammogram. You wanna get the results as soon as possible. You don’t wanna wait three weeks for your results. So So from the patient perspective, waiting time and then the answer, the report is those are often the two key measures. I will say for some longer exams like MRI or somebody’s maybe laying in the scanner for an hour and a half for a complicated exam, like that can also be a timeliness issue. Like making the scans as short as possible benefits patients. It also benefits other patients because the shorter the scans, the more patients we can see. So when you’re you know, long exams can lead to longer delays and care for everyone. And for ordering clinicians, it’s similar. I mean, the ordering clinicians are not as concerned maybe about the wait time. They don’t experience that, but they want results in a timely way. And for radiologists, we’d like to get through our work. So if we have a long list of things on on the, you know, that we have to read, we try to be as timely as we can. And so making it possible for us to get the exams read in the time, like, often there’s a goal of certain turnaround time for reads. Being able to get our exams done in that time is what we’re interested in. And making this all work requires systems to support it. Right? You have to have staffing. You have to have check ins for in the clinics. You have to have, you know, enough radiologists to get through the work. So there’s it’s a whole systems, you know, way of thinking about how to get people their imaging is in a timely way.

[00:15:19] Summer Kaplan: Right. Which I mean, especially nowadays where everybody is probably pretty understaffed to some degree, and exam volumes are going up, up, up, up, which has benefit to it.

[00:15:30] Chris St John: Yes. It’s a very popular product. We have

[00:15:32] Summer Kaplan: Yes. Right.

[00:15:33] Chris St John: Yeah. It’s funny. I go to these meetings, you know, where we try to figure out, like, how do we deal with this growing demand for our services? And we try to figure out ways to decrease the demand for our services, which is wild because, like, who wants to decrease their market? Right? But it’s we’re limited. We can’t scan everybody all the time even though that might ultimately help.

[00:15:54] Summer Kaplan: And, like, I think I saw something published, you know, they estimated scans were going up, like, six to 8% a year, which I feel like that might even be a little low. And it’s not like y’all are getting six to eight percent more staff here.

[00:16:08] Chris St John: Right. For sure. Yeah. It’s difficult. I mean, our digital systems are so efficient. Right? We’re very efficient at getting scans done, so it’s easier to order scans and to perform scans and then try to keep up with the demand with the read.

[00:16:21] Summer Kaplan: Yeah. So, I mean, like, unless you have any other touch points on timeliness, honestly, I’d love to kinda, like, gloss over it a little bit. Because, like, while we’re talking about that, we’re talking about patient volumes. We’re talking about capacity in some sort of context. The next pillar that I wanna talk about, patient centeredness, I feel like really ties into the narrative at this point. So, like, what is a patient centered approach to imaging even look like?

[00:16:45] Chris St John: Yeah. So that’s, I would say, one of the most important pillars, and other pillars all lead into that. So in order to center on the patient experience, you want them to not wait around. You want them to not have a lot of distress when they’re in the scanner. In pediatrics, especially working with kids so that they’re not afraid of the scans is something that we do that would add into patient centered care, having child life services, explaining to people what to expect for the scan. So it’s really like the care part of health care. How do you make sure that patients and families feel welcome, feel like they’re in good hands? And so that’s ultimately what we are trying to do, but how to measure that and how to ensure that we are providing patient centered care is one of the more challenging things to measure. And we try to measure it with surveys. People if you go to the if you’ve been to the hospital or been to the doctor’s office, people often get an email survey. How was your experience? And who has time to read emails and fill out surveys? People who are angry. People are angry. And so you don’t get necessarily the most realistic feedback. You get kinda biased feedback.

[00:17:47] Summer Kaplan: You get, like, worst case scenario feedback, I feel like.

[00:17:50] Chris St John: I mean, it’s good to know. It’s good to know, but it’s not a really good representative measure of how we’re doing. So it’s a struggle, and it is the most important thing that we do. Some hospitals and some practices will have, like, uh, patient and family care advisories. So sometimes we do things like that to try to get feedback and make sure that our imaging practices are serving that need for patients.

[00:18:13] Summer Kaplan: I mean, I’m curious, like, obviously, patients. I feel like it’s so often on this show and and just in general in health care talking about patients as a monolith. Right? It’s like, obviously, they are not. They are humans, which were a diverse little group. But I’m curious, like, with the patients that you interact with, like, do you feel overall, like, they are, like, internalizing and, like, appreciating the value of being imaged to some degree?

[00:18:42] Chris St John: Yeah. That’s a good question. So I think yes and no because patients are diverse.

[00:18:46] Summer Kaplan: Tell me about it. Yeah. In with the understanding that non monolithic patients. Right? Yeah. And I

[00:18:52] Chris St John: can give you a couple of examples on either side. A lot of times, patients arrive in the ER asking for imaging. Like, they’re there because their head hurts and they want a CT. And so for patients who can and I’ve actually been that person. Like, my son had headaches when he was seven, and I’m sure it was from just looking at his iPad, you know, six inches from his face all day. But, you know, you worry. So I call his doctor, and she listens to the story, and she’s like, yeah. This doesn’t really warrant an a head CT, but just, you know, do this, do that. And even as a radiologist knowing that she’s following appropriate clinical guidelines, I was like, but I want a CT. Like, I wanna know what’s going on. I wanna see what’s what’s in his head. So it’s even me as a radiologist has you know, I have that desire to see what’s going on, to see imaging. And so I think that’s true for many, many patients and families who come in with a problem. They wanna see the body part. They wanna see what’s going on. And so for them, like, the benefit to getting imaging is inherent. But then you also have, you know, in pediatrics, especially with kids who are too young to understand what’s going on or kids who are developmentally delayed and, you know, you really can’t explain the situation, It can be scary, especially things like MRI where you’re in a dark hole.

[00:20:06] Summer Kaplan: I had an MRI last year. It was horrifying.

[00:20:09] Chris St John: Yeah. And you it’s hard not to be claustrophobic in there, or they come to fluoroscopy and we’re asking them to swallow some disgusting liquids so we can, like, look at the esophagus and their stomach and, like, you can’t explain it, so they don’t wanna do it. So that can be a challenging part of trying to provide patient centered care. Like, if the patient needs the exam in order to rule out a perforation or a tumor or something, but they don’t want it, How do you work around that? That’s something that can be challenging in patient centered care.

[00:20:36] Summer Kaplan: Well right. And it feels like to some degree, like, especially with peds or you said, like, some children who might be developing a bit more slowly. And on top of that, hearing you talk about being a mother with a child and wanting to get them imaged, it’s like it’s not just patient centered care. Right? To some degree, it’s family centered care. And how do you walk that balance involving parents of patients in these imaging decisions, especially if there’s, like, diagnostic uncertainty?

[00:21:04] Chris St John: Yeah. I mean, I think the way I try to approach it is to understand exactly what the concern is. And for parents, often it’s radiation is the concern. And so I try to explain how low the risk actually is because there’s so much scary news about kind of outlying unusual, like one in a million cases that the vast majority of imaging is so safe. And I don’t know if this is effective, but I tell people sometimes that the imaging is, like, one of the safest parts of your day today. Like, your drive to the hospital was a 100 times more risky than this exam you’re about to have. Uh, it makes them feel bad, feel scared about leaving the hospital, but it’s true numerically.

[00:21:43] Summer Kaplan: That’s what I do on airplanes. I like as a kid, I loved to fly. But as an adult, I have developed some intense fear of flying, and I spend the whole time in the airplane being, like, the drive to the airport was more dangerous. The drive to the airport was more dangerous. Like, statistically, I am much safer here. But, I mean, for me, that approach does work decently well.

[00:22:06] Chris St John: Yeah. So trying to understand what the concern is. And sometimes if if a kid is just so agitated and in so much distress, you just can’t do the scan. You don’t wanna tie somebody down and force them to get a scan. That’s not okay. So do you reschedule? Do you bring in child life services? Do you need sedation? Like, you kind of work through the problem. So sometimes, you know, patient centered care means you can’t do the exam as requested at that time. We have to work around and maybe try a different time.

[00:22:34] Summer Kaplan: Moving on to equity. I think, especially in 2025, this is a very pervasive topic to touch on because, I mean, we know inequities exist in imaging across the country. Right? But, like, what are we not really talking about when it comes to equity in terms of quality?

[00:22:53] Chris St John: Yeah. So equity in general just means that the same solution is not gonna work for everyone. We’re all widely variable. And so with systems approach to providing equitable care in radiology, you just want to make sure that there aren’t certain populations of patients that are being treated differently, whether that’s having access to care. If you have 18 imaging centers and one of them has lower availability of appointment times or older imaging that breaks, like, the patients in that who go to that imaging center are not receiving the same care as other patients.

[00:23:32] Summer Kaplan: Right. And if they’re on older equipment that is breaking more, like, aren’t they quite probably getting higher dosages as well if some of this older equipment is what’s taking the images?

[00:23:42] Chris St John: Right. So sometimes those inequities can be geographically based. We worry about kind of your historical race based and socioeconomic, poor people getting worse care. You can also conversely see affluent people getting excess care. So there’s that aspect that also happens. And like so many of these pillars of quality, it’s hard to measure because people are so varied and we collect a lot of data in the medical system. It’s just there’s so much data. Who has time to look at it all? And so in research institutions, there are often staff to look at it. And so there are people whose academic focus is studying things like that. Like, are we systematically treating certain populations different than others? Unintentionally, usually? I mean, nobody’s intending to disenfranchise people, but it just happens. If you’re not alert to it, it can just happen without your noticing. So you have to pay attention and really look for the information.

[00:24:39] Summer Kaplan: Yeah. Have you seen any efforts or attempts either by you or by others, like, in an attempt to measure and track equity, like, within specific departments?

[00:24:50] Chris St John: Yeah. So in radiology, I think it’s a bit challenging for us because we get requests from clinicians. So we are the decision makers in who gets imaging. We just we do the imaging. But when it comes to, like, utilization of imaging, there are people who look at equities and inequities in utilization of imaging. And there are clinical guidelines around use of head CT for headaches. And so there was a paper, and

[00:25:15] Summer Kaplan: I hope I’m hope I’m not gonna misquote this, but there

[00:25:17] Chris St John: was a paper in the last few years looking at use of head CT in children with headaches in the ER. And like, is there a difference in terms of race, how often CTs are done? And it found that white patients are getting CTs more often than black patients or Latino patients. And so that’s identifying an inequity. And then the next question is, are the patients of color being under imaged or the patients who are white being over imaged? You know, so that’s a lot of research is like that. You you ask a question and then it just raises, you know, 18 more questions. But identifying race based differences in how you’re providing care is the first step. Because if you don’t look, you don’t know, and then you can’t address it.

[00:26:03] Summer Kaplan: Yeah. And how do we move from not just identifying inequity, but, like, how do we start building systems that can address closing that gap?

[00:26:12] Chris St John: Yeah. I think well, there are clinical practice guidelines that should be used, and that’s always challenging too because everybody’s different. Maybe you’re someone who doesn’t fit the guidelines, but ensuring that this kinda common practice guidelines that are used. It’s interesting. In in radiology, we don’t know people’s race. Right? I see an X-ray, a chest X-ray. X-ray. Like, I have no idea if you were black or white or if you’re an immigrant or not. Like, we just look at the picture. So in some ways, radiology is really blind to a lot of those things. As a radiologist doing the scan, I mean, the patients may have a different experience getting scanned, like the experience of coming to the hospital and how they’re treated at the front desk or, you know, there’s so many steps that the patients go through that I, as a radiologist, don’t really see or influence at all. But in terms of reading images, it’s very blind to all those factors.

[00:27:02] Summer Kaplan: Yeah. It’s funny. I hope this joke is not inappropriate, but I think about, like, the folks who say, like, oh, I don’t see race, which is problematic in its own sense. But you literally do not see race. Right? Like, you literally don’t. You’re looking at a scam.

[00:27:17] Chris St John: You could guess based on a name, but, like, you could be wrong. You have no idea. Oh, it’s literally black and white.

[00:27:23] Summer Kaplan: It’s like, no. No. No. I literally don’t see race. Sorry. It’s maybe off color joke, but it’s interesting nonetheless.

[00:27:31] Chris St John: Yeah. So I think when you talk about equities in radiology specifically, it’s a lot of it’s the patient experience that it’s not really the medical part of the practice, but it’s everything around that.

[00:27:41] Summer Kaplan: Yeah. Let’s hit efficiency. Is there such a thing as too much efficiency when it comes to imaging?

[00:27:48] Chris St John: I think so because, you know, when I think about health care, there’s health and there’s care. And care is not efficient You take time with people. And if you engineer your system for maximum efficiency, you’re not taking care of people. You’re not pausing to give somebody a little extra time when they need it on the patient side. On the radiologist side, if you’re being super efficient, you’re reading studies as fast as you can, and that’s a recipe for burnout. That’s a recipe for making errors. So I think efficiency is a little bit of a Goldilocks measure where you don’t want too much, you don’t want too little, you gotta find just the right spot where you’re not wasting time, but you’re also not rushing.

[00:28:29] Summer Kaplan: Right. And it’s like, we need to be more efficient, but efficient at what? There’s all these different pieces. Right? Like, efficient at getting the scan done, efficient at reaching a diagnosis, efficient at serving the patient. Like, the balance feels, uh, tenuous at best. Yeah.

[00:28:44] Chris St John: And I think the best way to think about it is just just not having a lot of waste in your system. Like, so patients shouldn’t have to fill out the same paperwork twice. They should fill it out once, and then we have the information. You know, I shouldn’t be reading studies and bouncing back and forth and being distracted in a way that makes it hard for me to focus on my work. Right.

[00:29:06] Summer Kaplan: And, you know, you touched on, like, efficiency being focused on to the point where it maybe starts to impact care negatively, like, have you ever come across a system that, like, just started getting way too efficient that they just started missing the point? Right?

[00:29:23] Chris St John: Yeah. I mean, outside of radiology, I think this is the most common patient complaint, right, is the doctors don’t take time with them. The doctor is typing on their computer, barely making eye contact. It’s a ten minute visit, and how can you get care in that time? In radiology, well, I think the volume of studies is an example of how we’re so efficient at taking an order, making an image, and then we have all these we, the radiologist, become the bottleneck in being able to read the studies in a timely way. And I think as a radiologist reading studies, you can be you know, if your system is designed for efficiency to get as much work as possible in the shortest amount of time, that’s not a good way to work long term. It’s good for the bottom line, but it’s not good for the radiologist. It’s not good for the patients because you don’t take time to look at the study and ask some questions and read about the patient.

[00:30:16] Summer Kaplan: Yeah. And I wanna respect your time today. So finally, touching on effectiveness. Right? How do you define whether an imaging exam was effective? Right? Is it just diagnostic accuracy?

[00:30:28] Chris St John: Yeah. So aside from patient centeredness, I think effectiveness is the most important pill well, safety. Okay. They’re all important. But effectiveness is really the core of what we do, and it’s so hard to measure how effective you’re being. And so I think, yeah, an accurate diagnosis is ultimately the most effective thing, but it’s often true that the exam may not give you a single diagnosis. You may have, you know, you see a thing and then you have a range of, like, three different things that could be. You need more information. So it’s still effective, though. I think if you have an imaging exam that helps direct the patient and the clinical team down the pathway, You rule out some things, you leave some other doors open. That’s effective when you’re changing care based on the exam. It’s not effective if an exam is done, I don’t know, for urinary tract infection and it’s a known urinary tract infection and we do an exam to check for urinary tract infection. Like that’s, we knew that already. Maybe the question is deeper, like how far up does it go? Is there any complication? But if the exam is just to look for something that’s already known or if the exam is ordered and it really can’t assess the question. I’m trying to think of an example of that. Yeah. So if the exam is ordered and it like, so in pediatrics, we do ultrasound to look for appendicitis, to spare radiation, but, you know, pediatrics go from age zero to 18. And so some of our older adolescent patients are adult size, and they don’t use ultrasound in adults because the larger the body, the harder it is to use ultrasound to see deep into the tissue. So if we have a larger adolescent patient and we use ultrasound for appendicitis evaluation, it’s not effective because it’s not the right tool. Like, for a patient who’s thicker, you need a CT, you need an MRI or something. So that’s an example of how you could use imaging in a way that’s not effective because you’re not using the right imaging for the question.

[00:32:25] Summer Kaplan: Right. And do you think there’s a good way to track or reflect imaging value, like, at a system level?

[00:32:31] Chris St John: So I guess the sort of economics answers that value is quality divided by cost. And so if your quality is higher, your value is higher. If your cost is lower, your quality your value is higher. But that’s such a simple equation, and it doesn’t really reflect the complexity of how do you get to quality? How do you develop these six pillars so that you’re doing quality care? And even cost is complicated. Cost to who? Cost to the patient? Cost to the hospital? Cost to the insurers? So that whole equation is too simple to define value in health care. I think the first step is just developing measures. So radiation is something we can measure. We measure it. Timeliness, turnaround times are things we can measure. So we measure them. And it’s a start, but there’s so much more that’s even more important to try to quantify in some way. And so that’s the challenge.

[00:33:26] Summer Kaplan: Yeah. I mean, is there a measure of effectiveness that you wish more health systems actually tracked?

[00:33:33] Chris St John: Yeah. So we have a lot of clinical guidelines. It’s even more true in adults, but even in pediatrics, we have guidelines for practice. And I don’t think there’s any system that really measures how much they’re followed. So I’ve been on guidelines committees, and it’s frustrating. Like, we spend so much time and effort and resources developing guidelines, and then who uses them? Like, maybe people use them, but they’re often not used. And so making it possible for those to be part of the clinical workflow, I think you can’t add more checks and more tasks to the clinical workflow because, you know, we talk we’re talking about hardships and challenges in radiology. But on the clinical side, there’s even more minutiae that creeps in every single day. So I think building a system that can measure effectiveness in a way that doesn’t add to the clinical burden is, like, the holy grail or whatever. It’s like what we try to get to.

[00:34:24] Summer Kaplan: Right. I mean, do you think, like, the radiologists are being asked to, like, prove their effectiveness more so today than in the past?

[00:34:32] Chris St John: I don’t think so. I think just the people rely on imaging so much, and I think that is like you asked earlier about the value of imaging and the benefit, I think that’s also speaks to the effectiveness of imaging that it’s the demand only goes up. And if it was not effective, that wouldn’t happen. So I think our volumes are are we’re a victim of our own success where there’s a benefit, there’s value, it’s effective, and so people use it.

[00:34:57] Summer Kaplan: And so we are starting to approach the end of our time today. But I’m just curious. You have hinted maybe not so indirectly at, like, pillars that resonate more with you, pillars that are maybe more nuanced or more complicated to talk about. What I’m curious, like, what do you think of the six pillars are the ones that radiology struggles the most with?

[00:35:18] Chris St John: I would say effectiveness because that speaks to a whole system of care, not just our work, but, like, how do orders come in to us? And that’s what’s the most challenging because we have no control over who decides to order, what, when. We have no control often over whether the study is the correct one. Decades and decades and decades ago, there were a lot more conversations between radiologists and the doctors ordering the studies, but that’s just not how it is anymore. And so effectiveness relies on input so that we can give effective output. And that’s challenging because our systems are so big and kind of impersonal at this point.

[00:35:56] Summer Kaplan: Yeah. I mean, last question to you is to ask about a question for you. Like, what question do you wish folks would be asking more when they’re talking about imaging quality?

[00:36:09] Chris St John: So I think for patients and families, when an imaging study is recommended, asking how will this help? How will this benefit? What are the risks? And for me as a radiologist, when I do talk to clinicians about a study that doesn’t seem like it’s the right one, I always want to get them to tell me what they’re concerned about. Like, so don’t tell me pain, tell me diagnosis. Like, are you concerned for appendicitis or a tumor or a a torsion? Like, what is your specific concern? Because sometimes they don’t have time to stop and think. It’s just like pain. Let’s image where it hurts. But to take that a little bit of extra time and think about what could be causing it, that helps us be more effective and get get the right study for the patients and for patients and families to advocate for themselves whether the study is going to help, in what ways is the study gonna help.

[00:36:59] Summer Kaplan: Before I let you go today, do you have any final thoughts on the six pillars that you wanna leave our listeners with? And no pressure if you do not because I basically asked to you just to just talk.

[00:37:09] Chris St John: Yeah. I appreciate the opportunity to talk to this to talk to you about this and to talk to your audience about it because we all want to provide and receive good health care. It’s scary to be a patient. And I hope it’s helpful to know that hospitals and health care centers are thinking about these things. The point of our discussion today to me in part is to help people understand how hard it is to actually measure these things. These are all principles that we believe in and we want to see put into practice, but how to measure them and be sure they’re happening is challenging. And we’re working on it, but it’s challenging.

[00:37:43] Summer Kaplan: Well, doctor Caplan, thank you so so much for joining us again today on Frame by Frame Rethink Imaging. It is truly always such a delight to have you here.

[00:37:52] Chris St John: Thanks, Chris. It was great talking with you.

[00:37:54] Summer Kaplan: It’s great talking with you too. Frame by Frame Rethink Imaging is brought to you by Imologix. 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 Imologix is rethinking imaging in health care, visit emologix.com. Be sure to subscribe to Frame by Frame Rethink Imaging on Apple Podcasts, Spotify, or wherever you listen. And from all of us here at

Questions from This Episode

What are the six pillars of quality in medical imaging?
They come from the Institute of Medicine, which defined them in the early 2000s: quality care should be safe, timely, effective, efficient, patient-centered, and equitable. Dr. Kaplan describes them as guiding principles the medical community adopted more than twenty years ago. The hard part is putting them into practice, since some pillars, like effectiveness and patient-centeredness, resist easy measurement.
How risky is the radiation from a single scan?
For an individual patient, a single diagnostic scan carries close to negligible risk, and doses sit 100 to 1,000 times below the levels that cause immediate harm like burns or cataracts. Concern grows with repeated imaging, and children get extra caution because their cells replicate more actively and they have more years ahead in which a cancer could develop. Kaplan tells worried families the drive to the hospital was riskier than the exam.
Why does radiology struggle most with effectiveness?
Kaplan names effectiveness as the toughest pillar because it depends on the whole system of care, and radiologists have no control over who orders what, when. Decades ago radiologists and ordering doctors talked through studies together, but today’s systems are too big and impersonal for that. An exam can also fail simply by being the wrong tool, like using ultrasound to check for appendicitis in an adult-sized adolescent when CT or MRI is needed.