Q&A: Amy Patel details her experiences providing breast imaging services in urban, rural areas

Breast radiologist Amy Patel, MD, recently transitioned from practicing at Beth Israel Deaconess Medical Center in Boston to overseeing a total of seven rural and community hospitals (including one in an urban setting) in northwest Missouri as a medical director. Radiology Business spoke to her about the differences in breast radiology practice in both rural and urban areas and current actions being implemented to ensure patients throughout the country receive equitable care. 

Radiology Business: As someone who has worked in both urban and rural areas, what are some of the most notable differences you’ve seen in the way breast imaging is practiced? Are there differences in the number of radiologists, equipment and facilities?

Practice type plays a substantial role. Academic institutions tend to be more saturated in larger, more urban cities. These types of practices tend to have multiple radiologists who have trained in a particular subspecialty, as there are usually bonafide "sections" such as breast, etc. However, radiologists who tend to be in private practice and/or cover more rural areas may have done a fellowship in a particular subspecialty, but tend to read additional imaging than in which they did their fellowship. Also, on the whole, they may have less fellowship-trained radiologists in a particular subspecialty, such as breast imaging. There may also be less radiologists covering a more diverse and/or increased volume compared to those in dedicated academic institution sections, but of course, there are certainly exceptions to the rule.

Additionally, the rural and community hospitals are sometimes not privy to state-of-the-art technology, largely due to financial constraints and inability to justify more expensive equipment if the number of patients will not demonstrate a return on investment. The skill level of a technologist may not be as robust as a technologist in an urban setting who may have access to more educational material, refresher courses, etc. There is simply not as much money to send technologists for continuing medical education as these smaller hospitals have less funding for these types of activities.

Amidst these differences, I still fervently believe it is our duty, especially if you are the lead interpreting physician and/or overseeing the radiology department in one particular aspect, to ensure they have the tools and equipment they need, from additional education to digital breast tomosynthesis (DBT). For example, in addition to my role in a more urban setting, I oversee six rural/community hospitals in northwest Missouri, and our goal is for all of them to have DBT capabilities, and that goal is likely to become a reality in 2019. I will drive to one of our hospital sites where multiple technologists from the other sites will congregate to hear me give a refresher lecture of interest.

What are some of the most notable differences between urban and rural patients? Are patients in either setting more aware of the need to get breast screening?

Education definitely plays a role as many women do not know when to start getting a mammogram or when to stop. However, there are other layers of complexity involved regarding our rural patients, and those include a lack of financial capabilities/insurance to cover the cost of a screening mammogram, let alone a diagnostic evaluation with subsequent possible biopsy. Thus, unfortunately, many women "suffer in silence," such as if they feel a lump because they are afraid they won't be able to pay for what's to come. Also, transportation issues are a challenge if a patient cannot get to the local hospital or even a larger women's imaging center as avenues such as public transportation are just not an option. We know that breast nurse navigators play a tremendous role in bridging the gap of innumerable disparities, particularly in rural areas, but there are some cases, that despite their best efforts, there are persistent access-to-care issues. 

Why do you feel these differences exist? Is there a lack of breast health education?

Regarding the educational component, as a breast imaging community, I think there is always room for improvement to strengthen our outreach efforts. Since I have moved back to Missouri, I have made it my mission this month to speak at numerous community events, from at community and rural hospitals to libraries, to the radio!

The more we spread the good word about breast health and relay the facts, the more our patients understand that they are a priority and will feel empowered to take hold of their breast health. Subsequently, I am already seeing this, and it is amazing to see. A little bit of outreach goes a long way.

What current changes have been implemented to address the lack of equality in these areas? How’s the radiology community moving the needle forward?

In regard to addressing the lack of equality of the hospitals for which I oversee breast imaging, I have previously shared how we are working to improve access to soon standard-of-care breast imaging, such as DBT, and I am working to refine our technologists' skills in these rural areas. I have also standardized breast imaging protocols at all of the sites I oversee so that they are in accordance with the American College of Radiology appropriateness criteria. I am also in the process of applying for grants so that women who cannot afford life-saving imaging or even transportation to get to a hospital will have access.

As a radiology community, there is always more we could be doing. However, there are some incredible, shining examples of our community moving the needle forward. For example, the institution at which I completed my breast imaging fellowship, Washington University in Saint Louis, has a mammography van that travels along the eastern part of Missouri, reaching women and ensuring they receive a mammogram who otherwise may not have access. In a state like Missouri, this has been an incredible game changer and has played a crucial role in narrowing the gap of breast health disparities. I also think that partnering with organizations such as Susan G. Komen, American Cancer Society, and in Missouri, organizations such as Show Me Healthy Women can be an incredible way to ensure our patients receive timely breast care, from the time to diagnosis to treatment, and all of the psychosocial factors that arise with such a complex and sensitive diagnosis.  

What are our opportunities to ensure equal breast care among all patients across America?

I think first, as a breast imaging community, we have to first acknowledge that deep disparities exist, and that the challenges in the rural areas can be quite different than what is faced in urban areas. These challenges can make ensuring these patients receive the same standard of care extremely difficult in certain circumstances. However, we must remain persistent and committed to improving breast imaging care in these areas, for if we are really dedicated to earlier detection and saving the most lives, this population will need to be made a priority regardless of geographic location. 

Do you have any final thoughts?

I encourage those who feel called to serve rural areas to seize the opportunity as your expertise is badly needed and there is a vast support network in our breast imaging community to support you to improve care in the area in which you practice. And if you are a part of an urban practice or institution where you oversee rural and community hospitals, do not settle for the status quo but strive to improve the quality of breast imaging care so that rural patients receive the same standard of care as urban. All patients, regardless of geographic location, deserve quality breast care and an equal chance of fighting the disease.