Verde Valley Medical Center (VVMC) recently resumed breast imaging services after a monthlong pause caused by a provider shortage.
But some of its former providers say there are still wider gaps in breast healthcare across the region, caused in part by a lack of breast fellowship-trained radiologists at Northern Arizona Radiology (NAR).
All four of the breast fellowship-trained radiologists hired in response to missed cancers found in screenings had left NAR by the end of June, leading to a temporary halt of some services at VVMC last month and shortages across northern Arizona more generally.
“In three years, they’ve had seven highly qualified, subspecialty-trained, NCI-level cancer center-type doctors come and go from the hospital for quality of care issues in the breast center," radiologist Dr. Mike Ulissey said of both NAR and Northern Arizona Healthcare (NAH), one of its partners and the healthcare system VVMC is part of. He worked as a consultant to NAH and NAR between May 2019 and December 2020.
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After a temporary period of "limited breast imaging services" that began June 28, VVMC’s breast clinic resumed offering services July 24, and NAR has since hired a new breast fellowship-certified radiologist.
NAH Chief Medical Officer Dr. Derek Feuquay said, however, that hiring radiologists with breast fellowship training is going above the standard of care typical across the U.S -- which he said was part of the reason radiologists with that training are so scarce.
"It's good to have lofty goals and we're sticking to that, that's what we think we should be doing," he said.
He added: "We're holding to that right now and making sure that's the standard we're meeting -- which is why NAR is getting breast fellowship-trained people as locums or temporary providers. But that's a standard that's higher than you're going to see almost anywhere else in the country."
Breast fellowship-trained radiologists
NAR first hired breast fellowship-trained radiologists in response to the discovery of missed cancers in screenings read by NAR through 2018.
While this was not a contractual requirement from NAH, Feuquay said that NAH had suggested having only fellowship-trained radiologists reading screenings in the Verde Valley, and that NAR had volunteered to do so.
In a statement sent to the Arizona Daily Sun in October in response to questions about the missed cancer in screenings, NAH’s then-acting CEO Josh Tinkle wrote that NAH had responded to the concerns by “advocating for a thorough re-review of patient mammograms by the team at NAR.”
“We ensured these mammograms were re-read specifically by a team of breast fellowship-trained radiologists,” he said. “ ... Since this review, we have implemented a process to go above the standard of care by ensuring all mammograms performed at NAH-operated breast imaging facilities are read by breast fellowship-trained radiologists.”
In early 2020, NAR hired breast fellowship-trained radiologist Dr. Kim Winsor, bringing the total working at the organization to four.
But by the end of June 2023, all four of those breast fellowship-trained radiologists had resigned, with three citing either working conditions or concerns about the two organizations’ response to those missed screenings.
"I'm not necessarily sure it was the right thing to have done in retrospect," Feuquay said of the commitment to having only radiologists with breast fellowship training read the screenings. "I think it was a really great move -- to tell everyone in Cottonwood and Verde Valley that after this event occurred, this is what we are doing. But we are working outside what the national standards are, which is why NAR is having a hard time filling the spots, because there just aren't enough providers to do it nationwide, especially in a smaller area like this."
Feuquay emphasized that general radiologists are trained in mammography during their required residency. NAH is continuing to try to meet the standard it set for itself, he said, both to keep its word and to give time for the other diagnostic radiologists to retrain after three years not reading mammograms while the breast fellowship-trained radiologists were employed by NAR and doing all of the readings.
The other breast-imaging provider Feuquay knew of in Flagstaff is Simon Med, which is not affiliated with either NAH or NAR. It's also possible that the new Flagstaff Medical Center campus, if the plans proceed, he said, will include an outpatient imaging center.
While NAR is an exclusive partner of NAH, reading mammograms conducted at VVMC’s ambulatory care center, and both conducting and reading breast imaging in Flagstaff (NAH does not provide breast imaging in Flagstaff, instead referring patients to NAR as necessary), NAH noted that the two are separate entities, so staffing and hiring questions should be directed to NAR.
NAR has not yet responded to multiple requests for comment.
Fellowship training
In medicine, a fellowship is additional optional training completed after a residency that focuses on a particular subspecialty -- in this case breast radiology. Breast imaging fellowships are typically a yearlong program for radiologists who plan to focus on breast health, helping them gain familiarity with the care they will need to provide and the types of equipment needed to do their job properly.
Among the tasks Winsor said breast radiologists perform are analyzing mammograms, ultrasounds and MRIs, conducting biopsies and localizations (helping surgeons identify the spot that needs to be removed in a lumpectomy), giving patients the news of breast cancer and connecting them with treatment options.
The technology used in breast imaging has been growing rapidly, she said, particularly in screenings, making the specific training that’s part of a fellowship more essential.
The FDA’s Mammography Quality Standards Act (MQSA) requires that those interpreting mammograms be certified to read radiological procedures and meet requirements for training and continuing education. It does not require breast fellowship training to interpret screenings.
The providers cited in this story all stated that fellowship training was preferred to keep up with the field's technological growth and provide a higher quality of care.
“With breast imaging, because it’s mammograms, ultrasound, whole breast ultrasound, biopsies, it’s become a subspecialty and a very, very high-tech subspecialty, because finding subtle changes on a mammogram requires a different level of acuity to be able to do that screening,” Dr. Beth DuPree, a breast surgeon who worked at NAH from 2017 to 2021, said of the need for specialized training. “ ... They’re the first line of defense for a woman. They’re the front guard."
NAH leaders, however, described the switch to using breast fellowship-trained radiologists as "go[ing] above the standard of care" seen in most of the U.S.
That NAR "used to have several breast radiologists ... is very, very unique," Feuquay said.
"There are very few people in the State of Arizona and even nationally that do breasts only -- which is why they have the struggle to find permanent employees to do that. ... In most places in the country, you're not going to have a breast-trained person reading your mammogram, it's going to be a general radiologist, who of course during their time in residency did a lot of mammography," Feuquay said.
Feuquay added: "That's just how the medicine world works."
Provider resignations
Most of the outgoing providers cited either quality of care or working conditions as the reason for resignation, according to some of those who left.
Winsor had returned to her hometown of Flagstaff in 2020 after completing her residency and breast fellowship training to begin practicing at NAR. She was the fourth breast fellowship-trained radiologist hired by NAR to go through their past screenings and look for missed cancers -- which she said was a requirement from NAH.
Feuquay said this was not a requirement, but something NAH had suggested and NAR volunteered to do.
“Ultimately, what this entire thing created was a tense relationship between the radiology group and the breast radiologists,” she said. “ ... They felt like it was a witch hunt. We worked for them, but they wouldn’t provide us with the necessary resources. It was a terrible work environment.”
Winsor ended up leaving the organization in March 2022 due to those working conditions. She said she was regularly working 18 to 20 hours in a day, with the shorter shifts being 13 hours, and was being asked to "cut corners."
The other three of that initial group of fellowship-trained radiologists also all left NAR between December of 2020 and June 2023, according to the providers cited in this story, along with other breast health providers at NAH, including surgeons and oncologists.
“The number of studies they wanted us to read without IT support, without the proper programming, without the proper staff, what they wanted from us was completely unreasonable, and that's why all of us got pushed out,” Winsor said. “ ... There’s no more breast fellowship-trained radiologists in Flagstaff or Verde Valley.”
Ulissey was the first of the radiologists to resign, parting ways in December of 2020. He said his resignation was because of NAH’s lack of response to the missed cancers in NAR’s screenings.
“One of the reasons I agreed to help them is I knew care wasn’t that good and I wanted to improve the quality of care in a town that I was going to retire in,” he said. “I wanted to give that back to the community, but if they really don’t want it, I’m not going to try and force it. I think it’s unfortunate that you have to go down to the Valley to get good care.”
DuPree left in December 2021 and said it was for similar reasons.
“I was told by multiple administrators that they were going to disclose to the community what had happened, hold that group accountable and make sure that we brought the breast imagers under the fold of NAH in order to allow them to practice and do what they needed to do because they couldn’t work for NAR,” she said.
An early-August statement from NAH said NAR had no breast fellowship-trained radiologists from the end of June through July 24 “due to NAR having some unforeseen staffing issues, coupled with a limited number of radiologists nationwide with breast fellowship experience."
Appointments for breast center services like biopsies and reading results of MRIs and mammograms originally set during that time period were rescheduled and VVMC’s breast services resumed with fellowship-trained radiologists on July 24.
NAH's June 28 announcement of that interruption noted that this was not the first pause of breast imaging services at VVMC.
“NAH previously announced a temporary pause in services in June, then resumed scheduling breast imaging services when NAR secured fellowship-trained providers to continue to provide the service," it said. "However, the radiologists’ availability is intermittent, requiring another pause in services until July 24.”
“There are no foreseeable delays in readings since those services resumed,” NAH noted on Aug. 8. “NAH does not contract with NAR for breast services in Flagstaff, only in Verde Valley.”
NAH does not employ radiologists, instead contracting with NAR. According to Feuquay, NAR does not currently have a permanent breast fellowship-trained radiologist, though it does have temporary providers with such training who they contract with on mammography readings.
NAH’s June 28 announcement of the pause in services at VVMC's breast clinic further outlined the relationship between the two organizations.
“NAH owns the imaging facilities at VVMC and manages the technical and support staff,” it said. “The radiologists who perform the imaging and interpret the results are employed or contracted by NAR, which has actively worked to recruit additional staff amid the unforeseen staffing shortage. NAR has agreed to continue to staff VVMC with breast fellowship-trained radiologists. NAR is bringing on additional fellowship-trained radiologists to work at VVMC and continue breast imaging services starting July 24.”
Accessing care in northern Arizona
For northern Arizona residents who need breast imaging and related healthcare, the providers said the shortage of breast fellowship-trained radiologists means either a prolonged wait or a trip out of town to access care.
DuPree and Winsor both said breast fellowship-trained providers are a necessity in modern healthcare and expressed concern about the backlog of screening readings being performed by more general technicians who are trained in radiology but don't have the specialized breast fellowship training.
NAR has not yet responded to requests for comment about whether there is a backlog, or if all of its screenings are currently being read by breast fellowship-trained radiologists.
“The women in our community aren’t getting their mammograms read in a timely fashion and they’re scrambling right now to try to find radiologists to come in to read these films,” DuPree said. “ ... You’re supposed to have your mammogram read within 30 days and the backup is huge. The health system is advertising on the radio, saying everything’s fine, but it really isn’t.”
“ ... They don’t have breast imagers, they don't have people to do what we need to do, and it's the community that’s going to suffer,” she added. “We’ll end up back in the same situation as before I got here, where women are not getting high-quality care. Since breast cancer’s the most prevalent, it needs the highest level of screening and everything that we have in cancer care, so women are going to take it on the chin.”
When DuPree first started working in the center in 2017, she led a program assessment that she said had found that the average time between a screening mammogram and diagnostic was 48 days, “which is unacceptable.” She said that during her time there that time lowered to between seven to 10 days and because of current staffing shortages took 30 days between a screening mammogram reading and a biopsy this July.
Winsor similarly said there were delays in reading patient mammograms, and that they were being read by radiologists who were not breast fellowship-trained personnel. Should those patients need a follow-up, she said, the wait was often two or three months.
“When I was working up here, we already saw patients coming to see us when they had findings concerning for breast cancer, or something on a mammogram for months," she said. "By the time they got to us, it was far advanced, and we saw this time and time again, mostly in those outer-lying areas that are underserved. ... Over time though, as we left, they didn’t hire more and the volume just became even worse. Ultimately, what started happening is they didn’t have enough slots to book patients. So if a patient did have a lump, or if they were called back, they would be scheduled two to three months out.”
She said she was concerned that these delays would signal to patients across the region that their issues were less urgent, leading them to delay seeking care. Ultimately, she said, this could lead to later diagnoses of breast cancer, a disease which becomes much harder to treat once it leaves the breast.
“I literally heard one patient saying, ‘Oh, if it was something that was really concerning, they’d get me in sooner,’” Winsor said. “...[For] so many of these patients, this is a very time-sensitive thing. Once it goes outside of the breast, that’s where we really lose the opportunity to save these patients; that’s where the mortality really increases.”
She added: “Telling the patient that they can be scheduled at a later date gives them the impression that that’s OK and that we are saying this is an appropriate time period, so a lot of those patients wouldn’t even know to go somewhere else. ... We will see much-later-stage cancers because of this, we will see more cancer deaths because of this.”
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