Meet Jeanine McNeill, MD. A board-certified radiologist with Renaissance Radiology Medical Group, Dr. McNeill, 49, works occasionally at the practice's outpatient imaging center, Parkview Community Hospital and Riverside County Regional Medical Center. But about two thirds of the time, she works from home, enjoying the benefits of the growing telemedicine trend.

Her at-home practice environment is an historic Riverside neighborhood dating back to the 1910s and 1920s. The Tudor faŤade of her home belies what's inside. Two high-speed computers, three oversized monitors, two Internet connections, two phone lines and a fax machine enable Dr. McNeill to do her job reading images from even higher-tech equipment--digital X-rays, MRIs, CT scans and ultrasounds.

Southern California Physician joins her Tuesday, Aug. 1, 2006:

Before work--I have about six business hours before my shift starts at 2:30 p.m. My top priority is to visit Mom, who, at 92, is recovering from a broken hip at a local rehab facility. I get there early to catch the doctor rounding so I can get an update from him directly. Mom's making good progress.

Back home again, I meet with the cabinet guys about my kitchen renovation. Later, I spot the neighbor's pool contractor across the street. I talk him into coming over to bid on my pool renovation. It's great that I'm home and can get so much done during the day.

2:30 p.m.--I checked my e-mail after lunch, so the computers have been on for a while. I lower the roman shade, save a six-inch slit of light across the bottom. I turn on the ceiling fan to mix up the summer air. I'm ready. I sit down to a list of 20 cases and start reading. The computer screen on my left shows the case inventory, while the center and right screens reveal the images. First up, a spine. I view the images and dictate the case, concluding: "New paragraph. All caps. Impression. Colon. Unremarkable lumbar spine. Period."

"Go to top," I say. The cursor jumps to the beginning of my dictated case. I read back the words, fix a typo by repeating the incorrect word, then say, "Go to end." Last, I say, "That's done," and the file is saved. With a single keystroke, the report is delivered to the appropriate fax machine--thanks to the essential, but behind-the-scenes clerical work of our Renaissance support staff.

I work my telerad system with two hands. My left hand controls my dictation screen and case inventory, while my right hand works the images. It's much more efficient this way. And after years of practice with speaking clearly, crisply and evenly, my speed and accuracy are excellent. In fact, the words I say aloud to Dragon Naturally Speaking are practically the only things I verbalize during my shift. To connect with the four other telerad physicians on duty with me, I use an instant messaging program, called Skype. We type occasional notes back and forth. I type 150 words a minute.

2:40 p.m.--The next case is a cervical spine. "An endotracheal tube is in place. Period. There has been surgical fusion of C5 and C6. Period. A discectomy appears to have been performed. Period. The alignment of the frontal projection is anatomic. Period. A surgical drain can be seen. Period. New paragraph. All caps. Impression. Colon. Postoperative changes as described. Period."

2:55 p.m.--My Skype chirps. It's an instant message from my CEO, Monika Kief-Garcia, MD. She wants me to look at a case for a second opinion. She's at Parkview right now, but can easily forward the images. Working together this way is fantastic. She sends the case to me; I send my opinion back. We don't waste time with telephone calls. It's a hip CT for fracture, but she has a question about a cyst. I message back, "Is it the acetabulum?" Right. We confirm a bone cyst on a 59-year-old male.

3:01 p.m.--I review X-rays of a diabetic foot, post amputation, for possible infection. Then a gall bladder ultrasound. Then another spine CT. Many of the cases today are from Riverside County Regional Medical Center, our biggest local contract. But because Renaissance has about 40 telerad contracts, the work can come from anywhere.

4:07 p.m.--A mobile diagnostic company sends images taken onsite at nursing homes in Virginia and North Carolina. I grab these cases, because I have licenses in those states. Not all my colleagues are licensed in as many places as I am. Across time zones and through the Internet, the time between the test and the result is about two hours. That's not bad considering it can take about 45 minutes to get a reading on most hospital inpatients.

4:30 p.m.--Two hours gone. I'm used to the long stretches of silence between my dictations. Only the occasional clatter of a passing truck on the street breaks it up. I'm reminded that some radiologists just don't like practicing like this. The concentration, the isolation can be too much. One radiologist I recruited to the practice tried it for three weeks. After that, she said, "I'm outta here."

But I've been working this way at least part of the time for about eight years, and as the technology has improved, I am enjoying telerad even more. This job is portable. I can do it from anywhere I go. I feel like I have job security.

Next up, a gall bladder ultrasound of an inmate (we have a contract with the local jail) and a congestive heart failure patient from Victor Valley Community Hospital (like many hospitals, it is understaffed, so we are helping out).

4:41 p.m.--There's a problem with a case from Victor Valley. It's a leg X-ray, but the legs are stretched really long. Someone pulled the film through the digitizer and distorted it. So I Skype Angel, a new member of the clerical staff, and tell him to get the hospital to scan the film again. He will call there and handle the issue, so I can keep going. Our clerical staff has a very important job in the telemedicine system. When a case comes in, they don't let us see it until every image has arrived. And they control where the results get delivered.

In the meantime, since I'm caught up, I work a bit on recruiting. There are 30 radiologists in our group, but we could take on more business if we had three or four more. I check for e-mail from a recruiter I've engaged in Iowa and from a telerad doc based in Maine.

We're trying something new by recruiting the Maine physician as an independent contractor, paid by the case. But the new model is complicated because of who pays for what, with high credentialing and equipment expenses. It can cost about $18,000 to set up a doc at home. Still, the Maine guy seems worth hashing out the details. There's a huge shortage of radiologists generally--telerad-trained docs especially.

Technically, I get one "administrative day" per month to work on recruiting. But I do it constantly, scheduling interviews, reviewing contracts, negotiating. Renaissance is a corporation I love, so I want it to prosper.

4:55 p.m.--I answer a rare phone call. Alfonso Carrillo, MD. There's a multidisciplinary meeting at Riverside County Regional Medical Center on Thursday about how to improve hospital practices related to trauma cases. Can I go in his place? It's at 7 a.m. My response: "Oh, bless your heart!" But since I'm the co-chair of the radiology department and I'm on duty at the hospital that day, I say yes--after making him sweat it.

5 p.m.--Time to sweat myself. Even though I haven't talked to them all day, I've been teaming with four other telerad docs. But at 5 p.m., they abandon me. So the goal is to have the board cleaned before then. I'm on my own from about 5 p.m. to 7 p.m., and things can go crazy with trauma cases.

5:02 p.m.--The screen looks incredibly good. But I know I won't be getting up for dinner or a break during the next two hours. I'll be moving as fast as accuracy allows through the cases, which will be mostly CTs and ultrasounds for emergency patients. I've been seeing a rash of appendicitis cases, and there are always a few patients with ectopic pregnancies or gallstones. Secretly though, I look forward to the traumas. You get interesting things. Gunshot wounds and stabbings. That's forensic radiology, and I'm a nut about watching "CSI" on TV.

5:05 p.m.--A complicated pulmonary CT with 65 images comes in. A 19-year-old patient has clots. I dictate the position of each embolus carefully, knowing what's next for this young man. Coumadin. Then a routine OB ultrasound, kidney ultrasound and head CT. Statistics show that about 85 percent of everything I read is normal.

5:35 p.m.--The red bar highlighting a case on my screen grabs my attention. A stat order from California Hospital Medical Center in downtown Los Angeles. A gunshot to the left shoulder.

As gunshots go, not a bad one. I dictate, "There appears to be destruction of the cortex of the left posterior humeral head. Period. No through-and-through fracture can be seen. Period." Still, the bullet's in there: "A metallic foreign body, consistent with a bullet, located posterior to the scapula. Period." And I know what's next for this young man as well. Surgery.

5:45 p.m.--I get back to basics with a string of head CTs and other ER cases.

6:15 p.m.--Rule out aortic aneurysm.

6:19 p.m.--Confirm appendicitis.

6:23 p.m.--Confirm pancreatitis.

6:30 p.m.--Rule out spine trauma.

6:35 p.m.--Confirm appendicitis.

6:45 p.m.--Finally, some happier work. I read an OB ultrasound to rule out placenta previa for a baby due Jan. 1, 2007. Happy New Year!

6:50 p.m.--This case gives me pause. It's a 29-year-old diabetic transplant patient, and she's really sick. I review abdominal and pelvic ultrasounds. I see atrophied kidneys, a transplanted kidney in the pelvis and three sizable abscesses. Sad.
As I dictate my impressions, I'm reminded exactly how important it is to proofread before filing the report. I do it unfailingly. In her case, Dragon picks me up as saying "improbable" when I said "and probable." A significant difference.

7:30 p.m.--I get out of my chair for the first time in five hours to walk to the door to let the cat in. Saki, my black and white tabby, wanders around the yard when I'm home during the day. Now that evening's here, she comes in the office and curls up on top of the briefcase on my desk. My dictations put her to sleep.

8:30 p.m.--Something's up. I blink and a flood of about 40 cases fills my screen. Then I remember that it's Aug. 1, and a new contract started today. We are supposed to get 100 to 150 cases a day from our client, a California mobile diagnostic company.

8:31 p.m.--I get a Skype from our clerical staff, apologizing for the onslaught. It seems a technical glitch just got resolved so our systems could communicate.

8:45 p.m.--Thankfully, Atul Patel, MD, happens to log in and see my challenge. He pitches in and we get going through the workload. It's important teamwork so we can deliver a quick turnaround for our new client. Thirty minutes from image submission to report delivery is the goal.

9:30 p.m.--My CEO Skypes me. She is back at work from her home telerad system. We strategize via instant messages about practice management issues late at night. Among Renaissance's three practice modes--outpatient facility, hospital-based and telerad--telerad is growing the fastest.

We discuss our next quarterly shareholders' meeting, where we bring everyone together. It's ironic to me that we physicians see each other in person so rarely, but our business is doing so well.

I love the mixture of our practice. I like working with the technologists, residents and medical students at the hospital. They all love to learn and are delightful. Working with patients one on one at the outpatient facility is great, too. And working telerad means a higher volume of cases, but the flexibility is amazing. I still get a kick out of the fact that I can open my door to let the contractor in while I'm at work.

All in all, it's not bad for a change that was made out of necessity. We launched the telerad business because there were not enough of us, and we were staying up all night long and then working the next day. When you work from home, you become more efficient. The toughest thing is getting referring physicians to accept the fact that they never see us face to face. The efficiency decreases communication, because we don't sit with the physician, discussing symptoms and history. I'm not sure our outcomes are always as good, but our ever-advancing technology makes up for a lot. We simply see things that we didn't before.

10:20 p.m.--Dictating the end of my 136th case today, I say, "That's done." And for the night, so am I.

BIOGRAPHY
Jeanine McNeill, MD

Birthplace: Takoma Park, MD

Current Residence: Riverside

Board Certification: Radiology, with competency in nuclear medicine

Undergraduate Degree: Andrews University, B.S. Biochemistry, 1979

MD: Loma Linda University School of Medicine, 1983

Internship: Loma Linda University Medical Center, 1983-84

Residency: Loma Linda University Medical Center, 1984-87

Fellowship: Loma Linda University Medical Center, 1987-88

Practice History: Renaissance Radiology Medical Group, 1999-present; Arlington Radiology Medical Group, 1988-99.

Medical Licenses: California, Kentucky, Massachusetts, Nevada, North Carolina, Ohio, Oregon, Tennessee, Utah, Virginia and Washington.

Hospital Affiliations: 38, due to teleradiology coverage.

Memberships: American College of Radiology, American Medical Association, California Medical Association, California Radiology Society, Radiology Society of North America, Riverside County Medical Association and Society of Breast Imaging.

Memorable Quote: "Radiologists love their toys." Her reference is to their expensive imaging equipment and computers.

Productive Habit: CME courses. Her yearly goal is 100 hours. As of August, she had 89.

Family History: Second-generation physician. Her general practitioner father died when she was 2 years old, and she read from his medical books at an early age. Her brother is an ophthalmologist.