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Editorial |
1 From the Department of Radiology, Stanford University School of Medicine, Room P-263, 1201 Welch Rd, Palo Alto, CA 94304. Received November 23, 2005; accepted January 6, 2006; final version accepted May 17. Address correspondence to G.M.G. (e-mail: glazer{at}stanford.edu).
At the turn of the 20th century, radiologists struggled to establish their profession as a respected medical discipline and wrestled with misperceptions of their laboratories as photograph galleries of amorphous shadows. Fortunately, the public perception of radiology no longer revolves around images of radiologists as picture takers and of their patients as portrait sitters. However, more than a century later, the discipline of radiology and the role of the radiologist still remain poorly understood by the public.
Within the past several months, an important incident occurred, and it highlights the need to make radiologists more visible to ensure the highest quality of patient care. In the August 20, 2005 New York Times article "Sick and Scared, and Waiting, Waiting, Waiting," Gina Kolata described a patient's anguishing story of waiting by the phone for her internist to call with the results of her computed tomographic (CT) examination for a suspicious mass in her lungs. It would be several weeks before Ms Odlum found out that the scan did not show cancer. As a result of this experience, Ms Odlum found a new internist (1). Neither the existence of a radiologist nor the discipline of radiology was mentioned by the patient or author in this front-page article.
We contacted Ms Odlum, as we surmised that in all likelihood her CT results had been interpreted by a radiologist very shortly after the examination was completed and that the delay in relaying the results to her was probably due to communication issues. We learned that Ms Odlum's results were available a little over an hour after the CT examination was completed. The radiologist had completed a careful interpretation of her CT scan on August 6, 2003, at 5:09 PM, and the report was dictated on August 6, 2003, at 5:20 PM (E. Odlum, written communication, October 2005). Why, then, were Ms Odlum's results not communicated to her within the day so that her anxiety could be allayed? Why did she wait weeks to learn that her cancer had not spread? This situation is particularly perplexing because technological innovations such as the digitization of radiologic procedures and rapid electronic communication now enable nearly instantaneous communication. Yet this possibility is generally unrealized today, and the result is an adverse effect on patient care, as highlighted in the Kolata article. The missing element impeding optimal care is the lack of involvement of radiologists in communicating directly with patients, which has led to radiologists and the discipline of radiology being invisible to many patients such as Ms Odlum.
Our society is aware of the revolutionary advances in imaging, and the two Nobel Prizes in Physiology or Medicine awarded for the invention of CT scanning and magnetic resonance (MR) imaging are evidence of the centrality of imaging to the health care of society. There is a rising wave of patient self-referral for early disease detection through imaging. Yet despite revolutionary technological advances that are resulting in high-spatial-resolution anatomic imaging, radiologists are still entrenched in the historic cultural practice of communicating with referring physicians only and not with patients. The increasing workload of imaging examinations also has compounded the communication problem by isolating the radiologist in a reading room or at a workstation so that, as in Ms Odlum's case, he or she is neither seen nor heard by the patient. We have become truly invisible to many of our patients.
Each decade a plethora of articles on the importance of improving physician-patient communication emerges, yet in each decade little change is made (2–34). The persistent lack of direct communication between patients and physicians has had detrimental effects on the quality of patient care. In a 2-year study of medical errors, the Colorado Research Network and the High Plains Research Network reported that in 2004, communication problems accounted for 70.8% of physician errors in 33 U.S. practices (35).
The failure in direct physician-patient communication is not restricted to the United States. In 2005, the Commonwealth Fund conducted a survey of over 2200 adults in six different countries and found that 19%–26% of patients reported communication problems (36). Thirty-four percent of U.S. patients reported some kind of medical error. Over half of these patients claimed that their primary care physicians did not communicate directly with them about their treatment options or care decisions. In addition, 9%–23% of patients who underwent blood testing, radiography, or other diagnostic examinations experienced a delay in being notified about abnormal test results; patients in the United States were at the higher end of the range (36).
The problems with direct disclosure in radiology are systemic and involve referring physicians, radiologists, and their patients. In the pre-CT and pre–MR imaging era before the 1970s, there was a focus on inpatient services and the radiologist served as an ad hoc consultant and sounding board to his or her clinical colleagues. During the 1980s, with the increase in managed care, the role of the radiologist as a gatekeeper gained momentum and the Joint Commission on Accreditation for Health Care Organizations stressed compliance to a standard requiring radiologists to review the appropriateness of ordered procedures (37). Many articles from the 1960s describe two key limitations of radiology: the capability to depict gross macroscopic disease only and limitations (38) in the "training, experience, interest, and ability of the examiner" (39). Forty years ago, radiologist Robert Sherman called for "personal confrontation between every radiologist and each of his patients" to ensure that the fundamental principle of ethical radiologic practice was fulfilled "to secure [the] maximum benefit for the patient" (40). In 1966, Dr Sherman noted that radiologic practice had a way to go before attaining this objective (40). In 2006, we still have a very long way to go before achieving this objective.
While many radiologists sought greater visibility, some outside the field argued for the invisibility of radiologists. Many viewed the radiography requisition as an order form rather than a request for consultation and viewed the radiologist as a vendor (24,41). Some nonradiologists feared that a "new breed of radiologists" who would "'interact' with the patient" directly and decide the time, type, and sequence of imaging examination would emerge and displace referring physicians: "[t]his bodes ill for the clinician and his patient and for the insurance carriers" (42). One physician even went so far as to say that he felt like Perry Mason, while radiology was like Paul Drake. On Perry Mason, a weekly television show during the 1960s, Perry Mason was a lawyer-detective whose fancy footwork in the courtroom was due in large part to the efforts of his detective, Paul Drake, who always entered Mason's office through the back door. Apparently, radiologists were to be back door doctors whose sole function was to "supply information (the x-ray report) in order to help the physician solve the case" (43).
The increase in very high-spatial-resolution imaging methods over the past decades has not been accompanied by any meaningful increase in the visibility of radiologists to their patients. With the burgeoning of health care systems in the 1990s, conditions were optimal for a dramatic change. Many radiologists advised their peers to be much more responsive to the needs of their patients by dropping the role of middleman and becoming primary care providers (25,44). Others saw their roles as two-pronged: They were simultaneously doctor's doctors or consultants, as well as physicians with a primary responsibility to their patients (36,42). Direct communication between radiologists and their patients was of particular concern: "We ... have to make ourselves known to the patient;.... The concept of a report the next day from the radiologist is a function of the last generation. Why should a patient worry all night if the findings are not significant? I have often wondered why many physicians prevent the radiologist from telling the patient at the end of an examination whether the results were normal" (25).
Results of surveys from this era also indicate a medical culture in transition. Many referring physicians, radiologists, and patients have favored the disclosure of information directly to the patient. A 1990 survey (17) revealed that 40% of 75 general practitioners were happy to have a radiologist give the result to the patient as a matter of course. Thirty percent of general practitioners agreed to have a radiologist give the result to the patient if the patient asked for this directly, while 22% agreed to this only if the result was good. Six percent believed that the radiologist should not give any information to the patient, regardless of the circumstances (17). In 1993, a similar survey of 188 radiologists and 248 nonradiologists from various U.S. departments revealed that 89% of radiologists and 76% of clinicians were willing to disclose normal results. However, only 33% of radiologists and 28% of clinicians were willing to have the radiologist communicate the existence of severe abnormalities directly to their patients. The more severe the abnormality, the less willing both nonradiologists and radiologists were to disclose the results (26). In a 1996 survey, 505 academic and private practice radiologists throughout the United States were in substantial agreement that "[i]f an adult patient who knows why a radiologic examination is being performed and what is being sought asks to know the results from the radiologist, the radiologist should answer truthfully (and immediately contact the referring physician with the results and the fact that the patient has been informed)" (20).
The majority of patients want to know their results. In 1993 (22), 501 patients, families of patients, nurses, medical students, and hospital personnel were surveyed. Patients and families of patients wanted their questions answered and their results explained no matter what the findings. Of 118 patients, 74% wanted to be told about the results if they were normal. If there was a minor abnormality, 56% of the patients wanted to be told the results. If there was a major abnormality, 73% wanted to be told either that the test result was not normal or that there was an abnormality. In 1995, a second survey of 261 patients revealed an even greater desire for the communication of all results: 92% of the respondents wanted to be told about normal results, and 87% wanted to be told about abnormal results (21).
As we entered the 21st century, much changed in radiology. The discoveries of CT and MR imaging and the subsequent improvements in these modalities have led to very rapid high-spatial-resolution examinations. These methods have been rated by leading internists in America as the most important innovations in clinical medicine over the past quarter century (45). High-spatial-resolution imaging methods are used to rule out diseases, confirm suspected diseases, evaluate the extent of disease, solve clinical puzzles, and guide biopsies and other procedures. Who is in a better position to communicate findings, understand the limitations of the test, decide what the future follow-up might be, and/or suggest what alternative imaging tests are available—the person who performed the examination or another physician untrained in radiologic methods?
Along with these advances, patients' expectations have changed. Most patients want to talk with their health care providers and to play an active role in health care decisions. We have the technology in place to give results to patients instantly through electronic medical record systems that allow patients to access their medical records online. One complicating factor is teleradiology. Because of the globalization of radiology and the infrastructure that permits it, intercontinental reading of images is now commonplace. Many fear that this system will further erode the radiologist-patient relationship. New York Times columnist and three-time Pulitzer Prize winner Thomas L. Friedman is among those who are predicting the demise of the radiologist: "Thank goodness I'm a journalist and not an accountant or a radiologist. There will be no outsourcing for me" (46). There are also concerns that computer-aided detection will replace the radiologist as well. However, neither a machine, nor software, nor a geographically inaccessible radiologist can provide effective communication with a patient.
Public policy and the courts have begun to respond to the current communication crisis. In 1991, the American College of Radiology (ACR) adopted the "Standard for Communication: Diagnostic Radiology" (47). This standard was modified in 1995, 2000, 2002, and 2003. At the 2003 annual meeting of the ACR Council, the standards were renamed practice guidelines and technical standards because the term standards implies rigid application and guidelines allow more flexibility on a case-by-case basis. Also, a legal consultant noted that the term guidelines implies a "less mandatory connotation than standards" and that deviations from guidelines are more justifiable than are deviations from standards (48).
In October 2005, new ACR guidelines went into effect (49). The preamble of the revised guidelines emphasizes that these rules neither are inflexible nor are to be used to establish a legal standard of care. The ACR's definition of direct communication has been replaced by the terms routine radiologic communication and nonroutine radiologic communication. In almost all cases, these terms refer to the communication of results between the radiologist and the primary care physician, not the radiologist and the patient. Radiologists are to report routine results to the primary care physician through the "usual channels established by the hospital or diagnostic imaging facility." Nonroutine results are defined as (a) "Findings that suggest a need for immediate or urgent intervention"; (b) "Findings that are discrepant with a preceding interpretation of the same examination and where failure to act may adversely affect patient health"; and (c) "Findings that the diagnostic imager believes may be seriously adverse to the patient's health and that are unexpected by the treating or referring physician." The guidelines recommend that nonroutine communications be "handled in a manner most likely to reach the attention of the treating or referring physician in time to provide the most benefit to the patient" (49). The communication of nonroutine results to the treating or referring physician or to his or her representative can be conducted by way of telephone, in person, or by way of other forms of communication that "demonstrate that the communication has been delivered and acknowledged." Physicians should communicate any imaging results directly to self-referred patients (49).
Despite these changes, the current state of communication in radiology is still unclear. The courts have strengthened the radiologist's duty to communicate radiologic abnormalities to referring physicians and, in some cases, to patients. Concurrently, the ACR's practice guidelines have been "liberalized so as to offer to the radiologist a panoply of options in providing the communication required when urgent or significant abnormalities are encountered" (50).
Even with these new guidelines and the abundance of literature indicating the desirability of direct disclosure, our systems for communicating to patients have evolved very little, probably because of the fear of communicating abnormal results. Yet the trepidation of direct disclosure is unfounded since the majority of test results are normal or do not indicate life-threatening conditions. In one 1990 study, 96% of 287 patients had test results that were normal or that indicated a nonmalignant condition (27). Estimations of the numbers of imaging examinations that lead to diagnoses of cancer each year confirm these conclusions. In 2003, there were 1 275 300 newly diagnosed cases of cancer and 23 345 radiologists in the United States (51,52). Even if all of these new cases were detected by radiologists—a grossly exaggerated possibility—each radiologist would be responsible for communicating only one abnormal result per week.
We recognize that this calculation excludes cases of questionable abnormalities and therefore underestimates the communication responsibilities of the radiologist. However, the apprehension of communicating questionable or relatively nonsubstantial results to patients is considerably less than that of communicating results of a more serious nature and thus should not inhibit direct communication. Furthermore, we believe that with added experience, a reasonable balance can be achieved between the amount of time radiologists spend thoroughly communicating the most important results and the amount of time they spend more succinctly relaying less important results. We advocate timely and direct communication and are not suggesting that the radiologist rush his or her interpretation, but rather that he or she thoughtfully communicate imaging results.
Although communicating bad news is challenging, the majority of individuals learn by doing. Since 1999, residents in radiology have been required to learn effective communication skills as part of their training. Currently, there are six general competencies that the Accreditation Council for Graduate Medical Education (ACGME) requires all training programs to impart to residents. The sixth competency is interpersonal and communication skills. The Residency Review Committee of the ACGME has defined this competency for radiology as the ability to "[c]ommunicate effectively with patients, colleagues, referring physicians and other members of the health care team concerning imaging appropriateness, informed consent, safety issues and results of imaging tests or procedures" (53). Performance must be measured by means of global faculty evaluation; an evaluation of the quality of reports; and 360° evaluations, which usually consist of surveys or questionnaires completed by a resident's superiors, peers, and subordinates. For other specialties, evaluations by patients and their families are often used.
In addition, there are a number of developing initiatives to increase the communication and visibility of radiologists to patients. The Radiological Society of North America (RSNA) is putting together a task force on the importance of radiologist-patient direct communication entitled "Putting a Face on Radiology." Dr Michael Brant-Zawadzki, chair of the Public Information Committee of the RSNA, reported that the committee is formulating several initiatives that will facilitate the development of an effective communications curriculum within radiology training programs (M. Brant-Zawadzki, oral communication, October 2005). Also, a few university radiology departments, like the University of Pennsylvania, are planning to send their patients letters acknowledging that their imaging findings have been read by a radiologist and including information about how they might get an electronic copy of the findings and/or a copy of their report (N. Bryan, oral communication, April 2006). While the optimal communication is always direct discussion between radiologists and their patients, this ideal is unlikely to be achieved for all imaging cases because of workload efficiency issues.
Some subspecialties of diagnostic radiology, such as ultrasonography (US) and mammography, are already leading the way toward establishing a new cultural practice of direct communication between the radiologist and the patient. In US, radiologists commonly communicate both normal and abnormal results, unless the findings are complex. In these cases, the sonologist may contact the referring physician before consulting with the patient (28,54). The Mammography Quality Standards Act of 1992 governs federal regulations for mammography and requires that personnel in each facility read the results within 30 days, send a written report to the health care provider as soon as possible but no later than 30 days, and give the patient a written letter of the mammography report in lay terms within 30 days after the examination (55). The personnel at some facilities hand the letter directly to the patient at the time of her visit, while others mail the letter only after the referring physician has the report (D. Ikeda, written communication, October 2005). Direct communication practices vary greatly between facilities; however, the radiologist often communicates normal results to the patient (19). We hope that the time frame for communicating mammography results will become shorter in the future, as we move toward more timely communication.
Certainly, there are short-term economic costs to establishing direct communication between radiologists and patients. Direct communication systems may slow down the practice of radiologists because of the added time needed to communicate with the patient, and it may result in the loss of referrals because the referring physician may not support direct communication. The long-term benefits greatly outweigh these temporary costs, however. Developing more direct radiologist-patient communication systems will enhance the visibility, stature, and role of radiologists in the health care system. Even more important, we will be acting more fully as physicians by allaying our patients' concerns and working together with nonradiologists for the welfare of our patients.
The need for direct communication between the radiologist and the patient will likely increase in the future. Owing to continuing advances in anatomic imaging, molecular imaging, and in vitro molecular diagnostics, we believe the Ms Odlums of the coming decades will have their diseases detected far earlier than they are detected today, possibly even before they are clinically evident. When disease-specific beacons signal the presence of relatively few aberrant cells, who will be better situated to determine the source and importance of these signals than the radiologist? As molecular imaging scientists develop new probes, the radiologist will be in a position to determine prospectively the most beneficial therapies for select patients and to monitor the responses to these therapies more rapidly and effectively than they are monitored today. Radiology will have a profound opportunity to emerge as a central patient care discipline if we embrace our role in communicating directly with patients in this coming age of personalized medicine.
The cost of our inertia is greatest for the patient. We believe that there is no defendable reason why a patient should wait for several weeks—agonizing over whether he or she has cancer or whether a cancer has spread—when the defining imaging result is available within hours after the completion of the examination. Dr Nick Bryan of the University of Pennsylvania Department of Radiology succinctly summarized the state of radiologist-patient communication in 2005: "The only thing a patient gets from a radiologist is a bill—at least in my department" (56).
We believe that the time has come to change the current mode of practice in which diagnostic radiologists rarely communicate directly with patients. We propose that we ask our patients whether they desire communication with us about the results of their imaging examinations. Those requesting results should be provided with them promptly. The Hippocratic Oath reminds us to always protect the good of the patient and serves as a covenant between the patient and the physician that is forever before us. Our primary obligation is to our patients. Radiologists may be the doctor's doctor, but they are the patient's physician as well.
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  M. L. Janower Public Relations Radiology, August 1, 2007; 244(2): 622 - 622. [Full Text] [PDF]
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