Building Trust in Pediatric Imaging

In pediatric radiology, credentials are important but not always enough. 

Rapport is critical, explained Marta Hernanz-Schulman, MD, radiology vice-chair for pediatrics and medical director of diagnostic imaging at Vanderbilt Children’s Hospital in Tennessee.

Building rapport with pediatricians typically comes through multiple interactions and consistently accurate diagnoses. Radiologists also need to demonstrate a clear interest in the patient and commitment to reducing radiation dose.

Still, there’s that first day on the job, and how do you know the interpretation is correct?  Pediatricians and other doctors may double-check the work of a new radiologist-a strategy Hernanz-Schulman recalled experiencing years ago when she had just completed her training.

A baby was vomiting, and through ultrasound she accurately diagnosed a narrowing of the passage between the stomach and small intestine. It wasn’t until later that Hernanz-Schulman learned that a surgeon had already diagnosed the condition through palpation.

“It happens everywhere,” Hernanz-Schulman said. “Pediatricians are comfortable with a person whom they already know and trust, and when a new person comes on, they may run over to the older person to check the results until they have confidence in the new person.”

So what do pediatricians look for in a radiologist, and what does it take to establish trust?

Adina Alazraki, MD, professor of pediatrics and radiology at Emory University School of Medicine in Atlanta, explained that her initial, five-year career as a pediatrician in urgent care before moving onto radiology gives her a dual perspective on the trust issue.[[{"type":"media","view_mode":"media_crop","fid":"32984","attributes":{"alt":"pediatric imaging","class":"media-image media-image-right","id":"media_crop_5043188604978","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3473","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 167px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Puwadol Jaturawutthichai/Shutterstock.com","typeof":"foaf:Image"}}]]

Pediatricians primarily want radiologists to answer their questions, she said. “Is there pneumonia, yes or no?  If there is a foreign body in the stomach, can they go home and it will pass, or do they need to go to the ER to have it removed?”

They also want radiologists who are willing to contribute to the overall care of the patient.  “Even if we don’t come up with the right answer, they want us to help them along the way to decide what to do next,” she said.  “This builds trust.”

Similarly, Alazraki said, the radiologist wants as much information as possible from the pediatrician. “The pediatrician might say the patient injured a hand while roller skating but won’t say where it hurts,” she said as an example. “Extra information about the exact location of the injuries can change your report.”

Holding Hands
At Stanford Children’s Health in California, neonatologist Susan Hintz, MD, medical director of the Center for Fetal and Maternal Health, said trust can be established quickly, given the complexity of the cases and rapport that must ensue between the pediatrician, or neonatologist, and radiologist.

Hintz added that at institutions like Stanford, with its history of and commitment to pediatric and fetal imaging, the burden of assessing the credentials and expertise of the new radiologist largely are lifted from her.

“We know our pediatric and fetal radiologists want to have the best possible colleagues,” she said.  “Their own level of evaluations is high, and they will want to bring on someone who similarly has high expectations.”

Among evaluators at Stanford is Richard A. Barth, MD, radiologist-in-chief at Stanford’s Lucile Packard Children’s Hospital.  He explained that pediatric care, at Stanford and other pediatric-centered facilities, requires close collaboration with  pediatric health care providers given the particular vulnerability of the patients and the difficulty especially young children have in articulating their symptoms.

“Radiologists need to advise and partner and hold hands with their pediatric colleagues,” said Barth, who also is chair of the Society for Pediatric Radiology’s board of directors. 

Pediatricians want to know that the radiologist is highly aligned with best practices, Barth said.   He explained that through specialized training, including a year of fellowship training in an accredited pediatric radiology program, radiologists can earn certification in pediatric radiology through the American Board of Radiology. That certification demonstrates to referring physicians and the public that the radiologist has the knowledge and skills necessary to be worthy of the public’s and profession’s trust, according to information from the ABR.  Maintenance of certification is required and evaluated annually, and a computer-based exam on cognitive expertise is required every 10 years.

Educating the Generalists on Radiation Dose
Radiologists also can demonstrate a commitment to excellence both by offering alternatives to exams that require radiation and by affiliating themselves with organizations such as the Image Gently Alliance, which is dedicated to safe and effective imaging for children.

Barth cited several studies, including a 2014 article that appeared in Pediatric Radiology, that reported differences in CT utilization rates for pediatric exams at pediatric-centered facilities versus those that are not pediatric-centered.

In the article, author Thomas L. Slovis, MD, professor of radiology at Wayne State University School of Medicine in Michigan, found that most pediatric imaging-as much as 85%-takes place at non-pediatric-centered hospitals. He further reported that these non-pediatric-centered hospitals are increasingly using CT scans on children, while the use of CT is decreasing at pediatric-centered facilities. Radiation dose on children in several metropolitan centers tends to be “poor,” he states in the article.

But as Barth explained, it would be unrealistic to suggest all children be imaged at pediatric-centered facilities. There are simply not enough pediatric radiologists to go around, and pediatricians are not likely to send families great distances for common conditions or injuries when a general radiology practice is down the road.

An important responsibility is to build awareness. “Part of our role as pediatric radiologists is to educate non-pediatric radiologists on how best to perform pediatric imaging,” he said.

Collaborative Value
Brian D. Coley, MD, radiologist in chief at Cincinnati Children’s Hospital Medical Center, concurred and added that in most cases it would not be necessary to drive long distances for a radiologist who specializes in pediatrics.

For the more complicated diseases, especially in younger children, possibly involving the growing muscular-skeletal system or conditions unique to children, pediatricians may recommend families seek out specialists in pediatric radiology, he said. 

The most effective pediatric radiologists are those who are engaged members of the patient care team, Coley said. While fielding phone calls may be frustrating when there are images to be read, he said, radiologists who specialize in children need to embrace the increased demand for personal interactions.

In short: if you can’t provide your impressions on what may be going on with the patient, your value is limited.

Pediatrician Janesta Noland, MD, of Burgess Pediatrics in Menlo Park, CA., could not agree more. She said she looks for radiologists who are available and engaged. 

“If they don’t call me back when I have questions, and if they don’t transmit results in a timely way, I can lose confidence quickly,” she said.

Reading Grainy Images
Alexander J. Towbin, MD, of Cincinnati Children’s, is among the radiologists interviewed who cited a 2012 study that ran in the American Journal of Roentgenology that looked at interpretation differences in images of children between general radiologists and those at tertiary care children’s hospitals.

For the study, the authors reviewed diagnostic imaging reports of pediatric patients referred to a children’s hospital between January 2009 and May 2010. Out of the total 773 exams included in the final report, major disagreements in interpretation were found in 168-nearly 22%.

In the paper, the study authors, who include Hernanz-Schulman at Vanderbilt, describe the rate of discrepancy as “substantial.” Hernanz-Schulman told Diagnostic Imaging she was not surprised by the results-specialists in all fields tend to be better than generalists at finding abnormalities.

Radiologists trained in pediatric imaging also are generally able to make their diagnoses using radiation doses even lower than acceptable standards, such as those set recently by the National Electrical Manufacturers Association (NEMA).

Towbin suggested radiology practices with a small percentage of pediatric clients might want to have small groups of radiologists consult on the readings. Through group readings, radiologists can gain not only expertise in pediatrics over time but also the trust of the pediatrician.

Rapport with Child and Parent
In addition to having the credentials and skills necessary to succeed in pediatric radiology, personality also is essential, said Sarah Sarvis Milla, MD, acting associate professor of radiology at Children’s Healthcare of Atlanta. 

“We’re very hands on,” she said, explaining that pediatric radiologists often have to go into the room to search for the patient’s pain and help make the diagnosis.

“As pediatric radiologists, you need the personality that lends itself toward gaining trust with both the parent and the child,” she said.  “That ability to create an instant rapport is really helpful and yields trust.”