Imagers hone bedside manner to court savvy consumers

In the children's book Jessica's X-Ray, a little girl with a broken her arm travels through a hospital getting various kinds of imaging studies, from old-fashioned plain films to economical ultrasound to sophisticated MRI. Given the current level of competition, diagnostic imaging specialists could be forgiven for wondering if little Jessica knows whether a real radiologist is in the proverbial dark reading room.

It's not just children who could use an introduction to radiology. Most adult patients have a basic idea of imaging but still don't understand a lot about diagnosis, radiation, benefits, risks, and alternatives. And little may be known about the practitioner.

"In the modern era, diagnostic imaging touches every patient. But it's all too easy for excellent radiology to be done with the radiologist out of sight in the background," said Dr. Philip Alderson, head of the RSNA's public information committee and chair of radiology at Columbia University Medical Center.

Absent personal contact, patients may not realize the value of services provided, according to Dr. Arl Van Moore, chair of the American College of Radiology board of chancellors.

"The more we interact with patients, the more they'll understand who we are and what we do," Van Moore said.

Patient information is high on the ACR's priority list, he said. The college has recruited Edelman Public Relations to create an educational publicity campaign that will help put an approachable face on radiology for consumers. The campaign will launch sometime this year and follows the Image Gently initiative launched in January. Sponsored by the ACR and other professional groups, this initiative focuses on improving radiologists' awareness of radiation dose in young patients. A parallel awareness campaign for consumers is under consideration.

USE IT OR LOSE IT

The RSNA and ACR already operate a patient information website called RadiologyInfo.org, which provides easy-to-understand information. Since 2006, the annual RSNA meeting has featured a refresher course called "Patient-centered radiology: Use it or lose it," which helps imagers learn how to boost their interaction and communication in several different practice settings.

"If a radiology group takes extra time with patients, patients and their referring doctors are more satisfied. What often happens is that radiologists start getting involved in the loop of patient referrals. That gives the radiology group a competitive advantage," said Alderson, one of the presenters at the refresher course.

The RSNA also participates in "60-Second Checkup," a program that airs on 68 radio stations and features experts discussing new technologies and their effects.

"Increasingly in all medical fields, the patient is being viewed as a customer, and competition is fierce to provide the best care, including good communication," said Dr. Stamatia Destounis, a radiologist at Elizabeth Wende Breast Care in Rochester, NY. "The radiologist needs to explain, empathize, support, offer solutions, educate, and also provide hope."

Responding to perceived demand, some hospitals are building new outpatient imaging centers with consulting rooms that allow patients to discuss results with radiologists, said Dr. Eric Trefelner, cofounder of NightShift Radiology in California.

"In the past, patients were passive-they accepted whatever a doctor told them to do. That is not the case with the baby boomers entering retirement. Patients today are more informed and are demanding more information. A more informed patient will go to the Internet before an appointment and come armed with printouts and questions," he said.

INFORMATION RICHES

Writing in Radiology, Dr. James Thrall noted the challenges of practicing in an "information rich environment that requires more effective communication between all stakeholders" (2006;239:621-625). As Thrall points out in the article, the Accreditation Council for Graduate Medical Education published a document in 1999 stressing general core competencies for physicians, including the ability to provide patient care that is "compassionate, appropriate and effective for the treatment of health problems."

The competencies also include "interpersonal and communications skills that result in effective information exchange." In a similar vein, provision of patient-centered care is the first of five core competencies spelled out by the Institute of Medicine in a 2003 report called Crossing the Quality Chasm: A New Health System for the 21st Century.

"In theory, every new physician is receiving training in communications skills. When the ACGME reviews graduate programs, they survey on this point," said Thrall, radiologist-in-chief at Massachusetts General Hospital.

The fifth core competency outlined by the IOM relates to effective use of informatics by health providers to manage patient care. Interestingly, way back in 1995, establishment of the radiologist as a "healthcare information manager" was a key strategy outlined in a vision statement from a meeting of the FutuRAD group of the RSNA, according to one event participant, Ron Schilling.

Diagnostic images are a vital element of the electronic patient record, and the radiologist can connect all of the diagnostic information with the patient, said Schilling, president of RBS Consulting in Los Altos Hills, CA.

"Information systems will dominate the game. And as information managers, the radiologist is in a very special place in terms of looking at overall diagnostic decisions," he said.

OLD DOGS, NEW TRICKS

Views are mixed regarding the ability of more established radiologists to adapt to patient-centered care. The perception is that many radiologists entered the specialty precisely because of the lack of contact with patients. Communication may not be their strong point.

"Radiologists are not prepared at all. Those who have been asked to do patient consults are reluctant, as it takes time away from work that will pay better and make their statistics look better," Trefelner said. "An informed patient will be less passive and more questioning, and this may make a lot of radiologists uncomfortable."

Traditionally, many physicians entered radiology to avoid patient contact, but that is really ancient history, said Dr. Mark Klein, a radiologist at Washington Radiology Associates in the nation's capital.

"I don't believe that radiologists are any more or less able to interact with patients than any other specialists, if the will and an appreciation of the benefits are present," Klein said.

There has always been a need to communicate with patients in radiology, Klein said. It is only becoming more of an issue now because patients are better informed and have higher expectations, and because competition among those performing imaging has increased.

"Speaking with patients is good medicine, and that is what should be driving the discussion, not issues of reimbursement or medical malpractice. It has always been said that 90% of the diagnosis is history, and speaking directly with the patient is the greatest and most accurate source of that history. Patients will often tell a doctor, even the radiologist, information they withhold from technologists and nurses," Klein said.

The physician also receives significant benefits.

"You get to meet a lot of interesting people and have the opportunity to make a real impact on their lives," Klein said.

SUBSPECIALTY APPROACHES

The extent of contact between radiologists and patients varies dramatically depending on the subspecialty. Pediatric imagers tend to work closely with patients and their parents. In nuclear medicine, patient history is a critical component of top quality medicine and requires face-to-face discussions, Alderson said.

Interventional radiologists have long had a classic patient-doctor relationship, and the need for good communication is critically important.

"IRs need to communicate with the primary-care doctors and regard the referred patients as 'their patients,' for whom they take care and responsibility. They have opened clinics where they see patients in consultation, versus just doing procedures," Thrall said.

Interventional radiologists have seen much of their vascular work snapped up by cardiologists, while hemodialysis procedures are being nipped away by interventional nephrologists, said Dr. David Dixon, a radiologist who oversees the residents program at St. Luke's Hospital in Kansas City, MO.

"With all the self-referral going on nowadays, interventional radiologists must get out there and develop their own outpatient practices and properly communicate with patients and referring physicians. We can't just hide in the hospital. I think interventional radiologists are finally realizing that this is necessary," he said.

To promote their outpatient practices, they can become better engaged with their communities, by giving talks, for example, at local service clubs, Dixon said.

ENLIGHTENED SELF-INTEREST

Klein also believes patient education could help radiologists in turf wars.

"Knowledge is power. The more a patient knows about what we do, the better for us. They should know something about our training in x-ray safety and that we usually have more state-of-the-art equipment compared with nonradiologists," he said.

Mammographers point out that the need to communicate with patients in breast imaging has always been there.

"A lump or suspicious finding is very emotional for patients and their families, and communication skills are very important," Destounis said.

Awards, certifications, and accreditations should be clearly visible in the main waiting rooms of a facility. A radiologist's report card can be made available either online on the practice's website or onsite in pamphlets provided to patients at the facility upon request, she said.

"We discuss with the patients how many mammograms we read a year and our positive predictive values for biopsies," she said.

Some in other specialties are not in favor of providing physicians' track records to the public, noting that patients may not be able to make sense of the statistics. Also, going public with performance figures could result in a flood of patients to the top performers, who will not be able to handle all of the cases.

Sources interviewed for this article agreed, however, that radiology providers should at least be tracking performance of their members privately and internally, for quality improvement purposes. After problems are identified, physicians can improve performance through continuing medical education.

BOOSTING INTERACTION

Some parts of radiology, such as general CT, MR, and plain film, are often invisible to consumers.

"In large portions of the practice, radiologists provide critical services to the medical decision-making process and then melt into the background. They may not ever see or be known by the patient," Alderson said.

It is possible to boost interaction in some settings. In the emergency room, for example, where patients visit and films are read in the same place at the same time, a radiologist could meet the patient and discuss symptoms before the interpretation, Alderson said.

One radiology practice in Arizona experimented with having office hours for patients to voluntarily visit and discuss their image findings for an out-of-pocket fee. Most of the referring physicians were receptive rather than threatened by this approach, Alderson said.

To succeed, however, radiologists may have to change their communication style, avoiding medical jargon and learning how to convey the same information in a patient-friendly manner. Another possibility in large imaging practices is for senior radiologists who are not involved full-time in mainline film reading to explain the imaging findings of their colleagues to patients.

"Good care is facilitated by making an effort to reach out to patients. This can help put a face on radiology," Alderson said.

Emily Hayes is a contributing editor to Diagnostic Imaging.