Radiologists, Referring Physicians Work Better Together

It’s a delicate dance radiologists and referring physicians play these days.

“Sometimes radiologists need to leave out clinical judgment and just let us make the call,” said Marcus St. John, MD, an interventional cardiologist at Miami Cardiac and Vascular Institute at Baptist Hospital of Miami. “But I understand, they are physicians and they are not reading a study in complete isolation.”

In an age where radiologists feel that their profession is at risk of becoming commoditized, and nearly everything is communicated through the report, staying relevant is more important than ever. Sometimes that means inserting clinical expertise - even if it puts referring physicians on the defensive.

St. John said he appreciates the information radiologists provide, and he relies on reports they provide for diagnosis as well as input on appropriate imaging, but he wants to make the clinical decisions for his patients.

David Winchester, MD, a cardiologist with a focus on noninvasive imaging at the University of Florida Health Shands Hospital, said his radiology colleagues often debate about what to include in the report. “We don’t want to tell someone how to take care of their patient, but we also want to provide them with useful information,” he said.

Winchester, who also helps run UF’s Chest Pain Evaluation Center at Shands, said they elected to do cardiac CT angiography as their noninvasive imaging test of choice. When physicians have to make a critical decision for each patient about whether to send them home or admit them, the study serves as an important clinical reference. 

“We sort of artificially have to take a complex description of somebody’s coronary anatomy and distill it down into what is actionable,” said Winchester.

In such critical situations, he stresses the need for clear communication in reports, which can include information on what should be done.

Technology’s Influence
The often strained relationship between referring physicians and radiologists has been brought on largely by the change in the way they communicate, said Richard Gunderman, MD, vice chair of Indiana University Medical School’s radiology department.

“The relationship is much less consultative than I would prefer,” he said.

“In some ways, the technology has tightened the relationship,” said E. Kent Yucel, MD, radiologist-in-chief at Tufts Medical Center in Boston.

But solutions are constantly in the works to try and enhance more personal connections for physicians that technology has tended to erode.

Cecelia Brewington, MD, professor and vice chair of radiology at the University of Texas Southwestern Medical Center, said her department has begun using a tool from Primordial Radiology Solutions that is integrated with UT Southwestern’s radiology department’s PACS system. It includes an avatar, or headshot, for the radiologistin the work list.

Although the tool is mostly used within radiology, certain critical care departments, like the ICU and ER, are included. “I think this is something that can help to improve the relationship and make it more personal,” she said.

Brewington said her department has also begun using the Lync system from Microsoft to share screens with other physicians. Companies are expanding enterprise messaging communication within those systems as well.

Other facilities, like NYU Langone Medical Center’s radiology department, tak[[{"type":"media","view_mode":"media_crop","fid":"30209","attributes":{"alt":"radiologists, referring physicians better together","class":"media-image media-image-right","id":"media_crop_3796662468242","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3159","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: 166px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]e it a step further with a virtual consult option for radiologists and referring physicians within the multimedia radiology report.

Some tools that were developed to communicate emergency findings are being used more often as every day communication tools. Yucel said his department has solved some communication issues with programs that allow radiologists to record a voice message and attach it to the report.

“Although it’s indirect, I think it has improved our communication,” he said.

Referring Physicians Seek Input from Radiologists
Robert Wears, MD, an emergency room physician and professor in the Department of Emergency Medicine at the University of Florida, said seeking advice from radiologists on which imaging test is best for a patient is one of the most common interactions he has with radiologists - especially with so much variation in advanced CT imaging. Common questions can be whether to give contrast or not, and then if that contrast should be IV or oral.

If he’s interested in one type of study, he’ll call up radiology and ask about the best way to order the study.

“All of these things depend on what you are primarily looking for and they have different logistical constraints,” he said.

He’s also noticed that as ultrasound technology has improved, there’s been a battle over whether it can be better than CT in certain cases - an area where radiologists can also influence patient-centered choices.

Within interventional cardiology, St. John said he often seeks input from radiology on the best imaging test to give a patient.

“When it comes to slightly more esoteric imaging tests or questions, our interactions with radiologists are often to not only find the best test but depending on the situation, we’ll actually go review the study with the radiologist just to complete our understanding of the issues to make the best informed decision,” he said.

If one of his patient’s has a weakness of the heart, for example, there could be several potential causes. Depending on what the physician is looking for, a cardiac MRI or a CT angiogram may be appropriate.

“Radiologists are often the best specialists to help you decide,” he said.

St. John’s imaging colleague, Ricardo Cury, MD, chairman of radiology and director of cardiac imaging at Miami Cardiac and Vascular Institute, said the collaborative effort among the different specialties at his institution is nurtured by leadership within various departments.

“Radiologists are uniquely positioned to lead the development of clinical pathways in their home institution with a multidisciplinary team, and guide the implementation of best practices by following appropriateness criteria,” he said.

Winchester said radiologists have a lot to offer just by knowing which imaging approach is best for a given patient. In his work, he can reach back to referring physicians and either tell them a test is unnecessary or encourage them to order a different test.

He thinks collaborative relationships are important as medicine becomes more specialized too. For example, at North Florida/South Georgia Veterans Health System, where he also works, they have both PET and SPECT imaging available. Although they can make PET available as a direct order, they have taken the stance as an imaging department on deciding who gets PET or SPECT because it’s not something the average primary care physician would know about.

“In settings where you can have collaborative relationships, I think that makes for the best choices for the patient,” he said.

Clinical Conferences
Both radiologists and referring physicians seem to agree that one of the best ways to improve communication is through participation in multidisciplinary care conferences or multidisciplinary hospital committees.

“In some ways, it’s the only vehicle we have now for direct contact,” said Yucel.

Multidisciplinary conferences, especially in the academic setting, can occur weekly, bi-weekly, or monthly. In any case, they get everyone together in the same room.

Wears said they often invite radiologists to come to their emergency room conferences to comment on images. He said it has always been helpful - perhaps most in a social sense.

“After you’ve seen someone and spoken to them face-to-face, it’s easier on the phone to call them by their first name and express your concerns without having to be quite so careful because you are dealing with a stranger,” he said.