The Real Customers: a Pilot Diagnostic Radiology Consultation Clinic

Who are the real customers of radiology? As a medical student, I was continually amazed by the versatility of a radiologist. From the start of my clinical year in internal medicine to my final neurology rotation, time and again my team would carry the weight of a complex case to the reading room, lay out the clinical information and sincerely ask for guidance. Through these interactions, my perception of a radiologist took shape; a physician with a broader understanding of complex disease processes who can assimilate clinical information across all medical disciplines and direct referring physicians with guidance and expertise.

Like many others, this is why I entered radiology. Intern year was much the same; we rounded… and rounded, and contemplated a patient’s diagnostic workup and management from all perceivable angles. But at the conclusion of rounds nearly twice a week, we visited radiology for guidance, reviewed cases and repeatedly left the radiology suite feeling as though a weight was lifted off our shoulders and with a better understanding of how to manage our patient. 

Entering radiology residency, I hoped to begin building this consulting ability and be the actual agent changing management plans. As I worked toward this goal of assimilating information and identifying acute diagnoses such as acute appendicitis or diverticulitis, a separate unexpected phenomenon caught my attention - incidental findings. I repeatedly found myself dictating macro “calc,” macro “emphysema,” and macro “fatty liver.” Struck by the frequency and general severity of these findings, while working with a mentor and research collaborator Dr. Garry Choy reading chest radiographs, we began to ask ourselves; do patients fully understand the importance of these incidental findings? I mean, do they really understand that these are changes that will likely shorten their lifespan? More importantly, there are well studied methods to halt progression and/or reduce the burden of atherosclerosis, steatosis or emphysema. If patients saw this directly and understood the clinical implications, would they change?[[{"type":"media","view_mode":"media_crop","fid":"25665","attributes":{"alt":"Mark Mangano","class":"media-image media-image-right","id":"media_crop_6586741043720","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2386","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":"line-height: 1.538em; height: 208px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

While I certainly enjoyed the reward of adding value making acute diagnoses and directing referring physicians in management, there has to be more we can do with these important but often secondary findings. As expert consultants who routinely direct referring clinicians in clinical care, why can’t we take these findings directly to the patient, show them their images, and utilize our consulting ability to provide a contextual realistic picture of what these changes mean?  Maybe we are not just consultants to referring physicians and can also effectively consult directly to patients. This was the impetus for our group to start connecting patients directly to these important incidental findings through the formation of a diagnostic radiology consultation clinic.

The logistics of the pilot consultation clinic are simple; select patients from referring primary care physicians’ routine clinic appointments with prior imaging changes of atherosclerosis, hepatic steatosis or emphysema and give these patients the option to discuss their imaging findings with a radiologist. The actual clinic visit is straightforward as well; we introduce ourselves and explain our role, outline the meaning and context of basic changes such as atherosclerosis, emphysema and steatosis, and then show patients their images while emphasizing the ability to prevent and/or slow progression of these changes through healthy lifestyle choices.

While we are still in the early phases of implementation, the early results have been promising; not only are patients motivated to improve their health and empowered to take charge of their own healthcare, but they are appreciative of the consult and leave with an improved understanding of a radiologist’s role.

Although I was initially hesitant of the unpredictable questions patients may ask during the session, these feelings were quickly cast aside when it became clear that patients are truly appreciative of the consult and generally eager for a physician to contextualize these important changes. Starting with the first consultation session, it was immediately clear that the patient-radiologist interaction was something special and could serve as a potential medium to impact clinical change in a meaningful and unexpected way.

While initially drawn to radiology by the value added interactions with referring physicians, using my clinical expertise to directly consult patients, our other important customer, has been one of the most rewarding experiences of my clinical career.