Tuesday, December 9, 2014

Should radiologists tell patients their test results?

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Both The Advisory Board and Dr. Jha speculated about the potential liability exposure of a radiologist whose advice might differ from that of the referring doctor causing concern for the patient and hostility from the doctor.

Unless the radiologist performs a history and physical examination, he will not know much about the patient. A lack of clinical context might cause a radiologist to misinform the patient.

Here's a scenario. A radiologist tells a patient she has a suspicious mass in her adrenal gland on a CT scan but can't tell the patient what should be done about it. Instead of anxiety about not knowing the test result, the patient would then have anxiety about having a mass and no plan to deal with it.

What about incidental or equivocal findings? Dr. Jha wrote, "Such findings, for example, could potentially, albeit immensely improbably, turn out to be cancer. Radiologists will find that the burden of ‘clinical correlation’ will fall upon them, and this task will be all the more challenging at a single time point."

A study found that a radiologist's discussion with the patient about a CT scan took a little more than 10 minutes. Would that time be reimbursed and if so, how? Dr. Jha pointed out that the discussion would have to be documented and the decrease in radiologist productivity would have to be made up somehow.

Since they rarely, if ever, talk to patients, radiologists may be extremely uncomfortable with this new role. I've known a few radiologists who are not even comfortable talking to other physicians. Many radiologists don't choose a career being sequestered in a dark room because they are "people persons."

The Times article described one patient's interaction with a radiologist. He said the radiologist "seemed physically afraid of me."

The real solution is for radiologists to communicate more rapidly with referring physicians and for those physicians to communicate more rapidly with their patients.

Here is what needs to happen. 1) A critical or unexpected result of radiologic examination should always be immediately discussed in a telephone call from the radiologist to the doctor who ordered the test. 2) Every doctor or her staff must promptly communicate the results of any radiologic test to a patient.

If those actions occurred on a regular basis, radiologists wouldn't need to talk to patients, and litigation due to overlooked important findings could be avoided.

So what I really would like to see is pathologists talking to patients.

16 comments:

Phil said...

As a radiology resident, this is something we discuss within our program very frequently. From a radiologist's perspective, the point about reimbursement is important, but even more important is the loss of time. Getting paid for 10 minutes of consultation is great, but that's still 10 minutes lost in reading a CT or several X-Rays. Clinicians generally want radiology reports as fast as possible, so regardless of whether or not the radiologist is paid for a consultation, his "customer" (who, more practically speaking, is really the ordering physician moreso than the patient) is upset because now results will take even longer.

Personally, one of my favorite aspects of radiology is discussing imaging findings with clinicians, and with patients too. Unfortunately, with the way radiology has been heading over the last couple decades, it would take a huge shift to change the focus from faster turn-around time to something like discussing results with patients.

Relaying results to clinicians is probably one of the least bad options, but it also comes with frequent headaches, since often times the ordering physician is not the same as the physician taking care of the patient (e.g. admitted by the overnight team, or the order was put in by the ER and not the primary team). And with frequent shift changes, even if they are the same, the radiologist ends up talking to someone who is just cross-covering for the other doc and doesn't know much about the patient.

Unfortunately, with the size and complexity of modern hospitals, relaying results to patients is not as simple as anyone would like it to be.

Anonymous said...

How about letting it be patients' choice? Giving us the scans, etc. and we'll look at it. If you want to make a recommend, have at it.

I look it all over, check it out against research.

Besides, I have a brain MRI I love to watch. Fascinating.

RuggerMD said...

My mother had a breast lesion and went for a mammography.
The mammo radiologist told my mother that she had breast cancer (or at least that's what my mom heard) and that she could tell by the imaging.
My mother was very upset that she now has breast cancer, as you can expect. I had a hard time calming her as it was a small lesion and had not even been biopsied yet. Plus anxiety for myself over thinking the radiologist felt the lesion suspicious.
A week later, excisonal biopsy done and benign lesion. Thankfully.

Skeptical Scalpel said...

Phil, good points especially about trying to reach the person who ordered the test. Surgeons have that problems as consultants too. The hospitalists change and it can be difficult to figure out who is responsible on any given day.

I'm not sure it would work as patient's choice. That might lead to staffing issues in radiology. They wouldn't know how many radiologists would be heeded to cover for those speaking to patients.

Rigger, good story. It's a nice illustration of how not to do it.

Anonymous said...

One of our radiologist routinely WAY overreads studies and routinely lists a lot of bizarre finding and possible diagnoses that do not match the clinical picture. It would be a problem if she started telling patients her interpretations.......

frankbill said...

Many times the radiologist doesn't always see the Xray untill after treating provider looks at it and gives there take on what they see.

Skeptical Scalpel said...

Anon, I would love to hear your radiologist explain some of the obscure incidental findings. It might take all day.

Frank, that has not been my experience. Except for orthopedists and maybe a few others, most docs just go by what the report says and never look at the images.

frankbill said...

Skeptical

Guess you have never been part of the Dartmouth Hitchcock medical center.

Having been care giver to both my parents I made many trips to the ED. Chest Xrays and Xrays due to falling were always looked by the ED treating Dr.

In my case I have had Xrays taken and hand carried the film to my providing Dr.

NeuroTrumpet said...

Skeptical-

Regarding your above comment, I can tell you as a neurology resident we *always* review the films ourselves. Because we generally have a pretty good idea where to look (the neurological exam is fantastic that way) we commonly catch things (subtle strokes, etc) that the radiologists miss.

Skeptical Scalpel said...

Neuro, I'm glad to hear that. Most general surgeons look at their own films too. I should have been more specific. At the risk of incurring the wrath of primary care docs, I would have to say I meant that they are the ones who go by reports and don't look at the x-Rays.

artiger said...

Scalpel, that is true for the majority of them, unfortunately. I don't know if it's a training deficit or a product of less time to see more patients for our primary care colleagues. Maybe both.

Skeptical Scalpel said...

Whatever the reason, it's not a good habit.

Libby said...

As a patient I've asked to look at the x-ray or asked my family doctor if he saw it (report was indecisive) & what his take was. He didn't look at them, just the report. I've had family doctors who looked at them, usually before the report or in conjunction with the report. It seems these young'uns rely on the reports more and more. I see the hazard in that if they aren't looking at them, they'll never learn and if there are errors they won't catch them. (*gasp*-errors? There have been provincial pathologists whose work had to be re-read due to a huge amount of mis-readings going back years. There was even a public announcement that anyone who had work done in a certain time period to contact someone (can't remember who) for the corrected diagnose).

Skeptical Scalpel said...

Libby, thanks for the interesting comments. I hadn't heard about that pathologist story.

Mitzi said...

I'm not a doctor, but I find medicine so fascinating, so I routinely follow a lot of doctor/nurse blogs. This post struck me as something that I have encountered as a parent. I think in the case of radiologists, the answer would be "sometimes"?

My daughter jumped off of a bookcase in her bedroom and broke her tibia right below her kneecap. I asked if the radiologist if it was broken and his answer was "I can't tell you that, you'll have to speak to her doctor", but I was in the room with him as he checked the films. He conveniently placed his index finger right next to the break and said "there's her leg". It was nice to know that we'd be heading back to the pediatrician to get splinted instead of waiting for a phone call.

Additionally, I had a miscarriage and continued bleeding. I had a follow-up ultrasound and I asked the US tech if she saw anything and she WAS willing to respond "there's something in there, but I can't read the findings." From all of my research, I knew I'd end up needing a D&C, so having that knowledge was comforting.

I think perhaps indicating that "something" is there would be okay, but a definitive diagnosis should not be made. Is that a good middle ground? That not-knowing can be so incredibly painful that at least this would give a patients a heads-up that something is happening.

Skeptical Scalpel said...

That's a good compromise. Maybe they should just say something's wrong. Talk to your doctor. I just don't know if everyone would be as ok with it as you were. I think a lot of people would press for more information.

Post a Comment