Out From the Reading Room: Three
Radiologists' Stories

Nick Mulcahy

November 22, 2019

Radiologists have traditionally acted as expert consultants to referring physicians who send patients for imaging. The radiologist off in a reading room is not outmoded in any way, but patient interaction is now being given emphasis by major radiology organizations. For example, at the upcoming annual meeting of the Radiology Society of North America, the president's December 1 address is entitled: A Matter of Perspective: Putting a New Lens on Our Patient Interactions.

But directly working with patients is controversial, with some referring physicians and radiologists objecting to disrupting the old paradigm. Medscape Medical News reached out to three radiologists about patient interaction — outside of obvious examples such as interventional radiology, which is a form of treatment — to collect some stories about the experience.

"Faster, Faster, and Faster"

When Jennifer Kemp, MD, began work as a diagnostic radiologist at Diversified Radiology in Denver, Colorado about 20 years ago, work life was slower and more personal.

"It was all film. The tech had to print the film, carry it to you, and then you would hang them up. All of radiology used to be manual and physical. You would then dictate into a little tape recorder and give the tape to a live transcriptionist, who would listen, type it out, and return the report to you. It was a much longer process and would take maybe 24 hours in total," she told Medscape Medical News.

The process involved multiple human interactions, including potential radiology department visits from referring physicians who wanted to talk about results of, for example, a chest x-ray or a CT scan.

Fast forward to the present, where Kemp has a very different story to tell: "We can do a CT scan and, 5 minutes later, the images are available [via digital delivery]. Voice recognition transcription can then make your report available in another 5 minutes [after you finish the report]."

The Picture Archival Communication System (PACS) means reading all images off a computer, she observed.

Over the past two decades, technology has been "amazing" with regard to efficiency and accuracy, said Kemp, but has been a "negative" with regard to human interaction and work pace. "Faster, faster, and faster" reading is needed to get reimbursed at previous levels, she pointed out.

As a partial antidote to sedentary, digital isolation, Kemp has adopted the practice of interaction with patients, preferably face to face.

"If we take 5 or 10 minutes to talk to a couple of patients a day, it's incredibly rewarding. It gets us out of our seat that we are sitting in for 8 to 10 hours a day. It's healthy for the radiologists and patients like and want it," she said.

The effort is also in keeping with Diversified Radiology's focus on having a patient-centered practice that involves multiple initiatives, including an "immediate results" program whereby radiologists call patients very soon after reading an imaging exam. The program is limited to certain patients but, once offered, is accepted 90% of the time, according to practice technicians. The radiologists conduct phone consultations between 8 AM and 10 AM on Mondays, Tuesdays, Wednesdays, and Fridays — when workloads are still relatively light.

Years ago, a simple gesture was one of the initial steps in building Diversified's patient-centered practice: adding the physician's phone number to imaging reports, so referrers and patients could directly contact the radiologist.

Making a phone contact, despite the digital revolution, continues to be nerve-wracking, Kemp said. "It can be so painful to find the right phone number to call [about a report]!" Phone trees, main switchboards, and receptionists/assistants are among the hoops radiologists may have to jump through — and it deters some from ever attempting. "We want to be available," she said about listing a personal phone number in a report.

The phone number gesture started with five radiologists, including Kemp, and eventually spread to all 60 in the practice. "Now we see it throughout Denver in reports from other radiology groups," she observed.

"You can do this in a non-academic environment," stressed Kemp about meeting with patients, either in person or on the phone.

Kemp's passion for communicating clearly, directly, and immediately with patients is driven by personal experience. Her husband was diagnosed with stage 3 rectal cancer 14 years ago. Quickly, Kemp developed a sharper understanding of patients with cancer — and "the fear they feel waiting for [imaging] results."

"If I can make a single patient's life better on any given day, that's what I want to do, even though I don't have time to do it for every patient," she explained.

"It's a little controversial," Kemp added. "Some referring physicians and some radiologists don't think it is a good idea — it's a hot-button topic." The objections include not receiving reimbursement for the consultation; not knowing a patient's whole history and therefore risking mistakes and inciting patient distress; and coming between a referrer and his or her patient.

Kemp prefers to run whatever risks might be present in order to provide personal care, when time allows, because she believes "it's the right thing to do."

A "Phenomenal Experience"

Eric Rohren, MD, is chair of radiology at Baylor College of Medicine and radiology service line chief at Baylor St. Luke's Medical Center, both in Houston, Texas.

But Rohren's career path has not been typical, despite stops at major institutions.

For a time, Rohren was in a small private practice in Florida, where he traveled to local clinics, usually working solo. The solitude gave him some professional latitude, providing his first experiences consulting directly with patients. Most memorable were patients with cancer.

"I had several patients that asked to come back and take a look at their PET scans…some had had multiple scans over the years and were very familiar with the process and very curious and forthright, [asking] 'What does my scan show?' " Rohren told Medscape Medical News.

"They were educated over time to know that decisions were being made based on their scans. And they wanted that direct information. They wanted to speak to the radiologist rather than getting a call from the oncologist several weeks down the road to learn 'if this therapy is working, do I need a new treatment, what needs to be done?' I would sit with them and explain the images and allow them to ask questions."

Rohren concluded: "That was a phenomenal experience. You get to see things from the patient perspective."

He subsequently did the same thing at MD Anderson Cancer Center in Houston. These experiences paved the way for Rohren's current work doing direct patient consults.

Breast cancer screening is offered in two different ways at his medical center's Women's Imaging Clinic. One is the Consultation Service, in which mammography results are personally provided by the radiologist immediately after screening, in a consultation room. "It is extremely well received by the patients," he said.

The second is the Express Clinic, which is the traditional model. In this model, Rohren explained, a woman gets a mammogram, leaves the facility, and gets a letter in the mail (2 days to 2 weeks later depending on mail service) with the results of the mammogram. That "period of uncertainty" is for busy people who don't have time for consult or need to get back to work or tend not to be worried about results, he said.

Interestingly, 50% of women choose one and 50% the other. The clinic's approach, which was started about 8 years ago by radiologist Emily Sedgwick, MD, is "pretty revolutionary," said Rohren.

Nationally, most practices do it the traditional way. "A radiologist will sit with a set of mammograms from a clinic and read 30 or 50 or 100 in a given period of time, and results go out by letter."

Rohren believes "seeing patients is very important for radiology as a profession" and that "having a lot of transparency around imaging studies does a lot to demystify the role of imaging."

"Patients learn that a CT or MRI has a lot to do with their eventual management and healthcare and it also personalizes the radiologists and reveals them to be an integral part of healthcare team," he added. "Radiologists tend to be invisible."

Rohren emphasized that there are some very important caveats to radiologists and patients interacting directly. "You need to be very careful about the conveyance of information outside of the primary healthcare team," he said. There is a great need to be "respectful" of that doctor and the doctor– patient relationship, because he or she is managing the patient. Rohren advises getting in touch with a primary care physician to get permission to discuss imaging with a patient.

In cancer cases, "there is a very real possibility of giving different information to the patient" that may "undercut" another clinician's work. Rohren gave the example of a radiologist seeing disease progression but the patient being on a drug that typically shows disease worsening before improving, as occurs with immunotherapy. So the "progression" may be expected by the referring medical oncologist, but the radiologist might deliver the message: "Looks like your medicine is not working." That may cause trust issues, he said.

Out of the Radiology Department and Into the Clinic

In the case of Xin (Cynthia) Wu, MD, at the head and neck clinic at Emory University in Atlanta, Georgia, the majority of her work follows traditional radiology practice — she prepares the report and consults with the referring physician, who then speaks with patients.

What's different is location. The reading room is embedded in the clinic and includes a dedicated radiology computer, "which is not a case of dropping a laptop on a desk," she says, referring to an array of distinctive computing qualities. 

The head and neck clinic is a creation resulting from the complexity of care for these patients' cancers, which include surgery, radiation, drug therapies, and supportive services such as speech and swallowing therapy. Importantly, a clinic enables the initial visit to take place in one day.

An important part of any first visit is the diagnosis — and an important part of that is imaging, said Wu.

The radiologist looks at the imaging with the entire team and consulting happens in "real time." If needed, Wu will talk directly to the patient. "A picture is worth a thousand words," she explained. Direct interaction is usually in the setting of a patient who needs reassurance of the treatment plan; patients may not understand why they have to undergo such extensive treatment for what they don't perceive as a "big problem" (because they don't feel or see anything wrong). "Showing images can help get them on board," Wu explained.

"We don't do that for every case," she also added.

This model is also being used at the University of Pittsburgh and elsewhere in the US, Wu told Medscape Medical News.

"It's always nicer to be there in person," she said about both interacting with patients or fellow staff. It also improves efficiency and clarity of treatment planning when done together: "You can knock out a plan in a couple of hours instead of days."

Interacting with patients is also a great clarifier of the work of a radiologist, said Wu: "Folks often think that if their primary doctor orders an x-ray and delivers a diagnosis, then that doctor made that diagnosis. They don't understand that there is another doctor involved."

Echoing Rohren's comment about radiologists being invisible, Wu said, "Patients don't know who we are."

After 3 years in the clinic, Wu sees patients almost daily at Emory. "It's one of the most rewarding things about the job," she said.

Kemp, Rohren, and Wu have disclosed no relevant financial relationships.

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