Do we hide behind our reports? The challenge of directly communicating results to our patients

November 3, 2010

“I hope my doctor can figure out why I’ve been having so much difficulty swallowing of late,” said the patient as I finished his upper GI study. During the procedure I clearly saw a large mass invading the lumen of Mr. Jones’ esophagus but I kept this knowledge to myself as I made small talk with him before heading back to the reading room.

“I hope my doctor can figure out why I’ve been having so much difficulty swallowing of late,” said the patient as I finished his upper GI study. During the procedure I clearly saw a large mass invading the lumen of Mr. Jones’ esophagus but I kept this knowledge to myself as I made small talk with him before heading back to the reading room. A few minutes later I would issue my report that would contain a diagnosis of esophageal cancer and recommendation for Mr. Jones to undergo an endoscopy and histologic sampling to confirm my suspicion of cancer. Why did I not communicate these results directly to Mr. Jones?

Radiologists have often been described as doctor’s doctors. This description arises from our role as consultants whose reports are communicated to referring physicians to assist in diagnosing ailments detected by imaging. As radiologists we typically do not convey our results directly to patients. I believe this practice stems from three misconceptions about radiologists and our field: (1) radiologists are ill equipped to speak to patients about their ailments, (2) imaging is only one component of a diagnosis and (3) radiologists make diagnoses but can not offer therapies.

Let’s address the first misconception. Radiologists, like all physicians in the United States, must complete medical school and pass standardized federal licensing exams prior to practicing medicine. We attend the same medical school classes and complete essentially the same rotations as other physicians. In addition, the current generation of radiologists have completed at least one year of a clinical internship that exposes them to general medicine or surgery. All of us have sat at the bedside of a dying patient, comforted a love one after conveying a dismal prognosis, and discussed the implications of worrisome test results with patients in clinic. Why then are we considered incapable of communicating results for an imaging examination in which we are the expert? A radiologist is no less compassionate than an internist.

Isn’t imaging just a piece of the puzzle? While many different pieces of information are gathered to make a diagnosis, imaging is often the most critical or revealing. In the case of Mr. Jones, the findings of the barium swallow is near pathognomonic. Histologic sampling would likely only confirm the type of malignancy and further imaging studies would stage his cancer. This may not always be the case, but the specificity of imaging has improved dramatically over the last decade allowing radiologists to pinpoint accurate diagnoses with imaging alone.

Another often used excuse of why it is inappropriate for radiologists to covey a diagnosis is that we are diagnosticians not “clinicians”. The growth and expanding role of interventional radiology is working to dispel this myth. If a CT scan detects a renal cell carcinoma, radiologists can offer radiofrequency or cryoablation. If a pelvic ultrasound or MRI detects multiple fibroids, a radiologist can offer uterine fibroid embolization. The list of therapeutic interventions offered by imaging departments grows every year. In addition, most interventional radiology practices now round on their patients and provide in office consultations.

Leonard Berlin, in a recent AJR article, argues that the time has come for radiologists to communicate results of all outpatient examinations directly to patients (Am J Roentgenol. 2009 Mar;192(3):571-3). We are capable, competent, and the best equipped to carry out this task. The subspecialty of breast imaging has led the way in demonstrating the effectiveness of direct communication to patients. Since the passage of the Mammography Quality and Standards Act (MQSA) and its mandate to directly communicate results of mammographic exams to patients, almost no medical malpractice suits have been filed for failure to communicate findings. But more important than avoiding litigation is the primacy of the physician patient relationship.

I hope that by directly communicating the results of his study, Mr. Jones can see me as his “doctor” and not a “technician” in the same way he views his gastroenterologist. In order for this to happen, however, I must discuss with him his results, their implications, and his options with the same respect, clarity, and compassion that the rest of his physicians afford him.

Dr. Krishnaraj is a clinical fellow in the abdominal imaging and intervention division, department of imaging, at Massachusetts General Hospital/Harvard Medical School. He can be reached at akrishnaraj@partners.org .