Patient contact proves vital for good practice

February 11, 2006

Thirty years ago, radiology residents were urged to meet all patients presenting for imaging. As the workload increased, this emphasis on communication continued, though trainees tended to see only outpatients. Residents had to speak with these patients prior to imaging and, when possible, explain the subsequent results. If the diagnosis involved difficult or bad news, these discussions required great care.

Thirty years ago, radiology residents were urged to meet all patients presenting for imaging. As the workload increased, this emphasis on communication continued, though trainees tended to see only outpatients. Residents had to speak with these patients prior to imaging and, when possible, explain the subsequent results. If the diagnosis involved difficult or bad news, these discussions required great care.

By the early 1990s, increased reporting workloads caused by the advent of fast cross-sectional imaging began cutting into residents' engagement with patients. CT and MRI examinations now generate hundreds of images within a few seconds.

Radiologists are not technicians or laboratory physicians. We are clinicians, and clinicians deal with patients. You can learn a lot simply by greeting a person. In a brief discussion with a cancer patient on his or her third or fourth outpatient visit to imaging, you can often gauge the effectiveness of treatment from the patient's appearance. You can detect new manifestations of the disease and adjust and manage the radiological procedure. These insights may be absent from the medical notes.

Emergency radiology can also benefit from resident-patient contact. We were performing 4000 CT examinations each year in the ER in the mid-1990s. This figure is now more like 12,000. Patients arriving at night may have to wait an hour before seeing a physician. Emergency radiology often acts as triage. If CT is part of the workup, very little clinical history may be available about the patient. Residents must obtain as much information as possible. By asking questions, they often learn that the "unknown" patient has past imaging reports that can then be retrieved.

Meeting a patient, whether in the ER or an outpatient clinic, can also help when planning an examination. It takes very little time to perform a focused physical examination. For a CT of the abdomen, we frequently look at a patient while he or she is in the waiting room or on the table. If our clinical assessment suggests aortic dissection or aneurysm, we will know what approach to take. Had our inspection revealed a patient with possible acute pancreatitis, we would have adopted a different approach.

Talking to patients takes time, which many residents say they do not have. It may take two minutes to greet a patient, another to examine the patient, and two more to talk after imaging. Five minutes per patient adds up. Residents might want to use that time to review a previous CT study or discuss the case with a supervisor. Electronic solutions, such as voice recognition software, improved PACS, better workstations, and automated prefetching of past images and reports, can all help residents be more efficient. If residents are still overburdened, then we have to consider how numbers could be increased.

Radiologists in Switzerland have a legal obligation to conduct a patient consultation. The total fee charged for a radiological examination includes a percentage toward this consultation. So if radiologists do not speak with a patient, or his or her family in the case of minors, the hospital is effectively gaining part of that fee unjustly.

The practice of remote reporting has yet to reach Switzerland, apart from cases requiring second opinions. Some U.S. hospitals outsource their primary reporting work via teleradiology to other qualified radiologists during weekends and the night shift. This can be cheap and efficient, but it is also a very risky strategy. It could be the end of radiology departments as we know them, if all reporting is outsourced and examinations are performed by technologists. It is the best way to kill the specialty within a few years.

I urge my residents to see as many in- and outpatients as possible, even if they require nothing more than a chest x-ray. I try to convince the residents that this is the only way for radiologists to be considered clinicians by patients and referring physicians, which is essential to improving our efficiency and preserving our specialty.

PROF. SCHNYDER is chair of radiology at University Hospital Lausanne in Switzerland.