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Emergency Radiology
Communication in Emergency Radiology
Physician-to-Patient Communication
Physician-to-patient communication is a unique challenge for radiologists. Radiologists and patients often have isolated encounters, without any prior patient-physician relationship established. Most radiology services, including an emergency radiology service, do not schedule dedicated clinic time, and therefore meeting with patients may not be a set priority in the daily workflow. Additionally, radiologists often do not have enough information from the emergency medicine team to discuss detailed management plans with patients.
For radiologists in the emergency department (ED), the physician-to-patient communication can come with a different level of challenges. Being physically in the ED and having regular shift work, emergency medicine providers are usually easier to reach for communication of study results, and they are responsible for conveying study results and diagnosis to patients with their management plans. In this setting, radiologists do not commonly encounter opportunities to discuss difficult and stressful imaging results with patients. However, situations requiring radiologist-to-patient communication may still occur. For example, it may be important for a radiologist to communicate with a patient and family when performing a focused assessment with a sonography in trauma (FAST) scan at the bedside.
In emergency radiology, physician-to-patient communication may be useful for obtaining additional clinical information not provided in the imaging requisition. At Harborview Medical Center in Seattle, Washington, emergency radiologists are embedded in the trauma section of the ED and frequently speak with patients for additional clinical history or may even perform a focused physical exam to correlate with imaging findings. In some situations, a radiologist is best suited for directly correlating imaging findings with symptoms or physical examination findings. However, such interactions may be challenging, and specific guidelines are useful to consider.
Five Tips to Begin a Successful Radiologist-to-Patient Communication in the Emergency Department
To begin, it is important to be aware of the time constraint, especially in the busy setting in the ED. It can be useful to initiate communication by explaining the special role that radiologists play in patient care, which is significantly different from the roles of other clinicians that patients usually encounter. Following this introduction, discussion should center around the actual imaging results, without commenting too extensively on the treatment options. The following list of strategies will help radiologists improve communication skills with patients and family members in the ED.
1
Use AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) for Patient and Family
In most interactions, including those between radiologists and patients, the first impression can set the tone for the entire conversation. AIDET, which stands for acknowledge, introduce, duration, explanation, and thank you, serves as a useful guideline in promoting effective communication with patients. The role of the radiologist in patient care is not well understood beyond the medical profession, so it is important to provide context to the patient at the start of the conversation. Having a standard scripted introduction can help radiologists begin the interaction smoothly and focus on the specific medical condition of each patient.
An equally important aspect in the first impression is to acknowledge the patient’s family members, friends, or caregivers at the bedside. Many patients present to the ED accompanied by key caregivers who may have just as much clinical information or be directly responsible for decision making. Radiologists should also be mindful of the patient’s privacy and always confirm whether the conversation should be conducted alone or in the presence of the other visitors.
Example for gathering additional clinical information: “Hi, I am Dr. Smith. I’m a radiologist here in the emergency department. Patients usually don’t meet with me directly, but I work behind the scenes with your emergency medicine team to review your x-ray studies and help them make decisions based on the imaging findings. I am in the process of reviewing your foot x-rays and would like to perform a focused physical exam to help me better understand what these images mean.”
Example for performing a FAST scan or other ultrasound study and addressing the patient’s family members: “Hi, my name is Dr. Smith. I am a radiologist here in the emergency department. I understand that you are the sister. I usually work behind the scenes with your emergency medicine team to review imaging studies so that the team can use the results to decide on an appropriate treatment. Today, I’d like to perform a quick ultrasound study. After I complete the exam, I’d also like to share with you what I see.”
2
Give Concise Information, Using Terminology the Patient Can Understand
Radiologists may need to explain medical terminology in simple phrases that are easier for the general public to understand. This can be substantially different from using standard medical jargon when talking to other colleagues in the medical field. In addition, it can be helpful to have images ready or to use hand gestures to provide visual context for the verbal explanation.
Example for gathering additional clinical information: “On your foot x-ray, there is a tiny crack in your bone at the same spot where I just pressed. It seemed like that is where you are having pain as well. From what you told me, this may be a stress fracture from increased running with the new marathon training program you recently started.”
3
Provide a Radiology Plan
Describing a concrete plan can help reduce uncertainty for the patient and increase the level of trust between patients and physicians. However, this is particularly challenging in the ED because treatment plans are often in flux during emergent situations, and there are multiple teams involved in caring for any single patient. In this complex environment, radiologists can help reduce patient anxiety by outlining the process as clearly as possible. For example, if the radiologist is asked to perform a FAST exam at bedside, it is helpful to specify how the result will be communicated to the ED provider, whether via phone or in person. The radiologist can also inform the patient that ED providers and the patient’s primary care providers will be able to access the images and the radiologist’s interpretations.
Example for performing a FAST scan: “The study is normal. I am going to return to my work station and review it again carefully with my colleagues to confirm. Immediately afterward, I will speak to your emergency medicine team to tell them the final results so that they can discuss with you further regarding a treatment plan or other test options. I will also submit a report of the study results into your medical record, so your doctors will be able to access my impression along with the images we took.”
4
Use Nonverbal Cues to Show Empathy
A major aspect of effective communication is making the patient feel comfortable through nonverbal cues. For example, physicians can show empathy for the patient by simply sitting down during their conversations together. This alone can convey that the physician has dedicated time to the patient and can foster an environment conducive to establishing trust.
It is equally important to perceive and respond to nonverbal cues from patients. Patients might indicate, through their body language, emotions that they do not feel comfortable expressing out loud. Being aware of these emotions and validating them verbally can be particularly useful in stressful environments like the ED.
5
Answer All Questions With Patience
Even with the limited time available, it is crucial to give patients a chance to ask questions. The radiologist should directly answer any questions pertaining to the imaging results but defer to the ED providers regarding management plans. In addition to answering questions patiently, the radiologist should reassure the patient that there will be future opportunities to ask questions.
Be Present and Add Value as a Radiologist in the Emergency Department
With recent healthcare reform, reimbursement will soon be tied to patient satisfaction. As such, effective radiologist-patient communications are critical for patient-centered value-based care. In one study, Kuhlman et al. showed that 64% of patients want to meet the radiologists who interpret their exams. Cabarrus et al. found that 85% of patients want to see images as part of the conversation when they receive results. Such data suggest tremendous opportunities for radiologists and emphasizes the increasing importance of effective conversation skills when delivering study results to patients. Radiologists must be cognizant and take advantage of such opportunities when they arise. Radiologists often overestimate the time needed to review images with a patient. In many instances, reviewing images can save time, because a visual explanation of the disease process or abnormality may convey more than even a lengthy verbal discussion. Increasing patient awareness of the radiologist’s role in their care is a valuable way to incorporate radiology in patient-centered care.
The American College of Radiology (ACR) Imaging 3.0 initiative emphasizes radiologists’ visibility and leadership. Providing optimal patient-centered care requires that radiologists employ effective communication skills with fellow physicians and providers and with patients. Using the five tips outlined earlier, radiologists can achieve brief but impactful conversations in the ED.
Physician-to-Physician Communication
Radiologists frequently find themselves professionally compelled to propose alternative imaging plans in discussions with physician colleagues in the ED. Unfortunately, the sensitive dynamics of these conversations all too often produce the conditions necessary for a hostile exchange, especially when the proposed alternative is to forgo imaging altogether. The source of this tension is rooted in some of the most common themes underlying medical staff conflict, namely, deficiency in communication, a lack of trust, and incorrect assumptions.
Despite the potential for conflict, up to 40% of referring providers note that they would like to discuss imaging protocols in advance, and up to 50% are interested in feedback regarding protocol selection. Working in a collaborative fashion can seem time-consuming in the midst of a busy shift; however, investing a small amount of effort initially will save time in the end. Communication skills, negotiation strategies, and a touch of charisma are essential. Radiologists must also be attuned to the needs and priorities of their ED colleagues, namely, assistance in rapidly triaging severity of pathology and provision of timely and accurate diagnoses. The following section lists several strategies that will help the radiologist mitigate conflict and deescalate confrontational interactions as they arise.
Four Key Steps in Mitigating Conflict
1
Ask for More Information
When an inappropriate imaging request is ordered, the first step is to call the provider and ask for more information. This is the most critical step in conflict mitigation and will break down barriers of incorrect assumptions and lack of trust. In most instances, acquiring additional information will prove that the study is indicated or aid in choosing a more appropriate study. In conversation, use the keywords “brief” and “quick” to demonstrate respect for their time and the frenetic nature of their specialty. For example, “Can you briefly describe what you’re looking for?”
Case scenario: A noncontrast head computed tomography (CT) is ordered for the indication chronic headache. The radiologist asks for more information, and the ED provider replies, “Yes, the headache is chronic but has acutely worsened in the last couple of hours.” This indication is now appropriate, and the radiologist prevented conflict by asking for more information and avoiding an incorrect set of assumptions.
2
Provide the Best Alternative
Assisting the ED provider in choosing the most appropriate study can be difficult at times, particularly if the alternative causes perceived delays in patient care. However, the radiologist has the responsibility of caring for the patient beyond the ED visit, often on an inpatient or outpatient basis as the patient’s care evolves. The radiologist can leverage this knowledge to assist the ED provider in confidently selecting the best study in the larger context of a patient’s care. In conversation, use the keywords, “Have you considered?” or “Have you thought about?” to demonstrate regard for their clinical judgment and expertise. Other key phrases such as “saves time in the end” or “best answers your question” connect with their fundamental need for rapid and accurate diagnoses.
Case scenario: A noncontrast head CT is ordered for the indication of chronic headache. The radiologist then proposes the best alternative: “Have you considered a brain magnetic resonance (MR) instead, possibly on an outpatient basis if the patient can be safely discharged tonight? This would ultimately yield the most information and is the best diagnostic test for chronic headache. Overall, this would save time in the end and best answer your question, as the head CT will add time and is unlikely to provide diagnostic value.”
3
Provide Coaching
Myriad factors drive ED physicians in their request for inappropriate or suboptimal imaging studies. However, every instance in which a better alternative is available represents an opportunity for shared learning. Navigating these conversations begins with a thorough understanding of the American College of Emergency Physicians (ACEP) clinical practice guidelines. The ability to confidently reference these guidelines enables us to effectively educate our colleagues regarding these nationally developed standards for clinical management of ED patients. One must initiate these opportunities deftly to avoid the air of condescension. Using the keywords “You’re right, however …” in conversation overall signifies agreement but allows for a small educational opportunity.
Case scenario: A noncontrast head CT is ordered with the indication syncope. The radiologist provides coaching: “You’re right, it is important to rule out acute pathologies in the emergency setting. However, the ACEP guidelines actually state that head CT is not indicated in syncope unless there is focal neurologic deficit, significant head trauma, or some other factor guided by history or physical exam.”
4
Arrive at a Resolution Together
Allow for the possibility that your clinical acumen and even widely accepted practice guidelines may not lead to the best solution for every patient. There are circumstances in which the best course may be to trust the ED physician to exercise clinical judgment and learn to trust his or her intentions. Practice guidelines are recommendations and not absolutes. However, the radiology department should track potentially nonindicated studies with quality improvement/quality assurance databases to link outcomes to provider feedback. Low overutilization rates will continue to be essential in keeping the cost of practicing radiology at reasonable levels, particularly in the transition to new payment models, such as value-based care.
How to Deescalate a Confrontational Situation
Confrontations will inevitably arise, and when they do, it is critical to artfully defuse the situation. One effective method is to redirect attention to the needs of the colleague so he or she feels accepted and understood. Take a moment, refocus one’s perspective, and view the interaction for what it is fundamentally: an ED provider who is worried about a patient. Understanding their basic intent encourages warm and genuine responses, which are two of the key tenants in effective and charismatic communication. Maintaining a friendly temperament despite the conflict helps radiologists foster reputations as valued and accessible colleagues.
During disagreements, tone is everything—in voice and language. Tone is directly related to one’s facial expressions, body language, and hand gestures, which unfortunately are absent in most provider conversations. Over the phone, words and intonation are increasingly important, because they are the radiologist’s only form of communication. It is also important not to let emotions control the conversation. Learn to anticipate conflict, which allows one to respond positively, rather than react negatively.
Communication experts recommend having verbal aikidos that we should all feel comfortable using when necessary. The term is a reference to the martial arts technique of redirecting one’s attacker and describes phrases we can use to defuse escalating tension. For example, phrases such as “you’re right” or “I understand” are generic enough to be used abundantly and provide time to generate thoughtful responses. These phrases also represent a small form of flattery and can validate self-esteem, which may be important as hostile conversation often develops as a result of our colleagues feeling that their professional competence and reputation are under attack.
If the conversation becomes frankly confrontational, redirect attention back onto our shared common goal: the patient. The keywords “Let’s take a step back…” allow for a swift, neutral change in the direction of a conversation and represent the subtle offering of an olive branch. Remind the provider of physician-patient shared decision making, in which informing patients of options, and explaining the risks and benefits, is the cornerstone of patient autonomy and respect. For example, “What do you think the patient would want, if we asked? Would he or she want a head CT now, knowing that it will not be helpful and expose the patient to radiation? Or would he or she be willing to wait for a brain MR sometime this week?”
Finally, if all else fails, reiterate one’s commitment to partnership with the ED provider and formulate a resolution, even if it may occasionally represent a suboptimal solution. Emphasize your commitment to the relationship by stating, “I am happy to do what you feel is best, and from my point of view, this has been an educational and productive conversation.” Medicine can be a contentious profession, and it is difficult not to take altercations personally. Long work hours and conflicting demands can lead to disrespectful behavior between medical professionals, and workplace depression causes inward self-focus, lack of empathy, and unwillingness to cooperate. Hopefully, by employing some of these tactics, such situations become the rare exception to what are largely cordial workplace relationships with ED providers.
Communication to Minimize Litigation
Inappropriate interpretation, transcription mistakes, or deficient documentation of communication and recommendation can lead to errors in radiology reports, which in turn may result in legal action against radiologists. A study of the Physicians Insurers Association of America from 1985 to 2000 demonstrates that radiology ranks sixth among all specialties in the number of lawsuits filed and closed. Medical specialties with higher numbers of malpractice suits compared to radiology include obstetrics and gynecology, internal medicine, family practice, general surgery, and orthopedics. However, this data represented the total number of legal cases, suggesting that radiologists actually encounter much higher litigation rates because they represent less than 4% of doctors in the United States. To minimize litigation risk and avoid anxiety related to malpractice suits, it is paramount that radiologists learn the legal ramifications of radiology reports.
Typical legal implications in radiology are related to a variety of deficiencies in interpretation and reporting. Observation errors and errors in interpretation include scanning errors (failure to focus on the area of lesion), recognition errors (focusing on the territory of the lesion but not detecting the lesion), and errors in decision making. Of the above, decision-related errors are the most common, accounting for approximately 45% of observation errors. Finally, satisfaction of search is an error that can occur after detection of an initial lesion, when radiologists can experience reduced perception of other abnormalities, resulting in false-negative interpretations of secondary lesions.
Communicating results and recommendations have also become an essential part of the daily workflow of radiologists. Four out of five malpractice lawsuits in radiology involve complications in communication. Radiologists can minimize the risk of lawsuits by clearly documenting when and how results are communicated to other providers and to patients. Documentation should include the date and time of communication, the name of the person spoken to, and the context in which the results were discussed. A common scenario in a teaching institution would be when an attending’s final report contains a discrepancy with the overnight resident’s preliminary impression. In some lawsuits, courts have ruled that the final report must be conveyed to the ordering providers and the patient, regardless of urgency.
ACR’s Practice Guideline for Communication of Diagnostic Imaging Findings, published in 2010, states that follow-up studies to clarify or confirm initial findings should be suggested and documented in reports. In lawsuits, an ordering physician can claim ignorance of the proper actions following a radiology diagnosis, because the radiologist did not provide recommendations. Therefore, it is important for radiologists to include concrete follow-up instructions to clarify, confirm, or exclude the initial impression.
Four Must-Do’s in Communicating Imaging Results
This section discusses the four key components of communicating imaging results (in the ED or elsewhere). This is an opportunity for radiologists to directly make a difference by ensuring quality patient care while minimizing litigation risk.
1
Physician-to-Physician Communication
For any critical result or incidental findings warranting further workup or change in management, the radiologist commonly makes a phone call to the ordering provider. When conveying the diagnosis, the conversation should be simple and to the point but ensure that pertinent information is understood. It is important to be very clear, especially when offering two or more diagnoses, and explain to the ordering provider why certain differential diagnoses are more or less likely. As discussed in the previous section on physician-to-physician communication, radiologists should remain professional but firm, even if the ordering providers disagree with the imaging diagnoses.
2
Physician-to-Patient Communication
Compared to the outpatient setting, needing to communicate an urgent finding directly to a patient when the ordering providers cannot be reached is less common in the ED because of the ready availability of dedicated ED providers and staff. However, direct radiologist-to-patient communication of imaging findings can occur in the ED when the radiologist is present for the examination (e.g., ultrasound) or is performing a procedure (e.g., esophagram for leak). Radiologists may also need to contact a patient directly when there is a discrepancy with a preliminary report, and the patient has already been discharged from the ED.
3
Documentation
Documenting communication accurately is a crucial component of the patient’s medical record and for minimizing radiologists’ litigation risk. Essential components include date, time, name of the person spoken to, and the information discussed. If any recommendation was conveyed verbally, it is helpful to include it in the communication section as well. Additionally, it is good practice to document multiple communications when multiple attempts were made or if a radiologist conveyed findings to multiple services on the same study. For example, “The above critical result of a large right-sided pneumothorax was communicated to Dr. Smith (ED resident) and Dr. Jones (surgery chief resident) by Dr. Lee at 1000 hours on 1/24/2017.”
4
Further Recommendations
Recommendations, such as follow-up imaging or interventions, should be made and documented when appropriate. In the ED, this may include recommendations to consult other specialties, such as general surgery or interventional radiology, although radiologists should be careful that such subspecialty consultations are truly warranted. For example, “Recommend follow-up head CT in 6 hours and neurosurgery consult.”
Communication Challenges in the Emergency Department
1
To Whom Should Results Be Communicated in a Busy ED Setting?
At a teaching institution, radiologists may need to decide between conveying results to the attending emergency medicine physicians or the residents. In these situations, one should consult the standard protocol in his or her institution’s ED. Regardless, it is important to always document if a radiologist is unable to reach the ordering provider and the subsequent action taken if any. For example, “Unable to convey results to attending physician (Dr. Smith); the above critical finding was conveyed to the senior resident (Dr. Jones) in the ED.”
2
How Should Nonurgent Incidental Findings Be Managed?
An incidental finding may not seem like a priority in the busy ED setting, but communication and documentation are still necessary to ensure needed outpatient workup. For example, “This is not an emergent finding, but further outpatient workup is recommended.”
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