The Radiological Identity Crisis

Some worrying conclusions can be drawn from the research of Prof. Lorenzo Derchi and his team at the department of radiology in Genoa, Italy, concerning the relationship between radiologists and patients. Paramount to this is their ongoing work exploring not only what patients think of the radiologist, but whether they even recognise which of the medical team they meet with during their exam, is the actual radiologist.

Prof. Derchi states that "Medical imaging is growing in significance in medicine, as physicians increasingly rely on imaging findings as a key part of the clinical examination of the presenting patient. Patients, too, have great trust in medical imaging; they more and more often go to their own family doctor asking not to be examined by him, but to be referred to an imaging examination. The referring physician then contacts the radiologist to perform the exam. However, in most cases, the radiologist is not in the actual room during the patient's exam, but in another room in front of the monitor of his/her workstation reading images. So, though patients rely on imaging to assist in diagnosis, there is great distance between patient and radiologist".

He continues, "There is a sort of factory mentality in the organisation of workflow that has developed in response to the explosion in the number of imaging studies being requested, which calls for efficiency and cost-control rather than greater recognition of the intrinsic value of patient-radiologist contact. Imaging departments are often regarded as "examination factories" and not as clinical services. In this interview, Prof. Derchi explains his findings in this regard and explains why radiologists need to interact with their patients. 

Patients Vs. Citizens & Politicians

Prof. Derchi draws attention to the dichotomy between a patient's desire for personal contact with their specialist, and the drive for efficiency: "Politicians and citizens alike want radiologists to spend tax funds efficiently on healthcare and imaging. In this situation, efficiency itself is regarded as the desired goal. On the other side, patients wish radiologists to be as human as possible – to show attention and care to the person as well as the image." When they are healthy, medical imaging is perceived by people in one way – when in need, it is viewed in quite a different light.

In their report, entitled "How often do patients ask for the results of their radiological studies?", Prof. Derchi and his team made a study of outpatients in their radiology department in Genoa, where they monitored how many patients were asking the radiologist or technician for immediate feedback after their imaging exam (1). 1,171 outpatients underwent CT (382) ultrasonography (384), or MR of the extremities (405). The first of three groups studied were undergoing CT exams, which was performed by technologists and nurses. In this case, the radiologist was only visible to the patient if there was the need for informed consent for the use of contrast agents.

In the second group, who were undergoing ultrasound, this was performed by an actual Board-certified radiologist.
In the third group, who were undergoing MR exams of the extremities, these were performed by physicians residents in training to become radiologists and then reviewed afterwards by a specialist. In both these groups this was followed by direct patient/physician interaction and dialogue. Results showed that more than 50 percent in the ultrasound and MR patient groups and only 23 percent in the group undergoing CT asked for more communication as to the results of their exam - from anyone in the room, not specifically the radiologist.

From this, Prof. Derchi and his co-researchers conclude the following: "If we communicate with our patients as physicians, they will treat us as physicians. They will enquire about their health just like with any other doctor". Prof. Derchi states that "Traditionally, radiologists receive a request from the referrer, and give the answer to the referrer and not the patient. The referrer is the physician to whom the patient will look for further information. There are a number of papers that focus on the role of communication skills in radiology, and all agree that direct contact with patients is important. We must learn how to talk with them, even when bad news has to be given. As for outpatients, it is becoming recognised that communication of the results has to be given directly to the patients, and not only to their referring physician (2)". Indeed, the conclusion of this study is that "We believe these results show the importance of the direct doctor-patient relationship during radiological studies. Communication, time to talk and provision of information are probably the most important things patients want from their doctors. Our study suggests that this is also relevant in radiology and, when given the opportunity to meet the radiologist, patients appreciate the interaction (1)."

What Can We Conclude?

Prof. Derchi is philosophical about any potential resolution to this schizophrenic view of the act of medical imaging: "Maybe the first step is not to obsess about efficiency to the point of excluding patients from our daily working lives. When we are looking at our workload with a view to patient scheduling, perhaps some time should be allocated for interacting with patients, not simply for when informed consent is required. Communication should be an integral part of workload planning – reading an exam can only be enriched by increased knowledge about a patient that comes from speaking with them about their condition. And patients will possibly feel reassured at seeing the 'man or woman behind the machine'." He restates that "Medical imaging is growing more and more important in clinical practice, overall. However, the role of the radiologist physician is becoming simultaneously less visible. We need to find ways to increase our visibility. We can do this by:
1. Introducing ourselves to the patient at the beginning of the exam;
2. Asking a few questions about why the patient is there, and
3. Considering the steps needed to make a complete radiological act and assessing where the radiologist can have more impact (a.} Justification for the exam b.} Plan the correct type of exam and protocol c.} Do the exam d.} Read the exam e.} Interpret it f.} Communicate the report to the patient, whenever possible, or the referrer).

With the growth of an increasingly factory-like mentality, we try to optimise time. When you realise that support staff such as clerks and technologists are already doing quite a portion of the above outlined steps, then the radiologist is in danger of becoming invisible. "In ultrasound, you see the patients, which adds context to the examination procedure." Worryingly, Prof. Derchi adds that "In our new research, we asked patients what they think about radiologists. It arose that patients were unable to differentiate radiologists from technologists in the department. Many who only have contact with the technologist assume that they must logically be the radiologist, since they are working with the equipment. This is a risky state of affairs for the professional recognition of the work of a radiologist, and a worrying symptom for the future if no action is taken".