Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy
■ Clinical Practice Management
■ Training & Education ■ Leadership

Failing to Communicate

Knowing that many referring physicians never read radiology reports may encourage radiologists to be more proactive in verbally communicating non-emergent but important clinical findings.

"What we have here is failure to communicate" and "The single biggest problem in communication is the illusion that it has taken place." Two quotes from two different sources. The first is from one of my favorite movies, "Cool Hand Luke", a 1967 film classic that celebrated its 50th anniversary last year. You may remember the oft-quoted line from the movie, uttered by Strother Martin (as the prison warden) to Paul Newman (as the stubborn prisoner), when the warden attempts to teach his prisoner a lesson in prison etiquette. The second is from a more literary source, attributed to the great Irish playwright George Bernard Shaw.

There is a robust literature that documents communication failures in radiology. The problem goes beyond the daily difficulty of trying to contact a referring provider regarding a critical result. Poor communication can occur between the radiologist and the referring provider as well as between the referring provider and the patient. As outlined by a 2017 RSNA study, another surprising instance of poor communication occurs when referring providers simply do not read the reports of studies ordered on their patients. Overall, 23 percent of reports are never viewed. Specifically, outpatient providers are more likely (33 percent of the time) to never view the report. Unfortunately, this is not a new problem. As far back as 1990, the ACR Bulletin recognized that "radiologists frequently cannot depend on the clinician to read a written report" and recommended that radiologists make direct phone contact before sending the written report. 

Amidst the ongoing chaos in the manner by which medical information is transmitted, radiologists are (fairly or unfairly) increasingly being held to a higher standardIt is no longer the expectation that 100 percent of the responsibility can be transferred to the referring provider if there is a bad outcome because of an unread study. In a court of law, the referring provider's failure to obtain the report may not necessarily absolve the radiologist of the duty to communicate an important finding. We all know of the legal and ethical responsibility to verbally communicate ER and inpatient critical findings in a timely fashion. What about non-urgent findings (such as lung mass, renal mass, AA, etc.) that may not require immediate intervention but would still be better relayed through a conversation rather than through the written report?

Why bother ordering a study if there is no plan to read the report? What if the unread study contains an important finding that is not addressed in a timely manner? The timely access to reports is further exacerbated by the growth in diagnostic test volume and the lack of effective test result tracking systems in many practices. An older 2004 study from JAMA Internal Medicine titled "'I Wish I Had Seen This Test Result Earlier" reported that the typical internal medicine physician receives 800 chemistry reports, 12 pathology reports, and 40 radiology reports per week. Without a rigorous, technology-enabled process, it is not too difficult to envision how results may go unnoticed and unreported. Recognizing the potential breakdown of communication between patients and their physicians, the Pennsylvania House of Representatives recently passed House Bill 1884The legislation requires imaging centers to communicate clinically significant findings directly to the patient within 20 days of the results being sent to the ordering physician. The test result may be communicated to the patient directly or be sent by email or fax, or they may be available through an online patient portal. Confirmation by the State Senate is pending.

As guidance, the latest 2014 revision of the ACR Practice Parameter for Communication of Diagnostic Imaging Findings contains language that suggests the communication of a diagnosis is as important as the diagnosis itself. The document outlines specific situations in which the radiologist "should expedite the delivery of a diagnostic imaging report in a manner. . . that ensures timely receipt of the finding." Although various ACR guidelines do not necessarily reflect the standard of care, they nevertheless carry significant legal weight and plaintiff lawyers know more about the guidelines than most radiologists.

Radiologists can be held liable for the failure to communicate non-emergent but important findings. We should become more comfortable with talking to someone when there is an unexpected finding. New techniques to identify instances of failed follow up are being used: electronic triggers using artificial intelligence, machine learning, and reading room coordinators are all being used to identify patients who may have fallenthrough the cracks. A simple phone call and documentation of the conversation is still a good option. Moreover, a conversation helps maintain a good relationship with the referring provider and may also provide the radiologist with additional diagnostic information. Better to spend a few minutes contacting a referring provider than to spend anxious days and weeks preparing for litigation.

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Thursday, 18 July 2019

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