The Right to Speak?

Experts weigh in on giving imaging results directly to patients.the right to speak

Radiologists have traditionally served as the "strong, silent type" in the health-care arena. Although they are a critical bridge between the patient and the referring physician, their voices were often unheard or deemed unnecessary.

But in this new era — where patients are educated, informed, and ready to litigate — radiologists can no longer afford to keep their silence. Today's professionals must be willing to stand in the gap between the patient and referring physician and, as needed, be an active, vocal partner, ensuring patients receive superior care. So, how do radiologists determine when they should speak up?

The first step toward charting the communication waters begins with understanding one of the most trusted documents on the issue: The ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Now in its fifth revision, the guideline has been mentioned in legal cases for and against radiologists and as a foundation for communication standards throughout the radiologic community.

The guideline remains a hotly contested topic among radiologists, accruing 110 comments since its creation in 1991. Despite garnering four times the feedback for a typical ACR standard,1 this document continues to be beneficial for today's practicing professionals. "Overall, the guidelines have more pluses than minuses," says Leonard L. Lucey, J.D., LL.M., legal counsel and senior director for the ACR Department of Quality and Safety.

While the federal Mammography Quality Standards Act already mandates that radiologists deliver mammography results directly to patients, the revised ACR standard recommends direct communication to the referring physician for findings that require immediate intervention. In the most extreme or life-threatening cases, radiologists can report results directly to the patient when that patient's physician cannot be reached. These cases include urgent imaging results from emergency and surgical departments, second interpretations that are significantly different from the first and may change a course of treatment, and any findings for which the imager believes a delay in communication will be seriously adverse to the patient's health.

The guideline also states, "Regardless of the source of referral, the interpreting physician has an ethical responsibility to ensure communication of unexpected or serious findings to the patient. Therefore, in certain situations the interpreting physician may feel it is appropriate to communicate the findings directly to the patient."2

While these new recommendations gave radiologists more license to speak up if needed, many were uncomfortable with circumventing the traditional reporting systems and rapport with referring physicians. "Not all radiologists are good at speaking to patients," says Richard N. Taxin, M.D., FACR, from Southeast Radiology Ltd. in Chester, Pa., and vice chairman of radiology at the Crozier Chester Medical Center in Upland, Pa. "[Also] patients may get things wrong when they hear things, and they may miss out on a lot. This can lead to all kinds of complications."

Armed Patients

Regardless of a medical professional's preference or comfort level, today's patients are demanding more from all of their health-care professionals — including radiologists. With the increasing popularity of medical websites like WebMD.com and MedicineNet.com, patients have more access to diagnostic information than ever before. Gone are the days of simply accepting a medical diagnosis without question or explanation. Instead, patients are well informed and want to partner with their medical professionals.

"Historically, radiologists did not communicate directly with patients," says Leonard Berlin, M.D, FACR, vice chair of radiology at Northshore University HealthSystem at Skokie Hospital in Skokie, Ill., and radiology professor at Rush University Medical College in Chicago. "Radiologists would make sure the X-ray was done, write up a report for the referring physician, and send it back," Berlin continues. "Now, we are beyond the age of 'paternalism' in medicine where the doctors are the ultimate authority. We are now in an age of 'consumerism' where patients are very involved and want to know about their treatment options."

Empowering patients is an important principle for Harley J. Hammerman, M.D, CEO of Metro Imaging in St. Louis. When local physicians in his area began acquiring their own imaging equipment, Hammerman made the decision to provide imaging results directly to his patients. Although there was some grumbling from his fellow physicians, Hammerman believes that immediately giving his patients their results provides peace of mind and helps them make better decisions.

"Patients don't want to spend weeks being worried or concerned," he says. "They would rather hear and know [their results]. This gives patients the time to do their research and be better prepared to have a discussion with their physician."

Berlin similarly advocates for keeping patients in the loop. He says, "If I saw something on a patient's film, I couldn't bring myself not to tell him or her about it. [Delivering results] to my patients never worked against me, and it helped me build up a nice relationship with them."

While Taxin believes direct communication is a great courtesy to extend to patients, he argues that it takes a lot of time. "Our practice reviews more than 365,000 examinations every year," he says. "While [we are required by law] to discuss diagnostic mammography results with every patient, we wouldn't have time to provide this service for every patient. I believe that, in general, patients are best served by their referring physicians, who can explain the intricacies of a diagnosis with more detail."

When the Law Intervenes

The decision to cross the communication divide with patients is more than just a professional preference; it also comes with legal considerations. While the ACR guideline states, "the ultimate judgment ... of any procedure or course of action must be made by the physician or medical physicist," several prominent court cases, including Phillips v. Good Samaritan Hospital, Jenoff v. Gleason, Stanley v. McCarver, and Williams v. Lee, have also made radiologists equally responsible for the patient's ultimate well-being.
"Imagine having to stand before a jury and defend why you didn't tell a patient that you saw a potential cancer in his screening," Berlin says. "If you were to simply say, 'It wasn't my job to deliver those results,' and the patient dies because they didn't receive the news in a timely manner, that's a very hard thing to defend legally and morally."

If a radiologist has to stand on trial, Hammerman believes that developing a relationship with patients will be beneficial. He says, "Most of the physicians who are sued don't have a relationship with their patients. When we take the time to develop a relationship with them, if something goes wrong, we are less likely to be sued."

Even if radiologists aren't comfortable delivering critical medical news to a patient, they are still obligated to ensure that image results get to the referring physician quickly and efficiently. "Courts generally hold radiologists responsible for getting a report where it needs to be and making sure that it is acted upon," Lucey notes. "Although, the communication guideline does also emphasize that referring physicians share in the responsibility of obtaining results of imaging studies they order," he adds.

While many radiologists are still divided about communication, the next cue may come from patients. "The trend is moving in the direction of providing [imaging] reports directly to patients," says Berlin. "It's the right thing to do and I believe it is eventually going to happen." Regardless of where you stand on the issue of communication, the ultimate responsibility is clear — every radiologist must make decisions to ensure the health, safety, and well-being of patients.


ENDNOTES
1. Lucey L et al. “The ACR Guideline on Communication: To Be or Not to Be, That Is the Question.” Journal of the American College of Radiology 2010;7:109−114.
2. ACR Practice Guideline for Communication of Diagnostic Imaging Findings. American College of Radiology, Reston, Va., 2005.


By Leah Lakins

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