In radiology, the degree of direct patient contact is extremely variable depending on the type of exam that is being completed, degree of involvement of the interpreting or operating radiologist and the geographic region of practice [8
]. Restructuring the method of delivering results to patients offers an area of possible enhancement within the daily practice of radiology. The augmentation of value of a radiologist through direct patient communication may also hold great potential [9
]. In addition, a blended practice pattern of establishing patient relationships via direct result communication and imaging review may help alter patient behavior [22
]. Arguments for increased interaction with patients and direct communication have ranged from patients’ desire to hear results after exams, legal and ethical responsibility, and increasing promotion of the field of radiology and its role in healthcare [5
]. Direct communication of results by radiologists may also result in improved patient care by closing the communication loop [6
]. Prior work analyzing a novel direct electronic communication with referring physicians regarding important, but non urgent findings, encountered during exam interpretation displayed 15.4% of these notifications went unread [24
]. In addition, increased direct communication may also help improve public awareness of radiologists. Our data showed only 56% of patients recognized a radiologist as a physician who interprets imaging exams. This is similar to prior survey work conducted by the American College of Radiology in 2008 which showed only 48% of respondents knew that a radiologist was a licensed physician who interprets results of imaging tests [22
Many opposed to direct communication of results have raised several important points ranging from increased legal liability, possible harm by communicating results without full patient history/results, lack of an established relationship with the patient, lack of time due to high clinical volume (especially in private practice environment), creating increased work for referring physicians, and discomfort when communicating bad news such as a new diagnosis of malignancy [4
]. A survey conducted in 1992 showed that as results become more complex or severe, there was a decrease in both the radiologist’s desire and referring physician’s acceptance of result disclosure by the radiologist [13
The preferences of patients receiving care in the United States have been investigated in prior survey studies and displayed preference for direct disclosure of results by the interpreting radiologist both within and outside of mammography[1
]. Our study differs from prior work with 91% of our patients expressing preference to hear results from both the radiologist and ordering provider after completing our consultation session. This is much higher than a recent survey only study where 14% of patients chose this method for normal results and 27% for abnormal results [1
]. Our data also showed a much higher acceptance (99%) of hearing both normal and abnormal results from the interpreting radiologist after the consultation session. This discrepancy likely relates to a more uniform acceptance once patients meet the radiologist and review the results/exam in person as done in our study.
Additionally, our results revealed a statistically significant change in reported anxiety levels; with most patients reporting decreased anxiety after radiology consultation session. A similar trend in patient preference to hear results quicker found in prior work was confirmed by our study with the vast majority of patients (98%) choosing the opportunity to always review or have option to review future exams with a radiologist the same day even if it meant waiting longer [1
]. The benefit of immediate communication would eliminate the additional waiting to hear from the ordering provider under normal current practice, a time described by many patients as a period of high anxiety [7
]. However, it should be noted that even those patients in our study with clinically significant or important findings (assigned category 4) showed no statistical difference in desire to review future exams with the radiologist or perceived benefit of reviewing the exam with the radiologist. In addition, most in this category also reported a decrease in anxiety levels after consultation.
An important issue to consider is the time that such encounters take and the result on the workflow in a radiology practice. We found that the overall time for reviewing ultrasound exams was shorter than that of CT which likely relates to the number of images in each exam. As ultrasound exams tend to be shorter, they can be reviewed quicker and at our institution (and many other academic settings) the exams are always reviewed by a radiologist prior to patient dismissal, so no additional time was needed for this portion of the study protocol. The consultation session duration was also shorter for ultrasound then CT. Range of session time was variable, largely based on the complexity of the exam/number of images, the exam findings and patient questions. We acknowledge that instituting direct communication may temporarily diminish revenue as prior work in mammography assessing direct communication concluded, “talk isn’t cheap” [14
]. Based on our data analysis, a radiologist could expect a “cost” associated with time needed to review results directly with the patient, which is not reimbursed.
As this was a pilot study not previously performed at our institution it was new to both the investigators and patients. Many of our patients had never seen their images or had them formally reviewed and hence had many basic questions which necessitated overview of the exam, and review of basic of anatomy with the patient prior to reviewing actual results. We would expect the time to review studies would improve as practices and patients become more accustomed to this process.
Unique patients’ preferences based on cultural and geographic background was suggested by a prior German study which showed slight preference in receiving results from the referring physician rather than the radiologist [26
]. While our data is limited by small sample size a similar preference was also seen in patients within race category Asian and Other () prior to the consultation session. In addition, as shown in a higher percentage of patients in these race categories opted to only review future exams with a radiologist when they ask while most Caucasian or African American patients opted to always review future exams with the radiologist. This may relate to a partial language barrier for these patients especially if the ordering provider/PCP speaks their primary language.
There are several limitations to our study. There is a potential for selection bias by enrolling only those patients that have an interest in meeting with and having results given by a radiologist. We did not formally document the reasons that eligible patients chose to decline enrollment and it is possible that those patients were not comfortable interacting with or hearing results from a radiologist. We did not assess patient education in this study, with prior work showing a statistically significant trend in higher educated patients asking for results immediately or the exact reason patients found the consultation helpful (i.e. quicker results, education on disease process, enjoyed viewing images, etc) [18
]. Only a limited cost analysis based on typical revenue generated by a fellow in our department was performed. Potential loss in revenue would be variable based on the number of exams reviewed and productivity of the radiologist. Our cost analysis did not assess any effect on patient outcomes, reduction in downstream costs such as eliminating unnecessary follow up appointments to receive results, or change in exam volume from initiation of this practice (which has been reported to increase referrals/revenue) [20
]. In addition, all consultations were performed by a radiology fellow minimizing impact on the radiology attending’s work flow. While this method may not be applicable to most private practice groups, similar methods of allowing direct result communication are already being performed by some groups [20
]. Incorporating direct communication into daily practice could potentially mean that groups would have to decrease scheduled patients per day to allow communication time or assign a provider to act as a “patient consultant” for the day. Further work is needed to better evaluate potential changes in practice management and revenue if direct communication of results was implemented or offered. Only three different individuals, all of whom were American Board of Radiology certified radiologists completing an abdominal radiology fellowship, participated in the patient consultations sessions and therefore data may be skewed by these investigators’ communication abilities, “bed-side” manner, and clinical knowledge which may not apply to all radiologists. No assessment of our referring physicians’ opinion on this model was undertaken but prior work assessing referring physician comfort with result disclosure by radiologists has indicated acceptance, especially when the result is normal or with “mild” abnormality [13
]. We acknowledge the limitation of applying our results to all patients given that our study excluded hospitalized patients, known oncology patients and patients undergoing exams for neurologic or musculoskeletal indications, which are read by separate sub-specialized radiologists at our institution. Lastly, 58% of our exams were rated as normal or with clinically unimportant findings, which could have resulted in better acceptance by our patients regarding direct communication of results by the radiologist.
We believe acceptance of a new role of the diagnostic radiologist in result communication in CT, US or MRI could mirror that seen after implementation of MQSA in mammography [7
]. While direct radiologist communication of results to patients will likely remain a hotly debated topic, our study clearly demonstrates that patients desire direct communication of results after exam completion, are comfortable hearing both normal and abnormal results and anxiety decreases (for most patients) following result communication. The time added to daily practice by incorporating result communication seems reasonable and will likely decrease with time, yielding more informed and satisfied patients.