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Radiologist-Patient Communication: Current Practices and Barriers to Communication in Breast Imaging
ORIGINAL ARTICLE
Radiologist-Patient Communication: Current Practices and Barriers to Communication in Breast Imaging Shadi Aminololama-Shakeri, MD a, Mary Scott Soo, MD b, Lars J. Grimm, MD, MHS b, Meredith R. Watts, MD c, Steven P. Poplack, MD d, Jocelyn Rapelyea, MD e, Nicole Saphier, MD f, Rand Stack, MD g, Stamatia Destounis, MD h Abstract Purpose: The aim of this study was to assess variability in radiologist-patient communication practices and barriers to communication among members of the Society of Breast Imaging (SBI). Methods: A 36-item questionnaire developed by the SBI Patient Care and Delivery Task Force was distributed electronically to SBI members to evaluate patient communication, education, and screening practices. Data from 14 items investigating patient communication (eg, practices, comfort, barriers to communication) were analyzed and compared with demographic variables using c2 or independent t tests as appropriate. Results: Ninety-three percent of radiologists reported that they directly communicate abnormal results of diagnostic mammographic examinations that require biopsy and malignant or high-risk biopsy results that require surgery. Radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. Most respondents were completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients, and 71% rated their communication skills as excellent. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication were that practices were not set up for direct communication (loss of revenue) and discomfort with angry patients. Conclusions: Although variation in breast imaging communication practices exists among radiologists and practice types, the majority of radiologists directly communicate the most distressing results to patients, such as those regarding abnormal diagnostic mammographic findings requiring biopsies and abnormal biopsy results leading to cancer diagnoses and surgery. The majority of radiologists are completely comfortable with these conversations, but all feel that enhancing communication with patients will lead to greater patient satisfaction. Key Words: Patient-centered care, patient communication, breast imaging, patient satisfaction J Am Coll Radiol 2018;-:---. Copyright 2018 American College of Radiology
INTRODUCTION Direct radiologist-patient communication is an integral part of breast imaging care delivery. For decades, standardized reporting and communication of breast imaging
results with patients and their providers have been federally mandated and facilitated by BI-RADS [1]. Breast imaging is the only practice in radiology required to provide a patient with her imaging results in a report
a Department of Radiology, University of California, Davis, Sacramento, California. b Breast Imaging Division, Duke University Medical Center, Durham, North Carolina. c Breast Imaging Section, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania. d Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri. e The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.
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ª 2018 American College of Radiology 1546-1440/18/$36.00 n https://doi.org/10.1016/j.jacr.2018.10.016
Memorial Sloan Kettering Cancer Center, New York, New York. WESTMED Medical Group, Rye, New York. h Elizabeth Wende Breast Care, Rochester, New York. Corresponding author and reprints: Stamatia Destounis, MD, Elizabeth Wende Breast Care, 170 Sawgrass Drive, Rochester, NY 14620; e-mail: [email protected]. The authors have no conflicts of interest related to the material discussed in this article. g
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written in lay language within 30 days of the examination. This patient communication is mandated under the Mammography Quality Standards Act [2]. Evolving with this process, many breast imaging radiologists have routinely discussed results and recommendations of diagnostic imaging and biopsies with patients and their providers. As such, the breast imaging model has been integrated into emerging initiatives to optimize patients’ experiences in radiology departments, such as the ACR Imaging 3.0 [3] and the RSNA Radiology Cares [4] campaigns, which emphasize patient-centered care (PCC). Defined by the Picker Institute, PCC provides information and education, respects patients’ values and preferences, involves family and friends, and provides emotional support to alleviate fear and anxiety [5]. Initiatives to enhance PCC and patient satisfaction may also affect reimbursements for some practices, as measures of patient satisfaction (eg, the Hospital Consumer Assessment of Healthcare Providers and Systems) are included in recent CMS payment models [6,7]. Effective radiologist-patient communication is one means of enhancing patient experiences in radiology [8,9]. In breast imaging, studies have shown that patients’ lack of understanding regarding stereotactic biopsy procedures is associated with higher levels of expected discomfort [10]. In addition, better communication with radiologists, as perceived by patients during breast biopsy recommendations and procedures, has been associated with lower patient anxiety [11,12]. Furthermore, patient-centeredness, equity, and respect from staff members are predictors of high patient satisfaction in breast imaging [13,14], and better radiologistpatient communication is associated with fewer malpractice claims and may positively affect patient outcomes and psychological symptoms during cancer treatments [15]. Direct radiologist-patient communication may therefore be a critical component of the delivery of optimal PCC and satisfaction [5]. However, barriers to communication and heterogeneity of practice settings could affect radiologists’ capacities to implement direct communication of results, education, and care initiation services. The Society of Breast Imaging (SBI) Patient Care and Delivery Task Force (PCDTF) was created to enhance patient communication and education, provide related resources to the radiology community, promote patients’ involvement in their own care, and enhance patient satisfaction. To begin to evaluate these issues, the SBI PCDTF surveyed breast imaging radiologists, 2
with the goals of determining the degree of variability in communication practices among breast imaging radiologists and understanding barriers to communication in these settings. The results of this study could provide valuable insights for creating further initiatives to enhance communication and other care delivery services as guided by Imaging 3.0.
METHODS Survey Measure A 36-item survey was developed by the SBI PCDTF to evaluate breast imaging practice patterns and perceptions related to patient communication, education, and screening practices among SBI member radiologists. Initial questions were generated and vetted by a subcommittee of the SBI PCDTF. A preliminary version of the survey was sent to a small group of practicing breast radiologists. Feedback regarding content, clarity, and length of survey was incorporated, and the final 36-item survey was reviewed and approved by PCDTF members. An electronic link to the survey (SurveyMonkey, San Mateo, California) was distributed via e-mail to all members of the SBI, targeting radiologist responses. All survey responses were collected anonymously. The survey items specifically related to communications presented in this manuscript are available in Appendix 1. Participants and Response Rate SBI members (n ¼ 2,672) at the time of the survey included 1,992 practicing radiologists, 615 radiology trainees (ie, fellows, residents), and 65 affiliates (eg, technologists). The survey was sent electronically on February 16, 2017, to SBI members via e-mail through SBI Weekly Member Update. The survey was available for 90 days, with reminders sent weekly. Participation in the survey was also encouraged daily during announcements at the 2017 SBI/ACR Breast Imaging Symposium. A total of 1,410 SBI members opened the e-mail, and 280 survey responses (10.5% response rate [280 of 2,672]) were received. The few respondents reporting that they were trainees (n ¼ 4) or technologists (n ¼ 1) were excluded from subsequent analysis, resulting in 275 responses in the final analysis. Data Analysis Comparisons were made between survey responses and demographic variables using c2 or independent Journal of the American College of Radiology Volume - n Number - n Month 2018
t tests as appropriate. Multivariate analysis was performed when noted with respondent demographic variables as inputs. Respondents without breast imaging fellowships but who (1) indicated that they trained before the introduction of breast fellowships or (2) had been practicing breast imaging exclusively for 10 years or more were included in the fellowshiptrained category. Statistical analyses were performed using JMP Pro version 13.0.0 (SAS Institute, Cary, North Carolina).
RESULTS Demographics The majority of respondents identified themselves as female (61%), fellowship trained (56%), and working exclusively (100% of their time) in breast imaging (56%). A plurality of respondents have been in practice more than 20 years (39%) and worked in large private practices (38%) (Table 1). Patient Communication Table 2 demonstrates the variability in who conveys the results of specific breast imaging studies to patients most of the time; respondents were permitted to choose all applicable options. The response “mailed letters/electronic notification” was most frequently selected as the primary means of notifying patients of normal results of screening mammographic examinations (84% of respondents), abnormal results of screening mammographic examinations (53%), and normal results of screening breast MRI examinations (57%). Ninety-three percent of radiologists reported that they directly communicate abnormal diagnostic mammographic results, whereas both radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. The only imaging results that the majority of survey respondents indicated were most often delivered by referring providers were from screening MRI (56% for normal results, 53% for abnormal results). Only rarely were radiology trainees and midlevel practitioners reported to be responsible for providing study results most of the time. To further understand radiologists’ involvement in communicating results to patients, Table 3 shows the percentage of time that radiologists, including trainees, discuss results of various breast imaging studies. Regarding communication of abnormal results, 80% of respondents indicated that radiologists in their practices Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
Table 1. Survey respondent demographics Characteristic Gender Male Female Defer/did not respond Age (y) <30 30-40 41-50 51-60 61-70 71 Did not respond Work environment Academic Small private practice Large private practice Managed care setting Other Breast clinical time 100% 75% 50% 25% <25% Did not respond Years in practice <5 5-10 10-20 >20 Did not respond Training type Fellowship trained General radiologist Trainee Technologist Did not respond
n (%) 80 (29) 171 (61) 29 (10) 1 (0) 63 (23) 52 (19) 89 (32) 40 (14) 8 (3) 27 (10) 95 (34) 48 (17) 106 (38) 4 (1) 27 (10) 158 (56) 52 (19) 32 (11) 7 (3) 4 (1) 27 (10) 39 (14) 53 (19) 51 (18) 110 (39) 27 (10) 157 (56) 91 (33) 4 (1) 1 (0) 27 (10)
frequently (76%-100% of the time) discussed abnormal diagnostic mammographic results with patients; likewise, the plurality (47%) also frequently provided patients with malignant or high-risk biopsy results. On the other hand, most respondents indicated that radiologists very infrequently (0%-25% of the time) communicated screening mammographic, abnormal MRI, and benign biopsy results to patients. Only 6% of respondents indicated that screening mammographic results were provided directly to their patients frequently by radiologists in their practices. 3
0 (0) 2 (1) 3 (1) 4 (1) 1 (0) 1 (0) 3 (1) 3 (1) 5 (2) 6 (2) 1 (0) 1 (0) 110 (40) 109 (40) 0 (0) 0 (0) 13 (5) 13 (5) 3 (1) 3 (1) 72 (26) 71 (26) 24 (9) 23 (8) 22 (8) 23 (8) 154 (56) 146 (53) 94 (34) 106 (39) 232 (84) 146 (53) 67 (24) 36 (13) 47 (17) 38 (14) 156 (57) 90 (33) 24 (9) 24 (9) 16 (6) 120 (44) 5 (2) 24 (9) 11 (4) 5 (2) 12 (4) 49 (18) 19 (7) 9 (3) 5 (2) 28 (10) 3 (1) 9 (3) 6 (2) 6 (2) 14 (5) 37 (13) 96 (35) 53 (19) 37 (13) 54 (20) 46 (17) 16 (6) 158 (57) 24 (9) 6 (2) 16 (6) 8 (3) 4 (2) 5 (2) 8 (3) 7 (3) 12 (4) 36 (13) 42 (15) 3 (1) 11 (4) 23 (8) 22 (8) 35 (13) 45 (16) 69 (25) 109 (39) 182 (66) 255 (93) 27 (10) 56 (20) 124 (45) 173 (63)
Note: Data are expressed as number (percentage). MMG ¼ mammogram; PA ¼ physician assistant; RA ¼ radiologist assistant; RN ¼ registered nurse.
Study Type
Normal screening MMG Abnormal screening MMG Normal whole-breast ultrasound Abnormal whole-breast ultrasound Normal /negative diagnostic examination Abnormal diagnostic examination Normal screening breast MRI Abnormal screening breast MRI Benign biopsy results Malignant/high-risk biopsy results
“In your practice, who communicates the results of the following examinations to patients most of the time? Check all that apply” Report/ We Don’t Letter/ Provide Electronic Referring Resident/ RN/PA/ Clerical This Service Other Notification Clinician Radiologist Fellow Technologist RA Personnel Table 2. Providing Patient Results
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Further analyses correlating respondents’ demographics with communication practices showed statistically significant differences among certain practice environments (Table 4). A higher percentage of respondents from small private practice groups reported that their radiologists frequently (76%-100% of the time) communicate normal screening mammographic results (13%), normal results of diagnostic workups (56%), and abnormal breast MRI results (33%) compared with academic (3%, 29%, and 17%, respectively) and large private practice groups (3%, 38%, and 10%, respectively) (P < .05 for all). Similarly, more respondents from both small private practice groups (35%) and academic practices (43%) indicated that benign biopsy results were frequently communicated to patients compared with large private practice groups (22%) (P < .001). These results suggest that small private practice groups engage in more direct communication with patients overall compared with academic and large private practice groups. Groups in managed care plans and respondents who did not indicate their practices were excluded from this analysis given the small number in this study (n ¼ 31).
Comfort With Patient Communication The majority of survey respondents reported that they are completely comfortable with directly communicating results to patients when recommending additional imaging (92% [248 of 275]), need for biopsy (93% [252 of 275]), and delivering biopsy results (86% [233 of 275]). Moreover, 71% rated their skills communicating with patients as excellent, and 26% rated their skills as above average. Only 3% of respondents reported average communication skills. There was a significant association between respondents reporting average communication skills and those spending less time in breast imaging. Respondents’ age, gender, years of practice, and other variables did not correlate with self-reports of communication skills. All (100%) respondents expressed that enhancing overall patient communication in their breast imaging practice would improve their patients’ overall satisfaction with care. Barriers to Communication Nearly one-half (47% [128 of 275]) of respondents reported that they perceived no barriers to effective communication with patients. However, other respondents indicated that their “practice is not set up to accommodate communication/loss of revenue” (23% [63 Journal of the American College of Radiology Volume - n Number - n Month 2018
Table 3. How often does a radiologist, including a trainee, communicate results? Study
0%
1%-25%
26%-50%
51%-75%
76%-100%
NA
Screening mammogram Whole-breast ultrasound Abnormal diagnostic mammogram Abnormal MRI Benign biopsy Malignant/high-risk biopsy
114 (41) 40 (15) 6 (2) 91 (33) 64 (23) 51 (19)
117 (43) 64 (23) 19 (7) 84 (31) 83 (30) 51 (19)
11 (4) 6 (2) 5 (2) 17 (6) 12 (4) 12 (4)
2 (1) 4 (1) 12 (4) 9 (3) 11 (4) 12 (4)
16 (6) 48 (17) 220 (80) 43 (16) 87 (32) 130 (47)
15 (5) 113 (41) 13 (5) 31 (11) 18 (7) 19 (7)
Note: Data are expressed as number (percentage).
of 275]) and that “discomfort with angry patients” (21% [57 of 275]) were barriers to communication. Respondents who had been in practice longer (P ¼ .004), were older (P ¼ .031), and were without fellowship training (P ¼ .005) were more likely to report a lack of barriers to communication. Respondents with fellowship training (P ¼ .001), those in practice less than 5 years (P < .001), and younger respondents (P ¼ .014) were more likely to report that their practices were not set up to accommodate communication or loss of revenue. On multivariate modeling with all respondent demographics included, the whole model was statistically significant (P ¼ .04) but individual variables were not. There were no significant associations with discomfort with angry patients, suggesting this could occur among a variety of practitioners in a range of practice settings.
Actions for Improving Patient Communication Radiologists were queried regarding their willingness to undertake additional communication training to enhance interactions with patients. This survey question was introduced with a statement reminding radiologists of the recent CMS value-based reimbursement plan, which includes questions about patient-physician communication in the assessment of patient satisfaction, a component in estimating value. Respondents indicated that they are willing to take additional steps to improve patient
communication to maintain high levels of patient satisfaction. Respondents were most willing to make additional educational information available at their practices (69%), undergo further communication training (62%), implement web-based communications (52%), hire or retrain personnel to communicate results (45%), and alter their existing practices to allow more time for radiologist-patient communication (37%). Only 13% of the respondents stated that they would not alter anything. Respondents who were more willing to use additional educational material were younger (P ¼ .014), earlier in practice (P ¼ .022), and fellowship trained (P ¼ .022). Respondents who were more willing to undergo further communication training were also younger (P ¼ .002) and had fewer years of training (P ¼ .028). Respondents willing to implement web-based communications were earlier in practice careers (P ¼ .043), in academic practices (P ¼ .030), and fellowship trained (P ¼ .001).
DISCUSSION Our study demonstrates variability among breast imaging practices in the degree of radiologist-patient communication regarding breast imaging examination results. Survey respondents reported frequent direct radiologistpatient communications of abnormal diagnostic mammographic results requiring biopsy, as well as malignant or high-risk biopsy diagnoses necessitating
Table 4. Based on practice type, how often do radiologists frequently (76%-100%) communicate the results of the following studies? Study
Academic Practice (n ¼ 92)
Small Private Practice (n ¼ 48)
Large Private Practice (n ¼ 104)
P
Normal screening mammogram Normal screening ultrasound Normal/negative diagnostic workup Abnormal diagnostic workup Abnormal MRI Benign biopsy results Malignant/high-risk biopsy results
3 (3) 16 (17) 27 (29) 73 (79) 16 (17) 40 (43) 44 (48)
6 (13) 12 (25) 27 (56) 38 (79) 16 (33) 17 (35) 28 (58)
3 (3) 15 (14) 40 (38) 84 (81) 10 (10) 23 (22) 49 (47)
.001 .322 <.001 .317 .033 <.001 .055
Note: Data are expressed as number (percentage).
Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
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further surgery. Radiologists’ direct communications with patients regarding these abnormal results could have a lifetime impact on patients and are particularly important to overall patient care and satisfaction [16-18]. The most common nonradiologist conveyance of breast imaging results was the notification of screening mammographic results. As expected, most radiologists communicate the results of screening studies via written letters, in compliance with federal Mammography Quality Standards Act. Only 6% of respondents indicated that their radiologists directly communicated screening results to patients the majority of the time, with significantly more small private practices represented in this group, compared with academic and larger private practices. Negative diagnostic imaging examination results are most frequently conveyed by mammography technologists, who have established rapport with patients during the examination and are available immediately afterward. Moreover, breast MRI and benign biopsy results are rarely communicated by radiologists; referring clinicians and midlevel providers were most often reported to provide these results. Compared with other areas of radiology, breast imaging radiologists are more frequently involved in direct, same-day communication of imaging findings [19]. This practice may alleviate some of the anxiety patients experience associated with uncertainty of results and yield greater patient satisfaction [20]. Some of these discussions require that radiologists convey critical content in the management of patients’ potential lifethreatening and life-changing breast cancer diagnoses. Furthermore, delivering untoward news often necessitates managing an emotional response elicited from the patient. Such conversations require establishing near immediate rapport to relay information, ensure patients’ understanding, and provide support as the patient processes the news while allowing time for questions and guiding follow-up appointments [21-23]. Radiologists’ expert knowledge of the complexities of breast imaging and breast cancer diagnoses makes them ideal individuals to deliver the content of the message. Many have developed skill in quickly creating supportive relationships with patients during these brief conversations that occur daily in busy breast imaging clinics. In discussing abnormal results, the large majority of survey respondents reported being completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients. Seventy-one percent rated their own 6
communication skills as excellent. The survey participants’ confidence regarding these often difficult patient communications shows promise for applying the 4R initiative in breast imaging [5,22,24]. The 4R initiative, emphasizing “right information and right care to the right patient at the right time,” proposes that at the time of breast cancer diagnosis, breast imaging radiologists assume the central role in breast cancer care initiation, developing a personalized care initiation sequence, coordinating activities, and engaging patients with their care team [25]. Efforts to further enhance patient communication are critical first steps for implementing the components of the 4R initiative, which would rely on patient interaction competence and teamwork skills. All of these factors embody the concept of optimal PCC and communication and could enhance overall patient care [5]. Some radiology practices may require additional support to enhance communications. Radiologists who spend less time in breast imaging reported only average communication skills and may require additional training to enhance their comfort with difficult communications. Barriers to communicating with patients were predominantly reported by younger radiologists, earlier in their careers, who felt that their practices were not set up to accommodate direct communication or that they would lose revenue by undertaking frequent radiologist-patient communications. One-half of the breast imaging radiologists in our survey reported no barriers to communication. This is in contrast to a recent study performed by the RSNA Patient-Centered Radiology Steering Committee Survey, which found that 73% of RSNA radiologists reported that time or workload frequently prevented them from communicating with patients [26]. In our study, almost one-quarter of radiologists reported that discomfort with an angry patient was a barrier to communication, a finding that did not correlate with years of experience in breast imaging, age, fellowship training, or practice type. This suggests that future training strategies aimed at improving communications with angry patients would have very broad interest and may be even more applicable and appreciated by general or non–breast imaging radiologists not included in this survey, who have less experience in patient communication. All radiologists surveyed agreed that enhancing patient communication in their practices would improve overall patient satisfaction. In addition, although the large majority of respondents felt completely comfortable with communicating abnormal results (additional imaging, Journal of the American College of Radiology Volume - n Number - n Month 2018
92%; biopsy recommendation, 93%; abnormal biopsy results, 86%), two-thirds were still willing to undertake additional training to improve patient satisfaction. Nearly one-half were willing to retrain current, or hire additional, personnel to communicate results to patients. The results of a survey conducted in 2009 similarly support the notion that breast imaging radiologists commonly communicate bad news to breast imaging patients. In that study, however, there was a progressive decrease in radiologists’ comfort in communicating results as the severity of the undesirable news increased (needing extra views, 95%; biopsy recommendation, 85%; positive core biopsy results, 67%) [27]. Furthermore, although very few radiologists had formal training in communication, the majority were not interested in obtaining additional training in breaking bad news [27]. There are several factors that could account for these differing results. We surveyed a larger and broader group of breast imaging radiologists, including a higher percentage of fellowship-trained radiologists, working in more private (large and small) practices compared with academic practices. We also found that respondents willing to undertake additional training or implement changes tended to be younger, earlier in their practices, and fellowship trained. Perhaps most importantly, our study was performed almost a decade later, at a time of greater awareness of the importance of patient satisfaction and PCC. Earlier movements toward standardization of reporting and communication in radiology predominantly targeted communication with referring providers [28]. More recently, a nationwide movement toward PCC has prompted initiatives (eg, the ACR Face of Radiology campaign, Imaging 3.0, Radiology Cares) that are direct reflections of a growing discussion in the radiology community as a whole regarding the practice of a patient-centered approach. Direct patient communication, patient satisfaction, and patient involvement in their own care are currently dominating efforts to optimize patients’ experiences in radiology departments [28]. Radiologists’ financial stakes in patient engagement could have some influence on this movement and on our survey responses. Currently, CMS reimbursements are evolving to incorporate a value-based payment plan, based in part on the results of patient satisfaction surveys, including questions regarding patient-physician communication. Beyond that, efforts to improve communication and enhance patient experiences have probably always been based at least in part on radiologists’ compassion and desire to serve patients, which also could be motivation for survey responses. Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
This study had several limitations. The survey response rate was 10.5%, and, as with all surveys, there was a risk for response bias among those who chose to respond. In addition, SBI member responses may not reflect the practices of all breast imaging radiologists. SBI respondents to the survey may be more engaged in patient communication than SBI members not responding and very likely are more engaged than general radiologists who provide a large volume of breast imaging in the United States. Finally, multiple practitioners from the same practice could have responded to the survey; however, this method did capture individuals’ perceptions of barriers to communication, regardless of practice affiliation.
CONCLUSIONS This survey was conducted as part of an initiative of the SBI PCDTF to identify areas of patient communication that can be enhanced to more directly engage patients in their care and ultimately heighten their satisfaction. Conducting this study was an important first step. The results have provided valuable insight to the receptiveness of the radiology community to communication enhancement initiatives. We found variation in breast imaging communication practices among radiologists and practice types, but the majority of radiologists appear to directly communicate results that are most distressing to patients, including abnormal results on diagnostic mammography requiring biopsies and abnormal biopsy results leading to cancer diagnoses and further surgery. The large majority of breast imaging radiologists reported feeling completely comfortable with these conversations, but all felt that enhancing communication with patients would lead to greater patient satisfaction. The most frequent barriers to communication included reports that practices were not set up for this direct communication (loss of revenue) and discomfort with angry patients. Given this better understanding of radiologistpatient communication barriers, one of the aims of the PCDTF is to produce training modules for general radiologists and breast imagers to facilitate low-cost improvements in communication skills, with particular attention given to improving interactions with angry patients. This work and future initiatives will serve to assist radiology practices as breast imagers become more directly involved in patient care and cancer care initiation. 7
TAKE-HOME POINTS -
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Although there is variation in breast imaging communication practices among radiologists and practice types, the majority of radiologists appear to directly communicate results that are most distressing to patients. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication included reports that practices were not set up for this direct communication (loss of revenue) and discomfort with angry patients. All radiologists feel that enhancing communication with patients will lead to greater patient satisfaction.
ACKNOWLEDGMENT The authors thank Elizabeth Morris, MD, immediate past president of the SBI, for her vision, leadership, and support in creating the SBI PCDTF. The authors also thank all members of the SBI PCDTF as well as the SBI staff. ADDITIONAL RESOURCES Additional resources can be found online at: https://doi. org/10.1016/j.jacr.2018.10.016. REFERENCES 1. Burnside ES, Sickles EA, Bassett LW, et al. The ACR BI-RADS experience: learning from history. J Am Coll Radiol 2009;6:851-60. 2. US Food and Drug Administration. Mammography Quality Standards Act and Program. Available at: https://www.fda.gov/RadiationEmittingProducts/MammographyQualityStandardsActandProgram/ default.htm. Accessed September 3, 2018. 3. American College of Radiology. Imaging 3.0. Available at: https:// www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3. Accessed October 5, 2017. 4. Radiological Society of North America. Patient-centered care. Available at: http://www.rsna.org/radiology_cares/. Accessed October 5, 2017. 5. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the patient’s eyes: understanding and promoting patient-centered care. Picker Institute; 1993. 6. Centers for Medicare and Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems. Available at: https:// www.hcahpsonline.org. Accessed September 1, 2018. 7. Centers for Medicare and Medicaid Services. Consumer Assessment of Healthcare Providers & Systems (CAHPS). Available at: https://www.cms. gov/Research-Statistics-Data-and-Systems/Research/CAHPS/. Accessed September 1, 2018.
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8. Steele JR, Jones AK, Clarke RK, Shoemaker S. Health care delivery meets hospitality: a pilot study in radiology. J Am Coll Radiol 2015;12:587-93. 9. Miller P, Gunderman R, Lightburn J, Miller D. Enhancing patients’ experiences in radiology: through patient-radiologist interaction. Acad Radiol 2013;20:778-81. 10. Handy RB, Fajardo LL, Innis CA, Witzke DB, Hunter TB. Patient perceptions of stereotaxic large-core breast biopsy. Acad Radiol 1996;3: 1007-11. 11. Miller LS, Shelby RA, Balmadrid MH, et al. Patient anxiety before and immediately after imaging-guided breast biopsy procedures: impact of radiologist-patient communication. J Am Coll Radiol 2016;13:e62-71. 12. Miller LS, Shelby RA, Balmadrid MH, et al. Patient anxiety before and immediately after imaging-guided breast biopsy procedures: impact of radiologist-patient communication. J Am Coll Radiol 2013;10: 423-31. 13. Donelan K, Mailhot JR, Dutwin D, et al. Patient perspectives of clinical care and patient navigation in follow-up of abnormal mammography. J Gen Intern Med 2011;26:116-22. 14. Ndikum-Moffor FM, Braiuca S, Daley CM, Gajewski BJ, Engelman KK, et al. Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women. Womens Health Issues 2013;23:e395-402. 15. Diefenbach M, Turner G, Carpenter KM, et al. Cancer and patientphysician communication. J Health Commun 2009;14(suppl 1): 57-65. 16. Anderson PF, Wescom E, Carlos RC. Difficult doctors, difficult patients: building empathy. J Am Coll Radiol 2016;13:1590-8. 17. Kuhlman M, Meyer M, Krupinski EA. Direct reporting of results to patients: the future of radiology? Acad Radiol 2012;19:646-50. 18. Kübler-Ross E. On death and dying. New York: Macmillan; 1969. 19. Mayo RC III, Parikh JR. Breast imaging: the face of Imaging 3.0. J Am Coll Radiol 2016;13:1003-7. 20. Holz K, Harvey SC, Alvin MD, Beach MC, Pisano K, Woods R. Communication in breast imaging: lessons learned at diagnostic evaluation. J Am Coll Radiol 2017;14:665-7. 21. Harvey JA, Cohen MA, Brenin DR, Nicholson BT, Adams RB. Breaking bad news: a primer for radiologists in breast imaging. J Am Coll Radiol 2007;4:800-8. 22. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-11. 23. Linver MN. Delivering bad news: a vital skill for professionals involved in breast cancer care. Breast Cancer Online 2009;12:e3. 24. Trosman JR, Carlos RC, Simon MA, et al. Care for a patient with cancer as a project: management of complex task interdependence in cancer care delivery. J Oncol Pract 2016;12:1101-13. 25. Weldon CB, Friedewald SM, Kulkarni SA, et al. Radiology as the point of cancer patient and care team engagement: applying the 4R model at a patient’s breast cancer care initiation. J Am Coll Radiol 2016;13:1579-89. 26. Kemp JL, Mahoney MC, Mathews VP, Wintermark M, Yee J, Brown SD. Patient-centered radiology: where are we, where do we want to be, and how do we get there? Radiology 2017;285:601-8. 27. Adler DD, Riba MB, Eggly S. Breaking bad news in the breast imaging setting. Acad Radiol 2009;16:130-5. 28. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings (resolution 11). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/ CommunicationDiag.pdf. Accessed November 19, 2018.
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Radiologist-Patient Communication: Current Practices and Barriers to Communication in Breast Imaging Shadi Aminololama-Shakeri, MD a, Mary Scott Soo, MD b, Lars J. Grimm, MD, MHS b, Meredith R. Watts, MD c, Steven P. Poplack, MD d, Jocelyn Rapelyea, MD e, Nicole Saphier, MD f, Rand Stack, MD g, Stamatia Destounis, MD h Abstract Purpose: The aim of this study was to assess variability in radiologist-patient communication practices and barriers to communication among members of the Society of Breast Imaging (SBI). Methods: A 36-item questionnaire developed by the SBI Patient Care and Delivery Task Force was distributed electronically to SBI members to evaluate patient communication, education, and screening practices. Data from 14 items investigating patient communication (eg, practices, comfort, barriers to communication) were analyzed and compared with demographic variables using c2 or independent t tests as appropriate. Results: Ninety-three percent of radiologists reported that they directly communicate abnormal results of diagnostic mammographic examinations that require biopsy and malignant or high-risk biopsy results that require surgery. Radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. Most respondents were completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients, and 71% rated their communication skills as excellent. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication were that practices were not set up for direct communication (loss of revenue) and discomfort with angry patients. Conclusions: Although variation in breast imaging communication practices exists among radiologists and practice types, the majority of radiologists directly communicate the most distressing results to patients, such as those regarding abnormal diagnostic mammographic findings requiring biopsies and abnormal biopsy results leading to cancer diagnoses and surgery. The majority of radiologists are completely comfortable with these conversations, but all feel that enhancing communication with patients will lead to greater patient satisfaction. Key Words: Patient-centered care, patient communication, breast imaging, patient satisfaction J Am Coll Radiol 2018;-:---. Copyright 2018 American College of Radiology
INTRODUCTION Direct radiologist-patient communication is an integral part of breast imaging care delivery. For decades, standardized reporting and communication of breast imaging
results with patients and their providers have been federally mandated and facilitated by BI-RADS [1]. Breast imaging is the only practice in radiology required to provide a patient with her imaging results in a report
a Department of Radiology, University of California, Davis, Sacramento, California. b Breast Imaging Division, Duke University Medical Center, Durham, North Carolina. c Breast Imaging Section, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania. d Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri. e The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.
f
ª 2018 American College of Radiology 1546-1440/18/$36.00 n https://doi.org/10.1016/j.jacr.2018.10.016
Memorial Sloan Kettering Cancer Center, New York, New York. WESTMED Medical Group, Rye, New York. h Elizabeth Wende Breast Care, Rochester, New York. Corresponding author and reprints: Stamatia Destounis, MD, Elizabeth Wende Breast Care, 170 Sawgrass Drive, Rochester, NY 14620; e-mail: [email protected]. The authors have no conflicts of interest related to the material discussed in this article. g
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written in lay language within 30 days of the examination. This patient communication is mandated under the Mammography Quality Standards Act [2]. Evolving with this process, many breast imaging radiologists have routinely discussed results and recommendations of diagnostic imaging and biopsies with patients and their providers. As such, the breast imaging model has been integrated into emerging initiatives to optimize patients’ experiences in radiology departments, such as the ACR Imaging 3.0 [3] and the RSNA Radiology Cares [4] campaigns, which emphasize patient-centered care (PCC). Defined by the Picker Institute, PCC provides information and education, respects patients’ values and preferences, involves family and friends, and provides emotional support to alleviate fear and anxiety [5]. Initiatives to enhance PCC and patient satisfaction may also affect reimbursements for some practices, as measures of patient satisfaction (eg, the Hospital Consumer Assessment of Healthcare Providers and Systems) are included in recent CMS payment models [6,7]. Effective radiologist-patient communication is one means of enhancing patient experiences in radiology [8,9]. In breast imaging, studies have shown that patients’ lack of understanding regarding stereotactic biopsy procedures is associated with higher levels of expected discomfort [10]. In addition, better communication with radiologists, as perceived by patients during breast biopsy recommendations and procedures, has been associated with lower patient anxiety [11,12]. Furthermore, patient-centeredness, equity, and respect from staff members are predictors of high patient satisfaction in breast imaging [13,14], and better radiologistpatient communication is associated with fewer malpractice claims and may positively affect patient outcomes and psychological symptoms during cancer treatments [15]. Direct radiologist-patient communication may therefore be a critical component of the delivery of optimal PCC and satisfaction [5]. However, barriers to communication and heterogeneity of practice settings could affect radiologists’ capacities to implement direct communication of results, education, and care initiation services. The Society of Breast Imaging (SBI) Patient Care and Delivery Task Force (PCDTF) was created to enhance patient communication and education, provide related resources to the radiology community, promote patients’ involvement in their own care, and enhance patient satisfaction. To begin to evaluate these issues, the SBI PCDTF surveyed breast imaging radiologists, 2
with the goals of determining the degree of variability in communication practices among breast imaging radiologists and understanding barriers to communication in these settings. The results of this study could provide valuable insights for creating further initiatives to enhance communication and other care delivery services as guided by Imaging 3.0.
METHODS Survey Measure A 36-item survey was developed by the SBI PCDTF to evaluate breast imaging practice patterns and perceptions related to patient communication, education, and screening practices among SBI member radiologists. Initial questions were generated and vetted by a subcommittee of the SBI PCDTF. A preliminary version of the survey was sent to a small group of practicing breast radiologists. Feedback regarding content, clarity, and length of survey was incorporated, and the final 36-item survey was reviewed and approved by PCDTF members. An electronic link to the survey (SurveyMonkey, San Mateo, California) was distributed via e-mail to all members of the SBI, targeting radiologist responses. All survey responses were collected anonymously. The survey items specifically related to communications presented in this manuscript are available in Appendix 1. Participants and Response Rate SBI members (n ¼ 2,672) at the time of the survey included 1,992 practicing radiologists, 615 radiology trainees (ie, fellows, residents), and 65 affiliates (eg, technologists). The survey was sent electronically on February 16, 2017, to SBI members via e-mail through SBI Weekly Member Update. The survey was available for 90 days, with reminders sent weekly. Participation in the survey was also encouraged daily during announcements at the 2017 SBI/ACR Breast Imaging Symposium. A total of 1,410 SBI members opened the e-mail, and 280 survey responses (10.5% response rate [280 of 2,672]) were received. The few respondents reporting that they were trainees (n ¼ 4) or technologists (n ¼ 1) were excluded from subsequent analysis, resulting in 275 responses in the final analysis. Data Analysis Comparisons were made between survey responses and demographic variables using c2 or independent Journal of the American College of Radiology Volume - n Number - n Month 2018
t tests as appropriate. Multivariate analysis was performed when noted with respondent demographic variables as inputs. Respondents without breast imaging fellowships but who (1) indicated that they trained before the introduction of breast fellowships or (2) had been practicing breast imaging exclusively for 10 years or more were included in the fellowshiptrained category. Statistical analyses were performed using JMP Pro version 13.0.0 (SAS Institute, Cary, North Carolina).
RESULTS Demographics The majority of respondents identified themselves as female (61%), fellowship trained (56%), and working exclusively (100% of their time) in breast imaging (56%). A plurality of respondents have been in practice more than 20 years (39%) and worked in large private practices (38%) (Table 1). Patient Communication Table 2 demonstrates the variability in who conveys the results of specific breast imaging studies to patients most of the time; respondents were permitted to choose all applicable options. The response “mailed letters/electronic notification” was most frequently selected as the primary means of notifying patients of normal results of screening mammographic examinations (84% of respondents), abnormal results of screening mammographic examinations (53%), and normal results of screening breast MRI examinations (57%). Ninety-three percent of radiologists reported that they directly communicate abnormal diagnostic mammographic results, whereas both radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. The only imaging results that the majority of survey respondents indicated were most often delivered by referring providers were from screening MRI (56% for normal results, 53% for abnormal results). Only rarely were radiology trainees and midlevel practitioners reported to be responsible for providing study results most of the time. To further understand radiologists’ involvement in communicating results to patients, Table 3 shows the percentage of time that radiologists, including trainees, discuss results of various breast imaging studies. Regarding communication of abnormal results, 80% of respondents indicated that radiologists in their practices Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
Table 1. Survey respondent demographics Characteristic Gender Male Female Defer/did not respond Age (y) <30 30-40 41-50 51-60 61-70 71 Did not respond Work environment Academic Small private practice Large private practice Managed care setting Other Breast clinical time 100% 75% 50% 25% <25% Did not respond Years in practice <5 5-10 10-20 >20 Did not respond Training type Fellowship trained General radiologist Trainee Technologist Did not respond
n (%) 80 (29) 171 (61) 29 (10) 1 (0) 63 (23) 52 (19) 89 (32) 40 (14) 8 (3) 27 (10) 95 (34) 48 (17) 106 (38) 4 (1) 27 (10) 158 (56) 52 (19) 32 (11) 7 (3) 4 (1) 27 (10) 39 (14) 53 (19) 51 (18) 110 (39) 27 (10) 157 (56) 91 (33) 4 (1) 1 (0) 27 (10)
frequently (76%-100% of the time) discussed abnormal diagnostic mammographic results with patients; likewise, the plurality (47%) also frequently provided patients with malignant or high-risk biopsy results. On the other hand, most respondents indicated that radiologists very infrequently (0%-25% of the time) communicated screening mammographic, abnormal MRI, and benign biopsy results to patients. Only 6% of respondents indicated that screening mammographic results were provided directly to their patients frequently by radiologists in their practices. 3
0 (0) 2 (1) 3 (1) 4 (1) 1 (0) 1 (0) 3 (1) 3 (1) 5 (2) 6 (2) 1 (0) 1 (0) 110 (40) 109 (40) 0 (0) 0 (0) 13 (5) 13 (5) 3 (1) 3 (1) 72 (26) 71 (26) 24 (9) 23 (8) 22 (8) 23 (8) 154 (56) 146 (53) 94 (34) 106 (39) 232 (84) 146 (53) 67 (24) 36 (13) 47 (17) 38 (14) 156 (57) 90 (33) 24 (9) 24 (9) 16 (6) 120 (44) 5 (2) 24 (9) 11 (4) 5 (2) 12 (4) 49 (18) 19 (7) 9 (3) 5 (2) 28 (10) 3 (1) 9 (3) 6 (2) 6 (2) 14 (5) 37 (13) 96 (35) 53 (19) 37 (13) 54 (20) 46 (17) 16 (6) 158 (57) 24 (9) 6 (2) 16 (6) 8 (3) 4 (2) 5 (2) 8 (3) 7 (3) 12 (4) 36 (13) 42 (15) 3 (1) 11 (4) 23 (8) 22 (8) 35 (13) 45 (16) 69 (25) 109 (39) 182 (66) 255 (93) 27 (10) 56 (20) 124 (45) 173 (63)
Note: Data are expressed as number (percentage). MMG ¼ mammogram; PA ¼ physician assistant; RA ¼ radiologist assistant; RN ¼ registered nurse.
Study Type
Normal screening MMG Abnormal screening MMG Normal whole-breast ultrasound Abnormal whole-breast ultrasound Normal /negative diagnostic examination Abnormal diagnostic examination Normal screening breast MRI Abnormal screening breast MRI Benign biopsy results Malignant/high-risk biopsy results
“In your practice, who communicates the results of the following examinations to patients most of the time? Check all that apply” Report/ We Don’t Letter/ Provide Electronic Referring Resident/ RN/PA/ Clerical This Service Other Notification Clinician Radiologist Fellow Technologist RA Personnel Table 2. Providing Patient Results
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Further analyses correlating respondents’ demographics with communication practices showed statistically significant differences among certain practice environments (Table 4). A higher percentage of respondents from small private practice groups reported that their radiologists frequently (76%-100% of the time) communicate normal screening mammographic results (13%), normal results of diagnostic workups (56%), and abnormal breast MRI results (33%) compared with academic (3%, 29%, and 17%, respectively) and large private practice groups (3%, 38%, and 10%, respectively) (P < .05 for all). Similarly, more respondents from both small private practice groups (35%) and academic practices (43%) indicated that benign biopsy results were frequently communicated to patients compared with large private practice groups (22%) (P < .001). These results suggest that small private practice groups engage in more direct communication with patients overall compared with academic and large private practice groups. Groups in managed care plans and respondents who did not indicate their practices were excluded from this analysis given the small number in this study (n ¼ 31).
Comfort With Patient Communication The majority of survey respondents reported that they are completely comfortable with directly communicating results to patients when recommending additional imaging (92% [248 of 275]), need for biopsy (93% [252 of 275]), and delivering biopsy results (86% [233 of 275]). Moreover, 71% rated their skills communicating with patients as excellent, and 26% rated their skills as above average. Only 3% of respondents reported average communication skills. There was a significant association between respondents reporting average communication skills and those spending less time in breast imaging. Respondents’ age, gender, years of practice, and other variables did not correlate with self-reports of communication skills. All (100%) respondents expressed that enhancing overall patient communication in their breast imaging practice would improve their patients’ overall satisfaction with care. Barriers to Communication Nearly one-half (47% [128 of 275]) of respondents reported that they perceived no barriers to effective communication with patients. However, other respondents indicated that their “practice is not set up to accommodate communication/loss of revenue” (23% [63 Journal of the American College of Radiology Volume - n Number - n Month 2018
Table 3. How often does a radiologist, including a trainee, communicate results? Study
0%
1%-25%
26%-50%
51%-75%
76%-100%
NA
Screening mammogram Whole-breast ultrasound Abnormal diagnostic mammogram Abnormal MRI Benign biopsy Malignant/high-risk biopsy
114 (41) 40 (15) 6 (2) 91 (33) 64 (23) 51 (19)
117 (43) 64 (23) 19 (7) 84 (31) 83 (30) 51 (19)
11 (4) 6 (2) 5 (2) 17 (6) 12 (4) 12 (4)
2 (1) 4 (1) 12 (4) 9 (3) 11 (4) 12 (4)
16 (6) 48 (17) 220 (80) 43 (16) 87 (32) 130 (47)
15 (5) 113 (41) 13 (5) 31 (11) 18 (7) 19 (7)
Note: Data are expressed as number (percentage).
of 275]) and that “discomfort with angry patients” (21% [57 of 275]) were barriers to communication. Respondents who had been in practice longer (P ¼ .004), were older (P ¼ .031), and were without fellowship training (P ¼ .005) were more likely to report a lack of barriers to communication. Respondents with fellowship training (P ¼ .001), those in practice less than 5 years (P < .001), and younger respondents (P ¼ .014) were more likely to report that their practices were not set up to accommodate communication or loss of revenue. On multivariate modeling with all respondent demographics included, the whole model was statistically significant (P ¼ .04) but individual variables were not. There were no significant associations with discomfort with angry patients, suggesting this could occur among a variety of practitioners in a range of practice settings.
Actions for Improving Patient Communication Radiologists were queried regarding their willingness to undertake additional communication training to enhance interactions with patients. This survey question was introduced with a statement reminding radiologists of the recent CMS value-based reimbursement plan, which includes questions about patient-physician communication in the assessment of patient satisfaction, a component in estimating value. Respondents indicated that they are willing to take additional steps to improve patient
communication to maintain high levels of patient satisfaction. Respondents were most willing to make additional educational information available at their practices (69%), undergo further communication training (62%), implement web-based communications (52%), hire or retrain personnel to communicate results (45%), and alter their existing practices to allow more time for radiologist-patient communication (37%). Only 13% of the respondents stated that they would not alter anything. Respondents who were more willing to use additional educational material were younger (P ¼ .014), earlier in practice (P ¼ .022), and fellowship trained (P ¼ .022). Respondents who were more willing to undergo further communication training were also younger (P ¼ .002) and had fewer years of training (P ¼ .028). Respondents willing to implement web-based communications were earlier in practice careers (P ¼ .043), in academic practices (P ¼ .030), and fellowship trained (P ¼ .001).
DISCUSSION Our study demonstrates variability among breast imaging practices in the degree of radiologist-patient communication regarding breast imaging examination results. Survey respondents reported frequent direct radiologistpatient communications of abnormal diagnostic mammographic results requiring biopsy, as well as malignant or high-risk biopsy diagnoses necessitating
Table 4. Based on practice type, how often do radiologists frequently (76%-100%) communicate the results of the following studies? Study
Academic Practice (n ¼ 92)
Small Private Practice (n ¼ 48)
Large Private Practice (n ¼ 104)
P
Normal screening mammogram Normal screening ultrasound Normal/negative diagnostic workup Abnormal diagnostic workup Abnormal MRI Benign biopsy results Malignant/high-risk biopsy results
3 (3) 16 (17) 27 (29) 73 (79) 16 (17) 40 (43) 44 (48)
6 (13) 12 (25) 27 (56) 38 (79) 16 (33) 17 (35) 28 (58)
3 (3) 15 (14) 40 (38) 84 (81) 10 (10) 23 (22) 49 (47)
.001 .322 <.001 .317 .033 <.001 .055
Note: Data are expressed as number (percentage).
Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
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further surgery. Radiologists’ direct communications with patients regarding these abnormal results could have a lifetime impact on patients and are particularly important to overall patient care and satisfaction [16-18]. The most common nonradiologist conveyance of breast imaging results was the notification of screening mammographic results. As expected, most radiologists communicate the results of screening studies via written letters, in compliance with federal Mammography Quality Standards Act. Only 6% of respondents indicated that their radiologists directly communicated screening results to patients the majority of the time, with significantly more small private practices represented in this group, compared with academic and larger private practices. Negative diagnostic imaging examination results are most frequently conveyed by mammography technologists, who have established rapport with patients during the examination and are available immediately afterward. Moreover, breast MRI and benign biopsy results are rarely communicated by radiologists; referring clinicians and midlevel providers were most often reported to provide these results. Compared with other areas of radiology, breast imaging radiologists are more frequently involved in direct, same-day communication of imaging findings [19]. This practice may alleviate some of the anxiety patients experience associated with uncertainty of results and yield greater patient satisfaction [20]. Some of these discussions require that radiologists convey critical content in the management of patients’ potential lifethreatening and life-changing breast cancer diagnoses. Furthermore, delivering untoward news often necessitates managing an emotional response elicited from the patient. Such conversations require establishing near immediate rapport to relay information, ensure patients’ understanding, and provide support as the patient processes the news while allowing time for questions and guiding follow-up appointments [21-23]. Radiologists’ expert knowledge of the complexities of breast imaging and breast cancer diagnoses makes them ideal individuals to deliver the content of the message. Many have developed skill in quickly creating supportive relationships with patients during these brief conversations that occur daily in busy breast imaging clinics. In discussing abnormal results, the large majority of survey respondents reported being completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients. Seventy-one percent rated their own 6
communication skills as excellent. The survey participants’ confidence regarding these often difficult patient communications shows promise for applying the 4R initiative in breast imaging [5,22,24]. The 4R initiative, emphasizing “right information and right care to the right patient at the right time,” proposes that at the time of breast cancer diagnosis, breast imaging radiologists assume the central role in breast cancer care initiation, developing a personalized care initiation sequence, coordinating activities, and engaging patients with their care team [25]. Efforts to further enhance patient communication are critical first steps for implementing the components of the 4R initiative, which would rely on patient interaction competence and teamwork skills. All of these factors embody the concept of optimal PCC and communication and could enhance overall patient care [5]. Some radiology practices may require additional support to enhance communications. Radiologists who spend less time in breast imaging reported only average communication skills and may require additional training to enhance their comfort with difficult communications. Barriers to communicating with patients were predominantly reported by younger radiologists, earlier in their careers, who felt that their practices were not set up to accommodate direct communication or that they would lose revenue by undertaking frequent radiologist-patient communications. One-half of the breast imaging radiologists in our survey reported no barriers to communication. This is in contrast to a recent study performed by the RSNA Patient-Centered Radiology Steering Committee Survey, which found that 73% of RSNA radiologists reported that time or workload frequently prevented them from communicating with patients [26]. In our study, almost one-quarter of radiologists reported that discomfort with an angry patient was a barrier to communication, a finding that did not correlate with years of experience in breast imaging, age, fellowship training, or practice type. This suggests that future training strategies aimed at improving communications with angry patients would have very broad interest and may be even more applicable and appreciated by general or non–breast imaging radiologists not included in this survey, who have less experience in patient communication. All radiologists surveyed agreed that enhancing patient communication in their practices would improve overall patient satisfaction. In addition, although the large majority of respondents felt completely comfortable with communicating abnormal results (additional imaging, Journal of the American College of Radiology Volume - n Number - n Month 2018
92%; biopsy recommendation, 93%; abnormal biopsy results, 86%), two-thirds were still willing to undertake additional training to improve patient satisfaction. Nearly one-half were willing to retrain current, or hire additional, personnel to communicate results to patients. The results of a survey conducted in 2009 similarly support the notion that breast imaging radiologists commonly communicate bad news to breast imaging patients. In that study, however, there was a progressive decrease in radiologists’ comfort in communicating results as the severity of the undesirable news increased (needing extra views, 95%; biopsy recommendation, 85%; positive core biopsy results, 67%) [27]. Furthermore, although very few radiologists had formal training in communication, the majority were not interested in obtaining additional training in breaking bad news [27]. There are several factors that could account for these differing results. We surveyed a larger and broader group of breast imaging radiologists, including a higher percentage of fellowship-trained radiologists, working in more private (large and small) practices compared with academic practices. We also found that respondents willing to undertake additional training or implement changes tended to be younger, earlier in their practices, and fellowship trained. Perhaps most importantly, our study was performed almost a decade later, at a time of greater awareness of the importance of patient satisfaction and PCC. Earlier movements toward standardization of reporting and communication in radiology predominantly targeted communication with referring providers [28]. More recently, a nationwide movement toward PCC has prompted initiatives (eg, the ACR Face of Radiology campaign, Imaging 3.0, Radiology Cares) that are direct reflections of a growing discussion in the radiology community as a whole regarding the practice of a patient-centered approach. Direct patient communication, patient satisfaction, and patient involvement in their own care are currently dominating efforts to optimize patients’ experiences in radiology departments [28]. Radiologists’ financial stakes in patient engagement could have some influence on this movement and on our survey responses. Currently, CMS reimbursements are evolving to incorporate a value-based payment plan, based in part on the results of patient satisfaction surveys, including questions regarding patient-physician communication. Beyond that, efforts to improve communication and enhance patient experiences have probably always been based at least in part on radiologists’ compassion and desire to serve patients, which also could be motivation for survey responses. Journal of the American College of Radiology Aminololama-Shakeri et al n Radiologist-Patient Communication
This study had several limitations. The survey response rate was 10.5%, and, as with all surveys, there was a risk for response bias among those who chose to respond. In addition, SBI member responses may not reflect the practices of all breast imaging radiologists. SBI respondents to the survey may be more engaged in patient communication than SBI members not responding and very likely are more engaged than general radiologists who provide a large volume of breast imaging in the United States. Finally, multiple practitioners from the same practice could have responded to the survey; however, this method did capture individuals’ perceptions of barriers to communication, regardless of practice affiliation.
CONCLUSIONS This survey was conducted as part of an initiative of the SBI PCDTF to identify areas of patient communication that can be enhanced to more directly engage patients in their care and ultimately heighten their satisfaction. Conducting this study was an important first step. The results have provided valuable insight to the receptiveness of the radiology community to communication enhancement initiatives. We found variation in breast imaging communication practices among radiologists and practice types, but the majority of radiologists appear to directly communicate results that are most distressing to patients, including abnormal results on diagnostic mammography requiring biopsies and abnormal biopsy results leading to cancer diagnoses and further surgery. The large majority of breast imaging radiologists reported feeling completely comfortable with these conversations, but all felt that enhancing communication with patients would lead to greater patient satisfaction. The most frequent barriers to communication included reports that practices were not set up for this direct communication (loss of revenue) and discomfort with angry patients. Given this better understanding of radiologistpatient communication barriers, one of the aims of the PCDTF is to produce training modules for general radiologists and breast imagers to facilitate low-cost improvements in communication skills, with particular attention given to improving interactions with angry patients. This work and future initiatives will serve to assist radiology practices as breast imagers become more directly involved in patient care and cancer care initiation. 7
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Although there is variation in breast imaging communication practices among radiologists and practice types, the majority of radiologists appear to directly communicate results that are most distressing to patients. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication included reports that practices were not set up for this direct communication (loss of revenue) and discomfort with angry patients. All radiologists feel that enhancing communication with patients will lead to greater patient satisfaction.
ACKNOWLEDGMENT The authors thank Elizabeth Morris, MD, immediate past president of the SBI, for her vision, leadership, and support in creating the SBI PCDTF. The authors also thank all members of the SBI PCDTF as well as the SBI staff. ADDITIONAL RESOURCES Additional resources can be found online at: https://doi. org/10.1016/j.jacr.2018.10.016. REFERENCES 1. Burnside ES, Sickles EA, Bassett LW, et al. The ACR BI-RADS experience: learning from history. J Am Coll Radiol 2009;6:851-60. 2. US Food and Drug Administration. Mammography Quality Standards Act and Program. Available at: https://www.fda.gov/RadiationEmittingProducts/MammographyQualityStandardsActandProgram/ default.htm. Accessed September 3, 2018. 3. American College of Radiology. Imaging 3.0. Available at: https:// www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3. Accessed October 5, 2017. 4. Radiological Society of North America. Patient-centered care. Available at: http://www.rsna.org/radiology_cares/. Accessed October 5, 2017. 5. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the patient’s eyes: understanding and promoting patient-centered care. Picker Institute; 1993. 6. Centers for Medicare and Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems. Available at: https:// www.hcahpsonline.org. Accessed September 1, 2018. 7. Centers for Medicare and Medicaid Services. Consumer Assessment of Healthcare Providers & Systems (CAHPS). Available at: https://www.cms. gov/Research-Statistics-Data-and-Systems/Research/CAHPS/. Accessed September 1, 2018.
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8. Steele JR, Jones AK, Clarke RK, Shoemaker S. Health care delivery meets hospitality: a pilot study in radiology. J Am Coll Radiol 2015;12:587-93. 9. Miller P, Gunderman R, Lightburn J, Miller D. Enhancing patients’ experiences in radiology: through patient-radiologist interaction. Acad Radiol 2013;20:778-81. 10. Handy RB, Fajardo LL, Innis CA, Witzke DB, Hunter TB. Patient perceptions of stereotaxic large-core breast biopsy. Acad Radiol 1996;3: 1007-11. 11. Miller LS, Shelby RA, Balmadrid MH, et al. Patient anxiety before and immediately after imaging-guided breast biopsy procedures: impact of radiologist-patient communication. J Am Coll Radiol 2016;13:e62-71. 12. Miller LS, Shelby RA, Balmadrid MH, et al. Patient anxiety before and immediately after imaging-guided breast biopsy procedures: impact of radiologist-patient communication. J Am Coll Radiol 2013;10: 423-31. 13. Donelan K, Mailhot JR, Dutwin D, et al. Patient perspectives of clinical care and patient navigation in follow-up of abnormal mammography. J Gen Intern Med 2011;26:116-22. 14. Ndikum-Moffor FM, Braiuca S, Daley CM, Gajewski BJ, Engelman KK, et al. Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women. Womens Health Issues 2013;23:e395-402. 15. Diefenbach M, Turner G, Carpenter KM, et al. Cancer and patientphysician communication. J Health Commun 2009;14(suppl 1): 57-65. 16. Anderson PF, Wescom E, Carlos RC. Difficult doctors, difficult patients: building empathy. J Am Coll Radiol 2016;13:1590-8. 17. Kuhlman M, Meyer M, Krupinski EA. Direct reporting of results to patients: the future of radiology? Acad Radiol 2012;19:646-50. 18. Kübler-Ross E. On death and dying. New York: Macmillan; 1969. 19. Mayo RC III, Parikh JR. Breast imaging: the face of Imaging 3.0. J Am Coll Radiol 2016;13:1003-7. 20. Holz K, Harvey SC, Alvin MD, Beach MC, Pisano K, Woods R. Communication in breast imaging: lessons learned at diagnostic evaluation. J Am Coll Radiol 2017;14:665-7. 21. Harvey JA, Cohen MA, Brenin DR, Nicholson BT, Adams RB. Breaking bad news: a primer for radiologists in breast imaging. J Am Coll Radiol 2007;4:800-8. 22. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-11. 23. Linver MN. Delivering bad news: a vital skill for professionals involved in breast cancer care. Breast Cancer Online 2009;12:e3. 24. Trosman JR, Carlos RC, Simon MA, et al. Care for a patient with cancer as a project: management of complex task interdependence in cancer care delivery. J Oncol Pract 2016;12:1101-13. 25. Weldon CB, Friedewald SM, Kulkarni SA, et al. Radiology as the point of cancer patient and care team engagement: applying the 4R model at a patient’s breast cancer care initiation. J Am Coll Radiol 2016;13:1579-89. 26. Kemp JL, Mahoney MC, Mathews VP, Wintermark M, Yee J, Brown SD. Patient-centered radiology: where are we, where do we want to be, and how do we get there? Radiology 2017;285:601-8. 27. Adler DD, Riba MB, Eggly S. Breaking bad news in the breast imaging setting. Acad Radiol 2009;16:130-5. 28. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings (resolution 11). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/ CommunicationDiag.pdf. Accessed November 19, 2018.
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