Key words
health policy and practice - socioeconomic issues - narrative review - patient centered
radiology
For better readability, the manuscript refrains from using feminine and masculine
forms of language simultaneously and uses the generic masculine where appropriate.
All personal designations apply equally to all genders.
Introduction
The phrase “patient-centered radiology” may initially seem like an empty platitude
to many radiologists. Mentioning this topic in professional circles sometimes leads
to the reflexive response that for us as radiologists and physicians, the patient
is always the focus. At first glance, this may seem to be true in terms of our feelings
and understanding of ourselves as physicians, but a closer look reveals that reality
is often different. In the context of the constraints of medical-economic conditions
and the simultaneous pressure of coping with an increasing number of radiological
examinations, in daily practice and reality a contradiction often arises to the sought-after
ideal image.
Patient-centered medicine means placing the individual values and wishes of patients
at the center of medical practice [1]. The Institute of Medicine (USA) succinctly defines patient-centered medicine as
“... respectful of, and responsive to, individual patient preferences, needs and values,
and ensuring that patient values guide all clinical decisions ...” [2]. In this case, the autonomy of the patient plays a central role: the physician is
no longer the sole decider regarding treatment, further examinations and treatment,
but also the patient participates in the context of his or her individual health history.
Patient-centered radiology, however, should not be reduced to the doctor-patient conversation.
The perception and “experience” of radiology rely on a complex process chain, some
of which is intrinsic to the subject, starting with examination registration (electronic
forms in the hospital information system or online patient portals or telephone appointment)
through the medical consultation, performance of the examination and subsequent discussion
of findings.
Patient interviews have shown that satisfaction and trust during contact are primarily
based on the perception of medical expertise and humaneness [3]. Regarding the “humaneness” in the interaction, the spatial environment and contact
time, but also mutual respect as well as understanding for the individual situation
are specifically emphasized. This leads to increased well-being of the patients and
the psychological and social aspects of the disease and the recovery process find
a suitable place in the treatment [4]
[5].
In 2006 the Radiological Society of North America (RSNA) established the first steering
committee and scientific meetings on the subject of patient-centered radiology at
its annual congress under the slogan “use it or lose it”. The first organized workshops
in 2009 were primarily focused on offering systematic training in communication with
patients and providing scientific support. In 2012, the RSNA put the website www.radiologycares.org
online, which offered collected literature and advanced training courses on the subject.
In the RSNA's last in-person event of 2019, the topic was identified as one of the
major themes spanning the event in congress President Valerie P. Jackson's opening
remarks, titled “A Matter of Perspective: Putting a New Lens on Our Patient Interactions”.
Likewise, in the German-speaking radiological community, the topic of patient-centeredness
has gained in importance in recent years in terms of perception and, in part, also
research.
The European Society of Radiology (ESR) in a recent position paper describes its approach
to “value-based” radiology [6]. The topic is also active in the German Radiological Society (DRG) through a focus
on content at the 103 rd German Congress of Radiology in 2022 under the motto “Living
Diversity – Shaping the Future”. In the context of the topic sustainability, the social
aspects of radiology in the interaction with patients should be emphasized. For this
reason, a new working group on sustainability was established in the German Radiological
Society (DRG) in November 2020, which will work on this topic systematically, scientifically
and practically. Broken down to its basic principle, sustainability is to be understood
that no more may be consumed than grows back or regenerates. In this context, the
term “sustainability” should not only be used one-dimensionally based on the principle
of resource utilization with preserved regenerative capacity, as originally known
from forestry [7]; instead, we favor the more complex “three-pillar model” for our medical specialty,
which in principle consists of three partly overlapping concepts of ecology, economy
and social aspects ([Fig. 1]) [8]. The ecological and economic aspects of sustainability can be considered self-explanatory
to a large extent. In the context of the three-pillar model, sustainability also means
not only limiting radiology to economics and ecology and benchmarking it externally,
but also taking into account the social aspects of our discipline [9]. A crucial core of this will be the radiologist's interaction with the patient.
However, the concept should be understood not only as “patient-centered radiology”
but expanded to “people-centered radiology”. Adequate and appreciative interaction
should not only characterize radiologists’ communication with patients, but by extension
should also encompass radiologists’ or medical-technical assistants’ working methods
and training, as well as radiologists’ interaction with their medical partners from
all disciplines.
Fig. 1 Modification of the so called “3-column-model” of sustainability with overlapping
subgroups regarding social aspects, ecology and economy [8].
In order to provide the radiological community in Germany the opportunity not to dismiss
the term patient-centeredness or person-centeredness as an empty phrase, but to work
together to implement it and incorporate it into their daily work and practice, as
a newly-founded working group in the German Radiological Society (www.nachhaltigkeit.drg.de), we have striven to first create the current situation in a literature review from
2010–08/2021 in the sense of a narrative review. We have primarily identified articles
which were indexed under the term “patient-centered radiology” in Pubmed. A scientific
and practical introduction to the topic has been provided based on the literature
compilation ([Table 1]).
Table 1
Summary of important topics in patient- or person-centered radiology with reference
to important literature on the subtopics.
|
(Patient) Experience of radiological examinations
|
|
Fear of the examination [17]
|
|
Limited freedom of movement when positioned in large equipment [18]
|
|
Anxiety due to uncertainty until disclosure of findings [18]
[19]
[21]
|
|
(Patient) Communication of radiological findings after the examination
|
|
Personal discussion of findings [20]
[24]
[30]
[31]
[32]
|
|
Comprehension of medical terminology and examination result [36]
[37]
|
|
(Referring physician) Communication with radiology department
|
|
Appreciation of radiological findings and work [12]
|
|
Quality of intercollegial communication [12]
[39]
|
|
Professional motivation and satisfaction in radiology
|
|
Professional stress level [45]
|
|
Professional appreciation and recognition [12]
[45]
|
Radiology as a Clinical Discipline
Radiology as a Clinical Discipline
Regarding the simple statement that radiology is an independent clinical discipline,
a simple Google search with automatic completion of the search query can be disturbing
at first. An input in the search engine “Radiologist are ...” is currently completed
by the most frequent search queries by users such that it can be seen that many Internet
queries want to clarify whether radiologists are physicians at all. Likewise, medical
literature often distinguishes between “clinicians” and “radiologists”. This linguistic
distinction alone shows that for many patients and physicians in the medical establishment,
the radiologist is not considered a clinically involved physician [10]. In the international English-language literature, these divisions between radiologists
and clinicians find expression in headings such as “The Relationship Between Radiologists
and Clinicians” [11]. It seems even more disturbing that even in radiology journals and lectures, the
distinction between clinicians and radiologists is consistently perpetuated [12]. And in everyday clinical practice, we as radiologists reinforce this completely
false and misleading dichotomy by talking about “clinicians” who want something from
us. However, this way of speaking almost automatically makes us the opposite pole,
“non-clinicians”.
Strictly speaking, a distinction is made in modern medicine between clinicians, i. e.
physicians who care for patients, and physicians whose focus is on education, research
or administrative activities. Radiologists probably rarely occur in patients’ perception
of physicians, which may be due, among other things, to the fact that patients rarely
visit a radiology department directly, but are usually referred, and during examinations
frequently do not meet the radiologist in person. There are different degrees of direct
patient contact depending on the subspecialty – radiologists, however, are clearly
clinicians, who, whether in procedures, mammography, ultrasound or conventional X-ray
or CT and MRI diagnostics, have an immediate and direct clinical responsibility for
each individual patient. As radiologists, we have a self-image that we are not theorists
who just look at images, but clinical physicians who add value to patients and referring
physicians based on the patients’ history and complex clinical context.
As radiologists we should consider eliminating this partly self-selected false distinction
between clinicians and radiologists linguistically, in order not to become victims
of a self-fulfilling prophecy. Terminology such as “referring physician” or naming
the medical discipline or department could be helpful here.
There are no systematic studies of the extent to which radiologists are perceived
as physicians. However, as radiologists, we also have a personal responsibility in
communicating with patients, colleagues, and referring physicians to accept and demand
the role in direct care.
Patients’ Experience of Radiological Examinations
Patients’ Experience of Radiological Examinations
Patient-centered radiology means much more than just talking to the patient during
the course of the examination, rather, patient-centered radiology aims to prepare
patients for the examination in advance, for example, through patient education and
information in social media or online presence [13]
[14]. This perception ranges from the scheduling and registration process through the
experience and knowledge gained during imaging or intervention to the creation of
reports, reporting of findings, transparent invoicing and the further communication
process in the scheduling of follow-up examinations. Patient-centered radiology does
not only mean communicating the results of the examination in person, but must also
be seen as an optimization of the overall experience in the radiology department.
To our knowledge, there have been no systematic studies of the pre-examination experience,
such as the registration process or information perception prior to radiological examinations.
Potenzially, multimedia information prior to the examination, such as videos on websites
or in the waiting area or virtual walk-throughs of the examination rooms, would be
one way to reduce uncertainty and anxiety regarding radiological examinations. However,
sufficient studies are currently not available on this topic. However, as part of
the radiology examination preparation, one of the areas evaluated was the understanding
of risk during CT examinations [15]. For example, a study of the CT informed consent process found that patients benefited
primarily from an individualized educational discussion, with a significant relationship
existing between educational status and risk comprehension [15]. A study of the subjective perception of the waiting time in the radiology department
at a university clinic through regular or optimized care came to the result that more
intensive care (more information and personal care, beverages, etc.) while waiting
subjectively estimated the waiting time to be shorter. As a quality criterion for
good radiological care, however, waiting time was rated as important by only 24 %
of respondents – more relevant for over 40 % of participants was a detailed discussion
with the radiologist before the examination [16].
The perception of a radiological examination by patients has already been examined
in many ways in the literature. For example, Munn et al. in a 2011 systematic review,
showed that 71.6 % found anxiety or panic to be the most common problem during an
MRI scan [17]. This applies not only to the actual performance of the examination, but also to
the time required to report the findings [18]. On the whole, emotions such as fear and uncertainty seem to play a major role in
the subjective experience of a radiological examination.
For example, during examinations with large equipment (CT, MRI), patients find the
limited mobility intimidating [17]. The combination of the spatial conditions and loud noises, such as those that occur
during an MRI, can trigger a sense of threat and cause anxiety and stress [19]. In addition, the patients must lie as still as possible for good quality images;
not being able to move creates additional discomfort [19]. For some patients, an accompanying feeling of loss of control can be reduced by
providing detailed information beforehand. The emergency button, with which the examination
can be aborted, as well as occasional acoustic contact with the examiner, is felt
to be helpful and reassuring [10].
The time after the examination until the discussion of the findings is also emotionally
charged for radiological patients. The wait for a possible diagnosis made by imaging
is an immense stressor for those involved. A subsequent announcement of a potentially
serious diagnosis is associated with a strong emotional reaction that can be experienced
as traumatic [18].
Thus, 75 % of patients would like to be notified of the findings within 30 minutes
[20]. The waiting time as such, both before and after the examination, has a great influence
on the satisfaction regarding a visit to the radiology department [11]. Follow-up examinations, for example for oncological patients, are perceived as
less emotionally stressful – in a way, a routine is created: patients know their diagnosis
and the course of the examination [18]. In addition, the patient's level of education affects how they handle a radiological
examination. Knowledge about the examination, possible diagnoses and therapies reduces
the anxiety level [18].
However, patients' own research can lead to problems. Patients may be misinformed
about examinations as a result of anecdotes from their friends and relatives or, for
example, Internet research they have conducted themselves [17]. Misconceptions thus formed can result in an attitude that is difficult to fully
eliminate even through extensive counseling. An example of this is that the anxiety
level in patients is higher before an MRI than before a CT scan [18], which objectively seen is paradoxical, since an MRI produces no radiation and involves
less risk. The reason for this could be that CT as a form of radiological diagnostics
is more common in everyday life and therefore better known than MRI. Theoretically,
however, the longer examination time and the confinement of the gantry in the MRI
could also be partly responsible. In general the informed consent process seems to
be a multi-layered element of individual perception. Thus, comprehensive background
information is fundamental for a positive feeling with which the patient then faces
the examination [17]
[21]. In the future, this could be improved by multimedia provision of informational
and educational videos as well as written material [22]
[23]. Despite written information, patients may have gaps in their knowledge if they
misread or did not understand sections of the material [19]. In addition, patients prefer to be informed about the procedure, risks, contrast
media, etc. in personal contact, as queries are possible, and concerns and uncertainties
can be addressed [17]
[19]
[21]. Even after comprehensive written and oral information, all patients still report
a certain basic level of nervousness and tension before a radiological examination
[19].
Communication with Patients after the Examination
Communication with Patients after the Examination
Interaction between radiologists and patients is considered a core element of patient-centered
radiology [24].
Early publications from 2007 and 2009 by L. Berlin offer an interesting image of relevant
attitudes [25]
[26]. Cited is a 1966 letter to the editor in Radiology in which a North Carolina radiologist writes, (loosely translated), “... we as radiologists
do not have to listen to long and vague descriptions of patients' symptoms or even
perform complete physical examinations. Anyone wanting to do that should become anything
but a radiologist ...” [27]. This quote illustrates the historical attitude of some radiologists in the early
1970 s. Based on the requirements of mammography screening in the USA to personally
inform patients of the findings within a defined period of time, Berlin sees a general
obligation to provide personal notification of findings in direct patient contact.
He emotionally appeals to radiologists to primarily serve the patient and have an
ethical responsibility.
The extent to which personal contact with the radiologist is relevant for the patient
and how this should ideally be structured has also been investigated. In one study,
for example, 84 % of outpatient ultrasound patients would like to have a discussion
of findings directly with the radiologist [28]. A study by Schreiber et al. showed that the majority of patients would like to
receive the information directly from the radiologist after the examination. In this
regard, 92 % of those questioned stated that they would like to receive normal findings
directly from the radiologist and 87 % would like to have a discussion with respect
to pathological findings [29]. A German written survey demonstrated that 48 % of patients and 59 % of referring
physicians wanted a doctor-patient discussion with the radiologist to take place after
the examination [30]. At the same time, patients in that study wanted to receive the results of the examination
within 30 minutes.
A consideration of all published articles regarding the desire for a personal conversation
with the radiologist in the case of unremarkable findings, the large spread between
12 % [31] and 94 % [28] is striking. This suggests an influence by the choice of study design. In an anonymized
theoretical survey after CT and MRI examinations, 34 % of patients wanted to be called
by the referring physician and 12 % by the radiologist if the findings were hypothetically
normal [31]. Only 2.6 % of the study participants wanted a personal discussion in the case of
normal findings. In the event of pathological findings, however, the request for telephone
reporting of findings was higher, at 49.8 % by the referring physician and 14.4 %
by the radiologist. These results from an online survey of patients with hypothetical
questions are then contrasted with the results published in 2019 by Gutzeit et al.
based on actual situations [32], in which 2 groups of 101 patients each were compared, with only one group having
a personal assessment conversation following their MRI examination. Across both groups,
76 % were concerned about diagnostic findings during the examination. The conversation
group was significantly more likely to rate “good radiology” due to the opportunity
for a face-to-face discussion with the radiologist, at 81 % compared with 14 % in
the control group. This further resulted in significantly higher retention at the
institution for future radiological examinations (93 % vs. 75 % in the control group)
and in a concurrent significantly higher assessment of the competence of the radiology
department in the conversation group.
Personal contact with the attending radiologist seems to have a significant influence
on the perception of the examination; thus, a heartfelt dialogue leads to a reduction
of stress and discomfort and to a better handling of the examination situation [19]. The option is found to communicate concerns and fears and to gain a better understanding
of the procedure, indication and possible outcomes. These are crucial aspects for
people who, owing to the situation alone, are confronted with their health risks or
vulnerability [18]
[21]. However, professional interaction between physician and patient not only optimizes
the subjectively perceived satisfaction of the patients, but also helps the treating
physician to achieve more professional satisfaction [24]. In addition, improved compliance on the part of patients leads to greater examination
quality [18]
[33]. These are beneficial developments that occur provided that patient autonomy is
strengthened through direct communication and concomitant facilitation of participatory
decision making [19]
[20]. A shift toward modern communication on equal footing and a partnership model of
a doctor-patient relationship is accordingly also desirable for radiology. In any
case, the research presented here suggests that prompt and personalized discussion
of findings should be integrated into treatment pathways. Nevertheless, offering direct
conversation in routine clinical practice is difficult to achieve due to economic
reasons and physician shortages. Potenzially, this could be remedied by the development
and implementation of “patient-readable” findings or by artificial intelligence support,
e. g., in the triage of critical findings.
In 2017 the Patient-Centered Radiology Steering Committee of the RSNA published an
interesting study based on an online survey that queried 694 radiologists about the
current status and awareness of patient care [24]. In addition it evaluated the extent of patient focus with extensive patient communication,
and the relevant reasons for its absence in the daily routine. This shows a remarkable
discrepancy between the desire and the reality in the radiologist's discussion with
the patient. Although the majority of radiologists (71 %) felt that these discussions
were important, only 21 % of respondents reported actually having these conversations
on a regular basis as part of their clinical routine. A high workload and number of
examinations on large devices as obstacles were cited by 73 % of the study participants.
A recommended solution was to financially reward discussions with the patient to compensate
for the quantitative loss of the study evaluation. This survey describes the real
problem of radiology, the desire to change from a quantitative to a value-based discipline,
but due to the increasing concentration of work, this is hardly achievable in reality.
A recent study from the Netherlands which analyzed online reviews of radiologists
confirms that radiology is generally highly valued by patients; however, the negative
reviews also show potential for improvement, especially in communication (30 % of
all negative reviews) and humaneness/caring (49 % of all negative reviews) [34]. Similarly, a recent survey by the European Radiological Society of 400 patients
from 22 countries shows generally high satisfaction with radiology, with 36 % expressing
dissatisfaction with information about the risks and benefits of examinations [35]. In this regard, 33 % of patients were dissatisfied with the radiologist's availability
for consultation.
Radiology Department Communication with other clinical Disciplines
Radiology Department Communication with other clinical Disciplines
In addition to the question of how and whether radiologists communicate with patients,
the comprehensibility of the findings for both the patient as a medical layperson
and for the referring physician is a research area of patient or person-centeredness.
Patient-comprehensible findings are one approach to making radiological results more
transparent [36]. According to initial surveys, what is most desired from the patient side is language
that is understandable to laypersons, in addition to an assessment and clear formulation
of urgency, an explanation with glossary, and a recommendation of the steps to follow
from the examination with visualization of the findings. Referring physicians primarily
want clear information on the finding with recommendations on further action as well
as the urgency of the finding [37].
Radiological expertise, quality of findings and communication are perceived positively
overall [38]. Based on a 2008 online survey from Belgium, 87 % of referring physicians surveyed
consider radiology reports to be essential. An evaluation of this survey was also
conducted separately for general practitioners (n = 282) and specialists (n = 453),
although no separate evaluation by specialty was available within the specialist group. Nevertheless,
23.5 % (101/430) of the specialists believed that they could make a better interpretation
of findings in their own discipline than the radiologist. This assessment was only
0.4 % among general practitioners [12]. Referring physicians (97.4 %) agree with radiologists (98.5 %) that good clinical
information and defined issues must be present. In addition to radiological findings,
intercollegial discussion on a personal basis or in clinical-radiological meetings
and tumor conferences is considered goal-directed and an additional benefit for patient
treatment [39].
Regarding the structuring of the report text, it is interesting to note that 50.1 %
of the referring physicians and 50.7 % of the radiologists assume that an organ region
was not analyzed and reported if it is not mentioned in the report. Therefore, 84.5 %
of referring physicians (65.7 % radiologists) would like to see itemized reporting
for complex radiology examinations. This concept is not simply to be equated with
the currently frequently-requested structured reporting, but rather implies that findings
are made either with topographic or hierarchical order, systematically itemized, i. e.,
listed individually, covering the most important organ regions [40]. But structured reporting, probably optimal in hybridization with the free text
findings, supports better readability and acceptance of the results in most cases
[41]. This can also be further improved by using multimedia enhancements such as linked
explanations and glossaries [42] or by integrating the relevant radiological image material into the report [43].
Job Satisfaction in Radiology
Job Satisfaction in Radiology
In addition to the relationships of radiologists with patients and medical colleagues
from other disciplines, job satisfaction is part of the subject of person-centered
radiology. The question of the determining factors that move students to become radiologists
and the correlation with subsequent job satisfaction during radiology training was
evaluated in a recent online survey of 488 participants in the United States [44]. The intellectual challenge of the specialty was most often cited (38 %) as a key
motivator, followed by enthusiasm for imaging (20 %) and the structured workflow of
radiology (20 %). A large proportion of respondents who felt primarily motivated by
the potential lifestyle offered by radiology experienced significantly higher levels
of dissatisfaction in later residency training.
Overall, there was a high level of job satisfaction in radiology, also in comparison
with other medical specialties [45]. For example, participants in a study conducted in Germany reported 65 % satisfaction
with their radiology residency, which was significantly lower in surveys of other
disciplines, such as internal medicine (38 % [46]), urology (44 % [47]), or ophthalmology (40 % [48]). A mono-institutional free text survey demonstrated that a good working atmosphere
with a high reputation of the radiological department as well as personal appreciation
by departmental management turned out to be the most important factors for satisfaction
and motivation [49]. Optimization potential was seen primarily in better communication within the team
with more transparency and the influence of employees on the department's planning.
In addition, continuous systematic training was perceived as an important component
of satisfaction. Despite high job satisfaction, only 36 % of participants with children
in the survey were satisfied due to the difficult work-life balance. Due to the relatively
high psychosocial stress when working in radiology, the analysis of work stress using
an industry-independent questionnaire using the effort-reward (ER) model also appears
interesting [50]. Simplified, the ER ratio describes the relationship between work input and reward
(recognition, salary, job security, etc.), so that values > 1 indicate an imbalance
with regard to a psychosocial workload. With an ER ratio of 0.6 for the average population
working full-time, the ER ratio in the survey for radiologists was 1.7 (e. g., in
comparison, urology was 1.4) [47]). Among other things, a particularly positive identification with the professional
image of the radiologist is suspected as a possible explanation here.
Summary and Outlook
Patient-centered or rather people-centered radiology represents a current focus in
research and clinical practice in the sense of a reconsideration and reorientation
of radiology to its original medical ethics and self-image. Especially in times of
massively increasing digitalization and orientation towards new challenges, such as
artificial intelligence as a support in the daily routine of radiology, which is characterized
by work intensification, the originally medical and human component of our profession
will become increasingly important.
In addition to the return to seeing radiology as an intrinsic medical activity and
therefore viewing ourselves as clinically active physicians, as clinicians, numerous
research approaches of person-centered radiology are emerging. Currently, most publications
focus on the physician-patient relationship in our specialty. Among other things,
the topics of experiencing a radiological examination during and after the imaging
are evaluated. Thus, the personal discussion between radiologists and patients appears
to strengthen patients’ confidence and personal responsibility. Consequently, radiology
is perceived positively as a distinct discipline and patient retention is better established.
However, this desirable ideal of a radiologist who is always and immediately available
for the discussion of findings must be viewed critically in the context of an increase
in imaging, also taking economic constraints into account. Under the same dilemma
of time pressure with increasing workload and the simultaneous desire of a radiologist
who is always personally approachable for referring clinical colleagues, optimization
of communication of findings, for example by structured or itemized reporting or should
also be a goal.
Since radiologists themselves and their staff should also be taken into account in
this context, the high level of psychosocial stress that still exists in a person-centered
radiology department must be seen despite the high degree of job satisfaction and
positive identification with the job profile, which have been confirmed in studies.
Here, too, optimization must be increased in the sense of sustainable radiology.
In our approach to the topic, an evaluation of the existing literature revealed that
the majority of publications simply consisted of the results of participant surveys.
Scientifically, we seem to be at the beginning, so that a systematic analysis of the
current situation was necessary. Currently, few studies address specific processes
that might, for example, improve communication between radiologists and patients or
referring clinical colleagues. Through our approach to the subject based on our narrative
review, we hope this can be changed and improved in the near future, so that we as
clinical interdisciplinary professionals can evolve to be not only device- and technology-centered,
but human-centered as well.
