Recommendations within the radiologyreport: implications for the primary care physician Andrew J. Gunn, MD Dushyant V. Sahani, MD Susan E. Bennett, MD Garry Choy, MD
Financial DisclosureThe authors have no relevant financial disclosures that would pose a conflict of interest with this study
Introduction• Radiology reports are the primary work product of the radiologist• Radiology reports are the principal means by which the findings of an examination are communicated to the patient’s care team• The radiology report is of particular importance to primary care physicians in the outpatient setting, who may not have the time or ability to consult the radiologist in person
Introduction• There is considerable interest in improving radiology reporting practices – RSNA Reporting Initiative – American College of Radiology (ACR) has developed “Practice Guidelines for Communication of Diagnostic Imaging Findings” – Multiple survey-based reports in the literature assessing referring physician preferences with regard to the radiology report
Introduction TECHNIQUE: Two views of the chest• It has been suggested that the radiologist should make HISTORY: As provided in header recommendations within the COMPARISON: None. report for further diagnostic FINDINGS: studies or treatment, if Lungs: The lungs are well-inflated and clear. There appropriate is no focal pneumonia or pulmonary edema. Pleura: There is no pleural effusion or pneumothorax. Heart and Mediastinum: The cardiomediastinal silhouette is• At our institution, we place unremarkable. recommendations in their own Bones: The bones are unremarkable. section within the structured IMPRESSION: Normal examination radiology report, which helps the reader recognize when a RECOMMENDATION: None. recommendation has been Figure 1 (above). Sample structured report for a made (Figure 1). chest radiograph which includes a separate “recommendation” section
Questions• How do primary care physicians perceive recommendations made by radiologists?• Do recommendations made by radiologists affect the practices of primary care physicians?• Does the wording or location of the recommendation within the report change how it is perceived?
Materials and MethodsAn on-line survey was distributed to 229 primary carephysicians at our institution through an internal listserv (Figure 2, next slide)
Materials and MethodsFigure 2. The on-line survey distributed to the primary care physicians.
Results• Respondents – 100 responses (43.6% response rate) – Averaged 19.1 years in practice (range: 2-50 years) – 95% order less than 20 examinations per week
Results Referring Physician Satisfaction 1-5 scale 3.9 3.5 Satisfaction with reporting in general Satisfaction with recommendationsFigure 3. Mean physician satisfaction with reporting overall was 3.9 on a 1-5 scale while mean satisfaction with radiologist recommendations was still 3.5, it was significantly less (p=0.02) than overall satisfaction
Results Single Biggest Problem with Radiology Reports Figure 4. “Too many 25% recommendations for 8% further diagnosis and treatment” was identified as the biggest 19% problem with radiology reporting while “Not 36% enough 12% recommendations forToo Many Recommendations for Further Diagnosis and Treatment further diagnosis andNot Enough Recommendations for Further Diagnosis and Treatment treatment” was the thirdUnclear or Non-Specific Language most commonly citedDidnt Answer the Clinical Question problem.Other* Gunn AJ et al. JACR, in press
Results• Referring physicians were Items Necessary in the Radiology Report allowed to select items they 100 felt were necessary in a 90 88 radiology report 80 Number of Responses 70 60 50 43 42 40• Figure 5 (right). Referring 30 20 physicians chose 10 “Recommendations for 0 further imaging” twice as Recommendations for Consultation Recommendations for Further Imaging Recommendations for Treatment much as other types of recommendations
Results Do You Feel Medico-Legally Obligated by Recommendations in a Radiology Report? 3% 3% Yes No Unsure 94%Figure 6. 94% of primary care physicians feel medico-legally obligated by radiologist recommendations.
Results Do You Feel More or Less Medico-Legally Obligated if Do You Feel More or Less Medico-Legally Obligated if the Recommendation has Qualifying Language? the Recommendation is Set Apart in its Own Section within the Report? 24% 12% 5% 2% More ObligatedMore Obligated Less ObligatedLess Obligated 72% No differenceNo Difference UnsureUnsure 23% 0% 62% Figure 7. 23% of primary care physicians feel more medico-legally obligated by the recommendation if it’s found within its own section in the report (above left). 62% of primary care physicians feel less medico-legally obligated by the recommendation if qualifying language such as “if clinically indicated” is added (above right). Gunn AJ, et al JACR, in press.
Results Should a Radiologist Adjust the Recommendation Based upon the Specialty of the Ordering Provider? 15% 6% Yes No Unsure 79%Figure 8. The majority of respondents felt that the radiologist should not change their recommendations based on the specialty of the ordering provider.
Discussion• Overall, satisfaction with both radiology reporting and radiologist recommendations is good amongst primary care physicians• Primary care physicians, however, are less satisfied with recommendations than they are with reports in general – The reasons for this difference are unclear and likely multi-factorial
Discussion• There is wide variability of opinion amongst primary care physicians as to the utility of radiologist recommendations – “Too many recommendations” was the most commonly cited problem with reports (36%) – “Not enough recommendations” was the third most commonly cited problem with reports (12%) – The literature suggests this variability, however, is shared by other physicians, even radiologists – This is a difficult conundrum to overcome for the radiologist
Discussion• Recommendations for further imaging were the preferred type of recommendation – Primary care physicians do not prefer the radiologist to suggest treatments or consultation – Suggests that primary care physicians would rather make those decisions themselves
Discussion• Primary care physicians feel medico-legally obligated by radiologist recommendations• Placing the recommendation within its own section in the structured radiology report increases this sense of obligation – In this location, the recommendation, either intentionally or unintentionally, has been given added significance• Adding qualifying language to the recommendation decreases this sense of obligation – Qualifying language provides the primary care physician more flexibility in clinical decision-making
Discussion• Radiologist recommendations have an impact on the practice of primary care physicians even though their attitudes regarding these recommendations are variable• This impact seems to be modulated by both the location and wording of the recommendation• Radiologists should consider these factors when making recommendations within the report
Selected References1. McLoughlin RF, So CB, Gray RR, et al. Radiology reports: How much descriptive detail is enough? AJR 1995;165:803-6.2. Friedman PJ. Radiology Reporting: Structure. AJR 1983;140:171-3. Fischer HW. Better communication between the referring physician and the radiologist (editorial). Radiology4. ACR Practice Guidelines for Communication of Diagnostic Imaging Findings. Revised 2010. Downloaded from www.acr.org.5. Lawson DE, Siegel SC. A recommendation regarding recommendations. AJR Am J Roentgenol 1997; 169:351-2.6. Kessler HB. The contemporary radiologist: consultant or film reader? AJR Am J Roentgenol 1997; 169:353-4.
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