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Negotiating Expertise: PACS and the Challenges to Radiology
1. Renegotiating Expertise: PACS
and the Challenges to Radiology
Allison A. Tillack, MA
UCSF Medical Scientist Training Program
UCSF-Berkeley Joint Program in Medical Anthropology
Richard S. Breiman, MD
UCSF Department of Radiology
2. Purpose of Study
To examine how the adoption of PACS has/has not
impacted:
Professional relationships among radiologists and clinicians
The role of the radiologist as a member of the patient care
team
3. What Is Medical Anthropology?
A subset of sociocultural anthropology:
“examines patterns and processes of cultural change, with a
special interest in how people live in particular places, how they
organize, govern, and create meaning” (AAAnet.org)
Medical Anthropologists are interested in how the health of
individuals and larger social groups are impacted by inter-
personal relationships and cultural and social norms
4. What is Medical Anthropology?
Qualitative
Primary research method is Participant-Observation:
“involves placing oneself in the research context for
extended periods to gain a first-hand sense of how local
knowledge is put to work in grappling with practical
problems of everyday life” (AAAnet.org)
Ethnographer is embedded into study population— allows
development of relationships of trust, movement beyond
rhetoric offered to a perceived ‘outsider’
5. Why Use Medical Anthropology/
Qualitative Research Methods?
Particularly good for investigating research questions about
complex, emergent situations
Generates detailed, rich data connected to specific contexts
Can highlight differences between what people say and what
they do
Helps generate important themes, patterns, hypotheses for
future research
6. Study Goals
Characterize nature of changes in clinician-radiologist
relationships post-PACS
Suggest possible causes/impact of these changes
Develop suggestions for enhancement of radiologists’
role in clinical medicine
7. Methods
A pilot project
3 months of observation of the daily practices of a small
sample of radiologists and a community of clinical
specialists (N=40)
Included interactions in reading rooms, during multi-
disciplinary conferences and tumor boards, and on rounds
8. Methods
Semi-structured interviews with 10 radiologists and 5
clinical specialists focusing on:
Perceptions of radiologists’ roles before and after PACS
Perceived changes in nature/substance/frequency/place of
radiologist-clinician interaction pre- and post-PACS
9. Methods
Extensive archival review of relevant scientific and
popular literature
Radiology, JACR, society bulletins, society websites
NEJM, JAMA, Lancet
New York Times, Washington Post, Wall Street Journal
10. Data Analysis
Verbatim interview transcripts and field notes (written
record of daily observations/interactions of
ethnographer) were analyzed for recurrent themes and
patterns
These themes/patterns were then correlated with
relevant literature
Special attention was paid to discrepancies between
what people said and what they did
11. Results
All study radiologists (broad range of levels of
experience) expressed belief that they interact much
less frequently with clinician colleagues after adopting
PACS, and that very few clinicians now visit reading
rooms (as compared to rate of visits before PACS
adoption)
All study radiologists voiced a high level of concern
about what this reduction in interactions will mean for
radiology in the future and for patient care
12. Results
For example, one senior radiologist said:
“We [radiologists] knew all the clinicians intimately
before. And then with PACS, this intimacy disappeared.
Before [PACS], I knew the face, name, wife’s name, and
kids’ names of all the clinicians, but now I don’t know who
you are if you joined the medical staff after we got PACS.
Now we’re operating in a void, because there’s no history
of the patient on the written image requests. Before, when
a clinician showed up, I could ask them and find out what’s
really going on with the patient.”
13. Results
Observations of and interviews with clinical specialists in the
study indicate that attending specialists and a large majority of
fellows and senior residents believed that:
PACS allowed them to see images frequently enough to develop
significant expertise in interpretation
They were unlikely to seek out the opinion of a radiologist unless they
already had a solid professional relationship with that radiologist and
felt they could “trust” that radiologist’s interpretation
At the study site, images were not embedded in radiology reports.
Often, the specialists would look at the image and not the dictation,
preferring to rely on their own ‘read’ and clinical knowledge of the
patient
14. Results
For example, a senior clinical specialist commented:
“In the acute setting when someone has a stroke and is in the
emergency department, we have our residents look at the
images on PACS and then a senior person, a stroke attending
like myself or one of the fellows, views the image as well, and
then makes a decision about emergent treatment. We make a
lot of decisions from home… we have our web-based PACS that
we can look at from home, so I wake up at 1 AM and stagger
down to the computer and look at the thing, and then tell
folks what we’re going to do.”
15. Results
• Trust was something that both study radiologists and
clinicians frequently talked about both informally and
formally
Difficulty of establishing/maintaining trust between
radiologists and clinicians post-PACS
16. Discussion
Anthropological studies have shown the importance of social
interaction in establishing/maintaining jurisdictions of
expertise and professional trust
Expertise is knowledge based, but also interactional and
performative
Without opportunities to create and reinforce relationships of
professional trust and displays of expertise in image
interpretation with which to ‘convince’ their clinician
colleagues of their expertise, radiologists are at risk of losing
their status as imaging experts
17. Discussion
As medical care becomes increasingly sub-specialized,
trust among clinicians is more important than ever
Relying on others for the production/interpretation of
information (i.e., lab tests, imaging, physical exam, etc)
involves risk
To work as a patient care team requires trust in the
competence of others
18. Discussion
PACS has revolutionized medical imaging and has had
many positive impacts on radiologic practice
But…
PACS has also disturbed the mechanisms by which
radiologists formerly established trust and communicated
their expertise to clinicians, which has led to a
marginalization of the radiologist as a member of the
patient care team
What can radiologists do to combat/reverse this trend?
19. Discussion
Some radiologists are already taking action:
Embedding reading rooms in clinical areas
Becoming more visible through multi-disciplinary conferences
(seeking out clinicians and patients outside the reading room)
Focusing more on providing clinically relevant information to
clinicians, faster… asking clinicians directly what they need,
how radiology can help them
Taking on role of patient advocate (especially for radiation
safety, reducing number of unneeded scans)
20. Discussion
This isn’t just a problem of less communication, but the
kinds of communication and the ways communication
takes place
A key question for future research: how can trust and
expertise be established/maintained using alternate
modes of communication (email, phone, IM, etc.)?
21. Avenues for Future Research
Sociologists have been investigating how trust is
established without personal interaction or knowledge
in virtual communities
Example: eBay—how do people conduct business via the
internet (and establish trust) with people they’ve never
met?
A particularly successful technique uses positive (as opposed to
negative) reputation systems
22. Ongoing Research
Pilot project helped to shape Ms. Tillack’s current dissertation
research
Combines both qualitative (ethnographic) and quantitative
approaches
Study is now multi-sited (in a different geographic region);
includes a large academic medical center, a community hospital,
and pre-PACS health care clinic
Also includes observation/interviews with multiple specialist
communities (ER, Neurology, Orthopedic Surgery, Hospitalists)
23. Special Thanks:
Dr. Breiman and the UCSF Radiology Department
Dr. Sunshine and the ACR
Dr. Borgstede and the U. Colorado, Denver Radiology
Department
Drs. Adele Clarke, Ian Whitmarsh, Sharon Kaufman,
Department of Anthropology, History, and Social Medicine
(UCSF)
The UCSF Medical Scientist Training Program
