Key to clinician interaction? Location, location, location

By Erik L. Ridley, AuntMinnie staff writer

May 16, 2013 -- Want more personal interaction with your referring physicians? Try moving your reading rooms out of the basement and into clinical areas. A new study in the Journal of the American College of Radiology found that such "embedded" reading rooms resulted in a big jump in personal visits from clinicians.

Researchers found that personal visits made up nearly half of the communications between radiologists and referring physicians when reading rooms where embedded in clinical departments. For the traditional reading rooms that weren't embedded, only 7% of total communications were personal visits; these rooms relied far more on computer-based communication with critical test results management (CTRM) software.

The study has intriguing implications as radiology looks to improve its ties with referring physicians -- and counteract the image of radiologists as prickly physicians working alone in dark rooms. However, the researchers qualified the results by saying that a department's culture could also greatly affect communication style (JACR, May 2013, Vol. 10:5, pp. 368-372).

How has PACS changed relationships?

Lead author Allison Tillack, PhD, from the University of California, San Francisco (UCSF), wanted to explore how PACS has altered the relationship between radiologists and referring providers. While working on her PhD dissertation in medical anthropology as part of the UCSF Medical Scientist Training Program, Tillack spent time in different reading rooms at her research site observing interactions between radiologists and referring providers.

"I began to notice there seemed to be a lot more interactions in the embedded reading rooms," she told "I was curious to explore this trend, since I'm very interested in finding ways to promote radiologist visibility."

The advent of PACS has certainly altered the relationship between radiologists and clinicians. At the RSNA 2010 meeting in Chicago, Tillack presented the results of a medical anthropological study: Thanks to PACS, clinicians were increasingly comfortable with their own image interpretation ability and were unlikely to consult with radiologists unless they had a solid professional relationship, the research showed.

As a result, radiologists need to proactively cultivate these relationships, she concluded in that study. In an attempt to facilitate and enhance communication, a number of radiology departments have begun to integrate some reading rooms into areas such as cancer centers, intensive care units, and emergency rooms.

For the current study, Tillack and co-author Dr. James Borgstede, from the University of Colorado at Denver, sought to investigate whether embedding reading rooms in clinical areas at a large, tertiary care academic hospital could increase direct communication between radiologists and clinicians.

The study compared two reading rooms embedded in clinical areas (breast and musculoskeletal [MSK] imaging) with two nonembedded reading rooms (body and neurological imaging) located in a basement. Tillack conducted 10 days of observations for each of the four reading rooms between the hours of 9 a.m. and 5 p.m., Monday through Friday. She observed the frequency, form, duration, and general purpose of communication between radiologists and radiology residents and nonradiology clinicians.

Communication types with referring providers by reading room
  Total studies completed CTRM messages sent Phone calls Personal visits Total communications
MSK 729 2 (3.3%) 38 (62.3%) 21 (34.4%) 61
Breast 201 5 (12.8%) 9 (23.1%) 25 (64.1%) 39
Body 155 16 (34%) 29 (67.1%) 2 (4.3%) 47
Neuroradiology 288 14 (50%) 11 (39.2%) 3 (10.8%) 28
Embedded 930 7 (7%) 47 (47%) 46 (46%) 100
Nonembedded 443 30 (40%) 40 (53.3%) 5 (6.7%) 75

The results indicate that the embedded reading rooms had a sharply higher number of personal visits (46, or 46% of total communications), compared with the nonembedded rooms (five visits, or 6.7%). On the other hand, the remotely located rooms relied more on CTRM software, with 30 messages sent (40% of total) versus only seven messages (7%) for the embedded rooms. The differences for personal visits and CTRM communications were statistically significant (p < 0.0001).

The differences in proportions of phone calls to and from referring providers between embedded and nonembedded reading rooms were not statistically significant (p = 0.4468).

In an interesting development, the two embedded reading rooms had significant differences in the proportion of visits (p = 0.0044) and the proportion of calls (p = 0.0002), while the two nonembedded rooms did not significantly differ in calls, visits, or CTRM messages.

Although the group found sharp differences in the communication modes between the reading rooms, Tillack said it's not certain that location was the primary factor. Several alternative hypotheses could explain the study's results, including culture, according to the researchers.

"Some specialist groups might be influenced by a senior member who is particularly committed to engaging in face-to-face consultations with radiologists," the authors wrote. "Similarly, certain reading rooms might prioritize reaching out to referring physicians and fostering a welcoming environment. Thus, the variability in communication practices that we documented could be due to reading room location but could also reflect patterns related to the specialties of the referring physicians or of the subspecialized radiology groups that are independent of location."

One size does not fit all

It's important to recognize and document the different communication patterns in each of the different reading rooms, Tillack said.

"It is widely recognized that radiologists need to augment their visibility and improve communication with clinical colleagues, but our research indicates that a 'one-size-fits-all' model may not be the best way to accomplish these goals," she said. "Instead, radiology departments may want to study how each reading room is interacting with members of different clinical specialties and then tailor interventions to further support and enhance the communication that is already taking place, while also providing new opportunities for interactions."

The study really stresses how complex and context-dependent the dynamics of communication can be between radiologists and referring clinicians, according to Tillack.

"Not only do individuals have different preferences and patterns for interaction, but so do different specialty groups and even institutions," she said.

Divided opinions

Anecdotally, radiologists and clinicians who were already working with embedded reading rooms tended to be very enthusiastic about them, Tillack noted.

"In fact, one of the musculoskeletal radiologists I spoke with said he felt that embedding the MSK reading room next to the orthopedic surgery dictation room was so successful he was having trouble keeping his [relative value units (RVUs)] high; every time he sat down to get some work done, he was interrupted by another referring provider stopping by or calling to get his opinion on a film," she told "However, he stressed that, in general, embedding the reading room was a huge step forward, and that it not only improved communication but his job satisfaction as well."

Referring providers also were often enthusiastic about the arrangement.

"Several of the emergency room physicians I talked to were especially excited about the notion of having a radiologist physically in the emergency department," she said. "They felt like having a radiologist on hand would not only help them determine the optimal study to order and improve patient care, but would allow the radiologist to appreciate the clinical and practical difficulties of care in the ED."

On the other side of the coin, many radiologists working in nonembedded reading rooms felt that while it was an interesting idea, it might be practically difficult, Tillack said.

"For example, one chest radiologist felt that moving to one location, like the intensive care unit, might make it more difficult for other referring providers like pulmonologists, emergency physicians, or surgeons to access the reading room," she said. "Other radiologists were wary that embedding the reading room would lead to too many interruptions, and that their location in the basement gave them a degree of 'protection.' "

Copyright © 2013

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