JACR: PACS can communicate images, but not physician trust

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The widespread adoption of PACS has led to a number of improvements in patient care–increased productivity, elimination of film, increased image accessibility–but along with those benefits, PACS adoption has put a wedge in communication between radiologists and referring physicians, according to a study published in the January issue of the Journal of the American College of Radiology.

Re-establishing relationships of trust with referring providers will be essential in this age of digital communication, according to authors Allison Anne Tillack, MA, of the department of anthropology, history and social medicine at the University of California, San Francisco (UCSF), and Richard S. Breiman, MD, of the department of radiology at UCSF. “Because PACS have caused a reduction in referring provider visits to the reading room, radiologists must seek out new opportunities to form personal relationships with other physicians.”

The researchers used ethnography, a technique of medical anthropologists, to examine how PACS adoption affected professional relationships among radiologists and referring providers and to evaluate the changing perceptions of the role of radiologists as members of a patient care team. Medical anthropology looks at healthcare through social, cultural, political and economic lenses, and ethnography involves long-term investigation from researchers who are “embedded” with their subjects.

“Although qualitative techniques may lack the ability to assess statistical significance, the data that are gathered can suggest important themes, patterns and hypotheses for future research that can be evaluated using quantitative methodologies,” wrote the authors. “Thus, rather than perceiving ‘anecdotal evidence’ or ‘personal bias’ as problems to be overcome, anthropologists consider these to be important sources of data, as they provide insight into how people think, remember and perceive events.”

After three months of ethnography marked by observations and interviews with radiologists and neurologists at a large academic medical center, final analysis revealed that radiologists believed they are interacting less with referring physicians and have less clinical information about patients. They also found it more difficult to establish communication with referring physicians due to the lack of face-to-face contact.

To underscore the radiologists’ points, the authors cited studies that showed more than 80 percent reductions in the rate of in-person consultation for radiography as early as 1999.

The neurologists involved in the study expressed a belief that PACS adoption has allowed them to become familiar enough with images that they have developed their own interpretive expertise.

“Often, the specialists would look at the image but not the dictation, preferring to rely on their own ‘reads’ and clinical knowledge of patients,” wrote Tillack and Breiman. “The dictation was consulted only when images had unusual or ambiguous findings.”

This comfort level with interpretation disappeared for neurologists when looking at images from less familiar modalities and body locations, according to the authors.

Another point of concern noted by the researchers was the development of trust issues between radiologists and neurologists. Neurologists were unlikely to seek out opinions from radiologists unless they had an existing relationship with them. On the flip side, radiologists also talked about clinicians they trusted to order appropriate studies or give accurate histories on request forms. With interaction occurring mostly over the phone or at weekly conferences, there were fewer opportunities to build that level of trust between providers.

“Although it may seem old fashioned in this era of numeric accountability and performance metrics, trust and effective communication among physicians remain more important than ever, especially given the trend toward the increasing specialization of medical care,” wrote the authors. “Trust is not simply a matter of exchange of information but involves certain expectations, risks, and actions that must be actively reproduced and renegotiated through social interaction. Care of patients requires trust in the competence of other specialists on both an individual and a group level.”

To learn more about meeting referring physicians' needs, read "The Referring Physicians' Wish List: What Clinicians Need from Radiologists" in the January issue of Health Imaging.