High-tech communication in 2012 is undeniably fast and efficient, but does it build trust? Among referring physicians who rely on radiologists, the question transcends the objective nature of science and drifts into the subjective world of personal relationships. Allison Tillack, MA, a student in the MD/PhD program at the University of California–San Francisco, is not afraid to tackle such topics in her dual role as clinical scientist and medical anthropologist. The fourth-year medical student hopes to be a radiologist one day, and she is determined to integrate technical expertise with a patient-focused approach that belies the solitary-radiologist stereotype. Tillack, who is now finishing her dissertation, sensed that old-fashioned face-to-face communication would build the most trust, but she needed evidence to back her intuition. Thanks to a vendor-sponsored 2011 RSNA Research Medical Student grant, she had the opportunity to interview and observe a variety of physicians for six months, asking them to reflect on the elusive bonds of trust and how they were formed. Widely used PACS have revolutionized radiology, but trust and communication have occasionally fallen by the wayside. “Back in the film days, reading rooms were the information clearinghouses of the hospital,” Tillack says. “If you wanted to know what was going on, chances are someone would be down there talking to the radiologists. All the teams would talk to the radiologists, and that’s where patient problems were solved. Now, there really is not a space for that.” Such conversations still occur in patient-care areas, but Tillack laments that radiologists are not usually present. In some cases, patient information might not be adequately relayed via electronic means. “This patient information is critical to how radiologists read the images and construct their differential diagnoses and recommendations,” she says. “The fact that they are not often in on these informal hypothesis-making sessions can be detrimental.” What’s New Is Old Despite increasing complexity in the imaging world, referrers in Tillack’s study appreciated an old-fashioned commitment to communication. They wanted radiologists not only to produce interpretations and link imaging findings to clinical information, but also to communicate actively with their physician colleagues. How does this communication inspire that elusive trust? When Tillack asked a pulmonary/critical-care attending physician about certain radiologists, he responded that he didn’t really trust the night radiologists—and didn’t even read their reports. Because they were generalists, he said, they were not as good as the subspecialists working days. He named a particular thoracic radiologist (available in the daytime) as someone who had his full trust, stating that his own interpretations matched those of the radiologist, which were correct. In addition to being pleasant and receptive to questions, this trusted radiologist did not hedge, gave differential diagnoses, correlated findings with clinical information, and described what he saw. Another pulmonologist expressed similar opinions about how he learned to trust the same radiologist, telling Tillack that it took only a short time. The radiologist called him about a patient and recommended bronchoscopy. This radiologist wants clinical interaction, which builds trust, and he is proactive in contacting clinicians. His helpful interpretations provide more information and are more definitive than those of the other thoracic radiologists, the pulmonologist told Tillack. While an affable disposition never hurts, Tillack found that even radiologists who are not particularly friendly can still be extremely trusted and valued. As one third-year resident in emergency medicine observed, a particular night radiologist is good, but is irritable when overloaded. Nonetheless, he always calls the resident when there is important information involved—while other night radiologists do not. That failure to call can interfere with the care of emergency-department patients, so the resident trusts the grouchy-but-responsible radiologist because he looks out for the clinical team. Establishing a Presence While the benefits of the digital revolution and PACS are clear, Tillack hopes that software manufacturers will create some innovative ways for radiologists to reinsert themselves into patient care. Companies are developing video-chat systems that would allow referring physicians, viewing images at a workstation, to click on a consultation box and video chat with radiologists. Such a service could help, but boosting face-to-face conversations by reorganizing the medical space might also help radiologists form more personal relationships. “Moving reading rooms to patient-care areas could potentially change the referrer–radiologist relationship,” Tillack suggests. “Make a welcoming space—not among cubicles, and not behind a door with an access code—a place where clinicians can stick their heads in and radiologists can easily go down the hall and ask patients a few questions. This could help to facilitate the integration of radiology into everyday patient care.” Even with PACS, or perhaps in spite of it, Tillack found that trust is still a major consideration for referring physicians and radiologists. Without face-to-face interaction, the opportunity to gauge each other’s expertise—and whether clinical decisions are well thought out—is no longer there. “Health care is being centralized, but with telemedicine, it is getting harder and harder to have those personal relationships,” Tillack says. “A lot of the emergency-department physicians were very hesitant to put a lot of faith in the interpretations they were getting from a teleradiologist—or someone they could not find in the building, if they had questions. They could call those people, but that daily give and take does not always happen over the phone. These personal ways to assess trust were still important.” Tillack contends that the most useful radiology reports ultimately should not simply contain a description of imaging findings, but should place these findings within the clinical context—and make recommendations to help guide patient care. Radiologists who generate these kinds of clinically informed reports will be sought for consultation, and their opinions will be more highly valued. The great eight Eight characteristics of a useful radiology report emerged in research conducted by Allison Tillack, a student in the MD/PhD program at the University of California–San Francisco. With a clear theme of effective communication running throughout, the most frequently identified characteristics are that the report:

• suggests a diagnosis, or a short list of possible diagnoses; • provides a detailed description of findings;
• provides information that guides the patient’s care; • includes unexpected/subtle findings;
• answers the clinical question that prompted the study; • offers recommendations for further imaging studies; • separates significant and incidental findings; and • doesn’t hedge or waffle about conclusions

New Glory Days Tillack has no desire to go back to the good old days of radiology, and she appreciates the speed and efficiency of the modern PACS. Lost films, for example, are no longer a problem. “The downside is that radiologists have a huge amount of pressure to keep up with the list and deal with that volume,” she says, “and clinicians have come to rely on incredibly fast imaging.” The culture shift allows referrers to access images, but that brings up a familiar concern. As referring physicians get more comfortable with images, some might not value the radiologist’s expertise as much as they should. Trust (through communication) can maintain the perception—and the reality—of a radiologist’s usefulness. While the renewed focus on communication might drift into the subjective world of personal relationships, this realm might very well shape the future of radiology. “When I talk to referring providers, the people they trust and value have a great grasp of radiology and clinical medicine, but are also open, kind, and pro-communication people,” Tillack concludes. “Many radiologists really want to be active as physician consultants, and interventional radiology has opened eyes about what the profession can do for patient care. Focusing on all of these human elements can ultimately improve relationships with referring physicians and bolster patient care.” Greg Thompson is a contributing writer for Radiology Business Journal. This article first appeared in the June 2012 issue of the online journal Radinformatics.com.