No analogy is perfect, but similarities certainly exist between sturdy referrer/radiologist relationships and till-death-do-us-part marriages.
For starters, both are collaborations whose ongoing success requires continual attention from both parties.
Secondly, just as changing circumstances impact how marriage partners work together for the sake of their families, new wrinkles in familiar processes affect the way radiologists and referring physicians cooperate for the good of their patients.
And in the case of medicine, the “changing circumstances” and “new wrinkles” now include the strain of U.S. healthcare’s push for value-based care.
Here are five observations offered by experts to help both sides sustain the harmony from this day forward, for better or for (when times take a turn for the) worse.
1. The struggle to adapt in an era of value-based care isn’t one-sided.
“Radiologists have been pressed to spend more and more time focused on the PACS, with decreasing capacity for meaningful interactions with referring physicians,” says Laura Findeiss, MD, the Emory University radiologist who serves as radiology chief at Grady Memorial Hospital and president of the Society of Interventional Radiology (SIR).
Findeiss points out the impeded personal engagement owes largely to increasing volumes and downward pressure on reimbursement, which together press radiologists to generate imaging reports fast and faster.
“Meanwhile the scope of radiology, both diagnostic and therapeutic, continues to get more complex, such that physicians outside of radiology struggle to optimize imaging for their patients,” she adds.
Radiologists need to keep this struggle in mind as they look for ways to improve their relationships with the referring community, Findeiss and other radiologists interviewed by RBJ agree.
An expanded definition of “value-based care” also comes into play. The term must imply giving patients increased direct access to information about their cases via portals and other means—and involving them more thoroughly when considering treatment options.
“As value-based care moves information into patients’ hands, referring physicians are going to need more and more assistance from radiologists in helping patients understand the information and recommendations they receive,” says abdominal imaging expert Arun Krishnaraj, MD, of the University of Virginia Health System, who co-leads his department’s efforts in quality and safety.
A key goal of tying value to patient engagement, the sources maintain, is maximizing information-sharing between radiologists and referring physicians so that patients end up with answers that are both clinically sound and economically sensible.
2. Reports remain an obstacle to better radiologist-referring physician partnerships. Fortunately, this hill is conquerable.
Tessa Cook, MD, PhD, whose duties include leading 3D and advanced imaging at the Hospital of the University of Pennsylvania and that school’s Perelman School of Medicine, says part of the “report problem” traces to radiology reports that, too frequently, lack the information referring physicians want or need.
To remedy the situation—and, in the process, strengthen partnerships with referring physicians—she advocates soliciting and listening to feedback from these colleagues without passing judgment or taking the input personally.
“If I asked your radiologist readership how many of them had asked a referring colleague what information they needed in a report for a particular type of study,” says Cook, a member of RBJ’s editorial advisory board, “how many would answer in the affirmative?”
Speaking from her own experience reading studies for cardiac or vascular surgical or procedural planning, she underscores that seeking out feedback is “critical to making sure the imaging protocols and interpretations generate the information these specialists need to execute their procedures with good outcomes.”
“We [radiologists] should write reports that help referrers feel as if we are a member of their team,” says Christopher Straus, MD, of the University of Chicago. “On the whole, relationships would benefit from structuring reports so information is presented in a simple way that gives referring physicians the concrete evidence they need to help them make decisions.”
Interventional radiologist Andrew Gunn, MD, of the University of Alabama at Birmingham believes radiologist/referring physician partnerships are more easily optimized when radiology reports include clear and prominent indications of whom to contact with follow-up questions and how—meaning email, cellphone number or both.
“Referrers have told us time and time again that they don’t want to be left hanging with no way to clear things up,” Gunn says. “And we can’t expect to have good relationships with them if we don’t give them a way to connect with us. It’s just that simple.”
3. Adopting and following a collaborative, consultative model is paramount.
The shift toward value-based care “has made breaking out of silos as important as better reporting protocols,” Straus says. He defines such breakouts as “working collaboratively and consultatively, with open communication, to augment and highlight how radiologists assist patients out of the hospital earlier.”
William Morrison, MD, director of musculoskeletal radiology at Thomas Jefferson University Hospital in Philadelphia, describes a similar focus at his institution. “We try to work with referrers through different diagnoses and ways to approach things,” Morrison says. “It’s more than writing reports.”
Findeiss holds that radiologists—both diagnostic and interventional—should make themselves accessible, interacting with referring specialists in a manner that demonstrates curiosity about patients’ presentation and history. At the same time, she says, it’s appropriate to communicate authoritatively about their own scopes of practice.
“I’ve found that patients are definitely best served—and relationships strengthened—when specialists join forces to devise a plan of care,” Findeiss says.
She cites as an example her relationship with the chair of urology in a university hospital in which she previously practiced. The two physicians shared consults on individual patients with small renal masses to establish the best course of action (ablation vs. minimally invasive surgical resection), basing decisions on tumor location, tumor size, patient comorbidities and patient treatment goals. By so doing, they “always came up with a plan that optimized treatment.” If patients had problems following surgery or ablation, “we had each other’s backs and could immediately help them, rather than arguing over turf.”
Another silver lining from this approach: Findeiss and the other physician learned about each other’s fields, a step she believes made them both better clinicians.
4. Radiologists can and should make concerted efforts to reinforce the profession’s identity as the doctors’ doctors.
Some radiologists quibble with the that term, deeming it misleading or trite. However, the experts’ consensus seems to be that accepting the mantle can increase the likelihood that referring physicians will meaningfully consult with, rather than obligatorily read from, their radiologists. The more appropriate the treatment, the higher the patient’s level of satisfaction with the referring physician who ordered it—and the greater the referring physician’s inclination to consult that radiologist again.
“At a time when value and patient satisfaction are a concern for all of us—in radiology and every other specialty—we cannot afford to avoid being ‘doctors’ doctors,’” Morrison states.
Morrison notes that this often starts with assisting referring clinicians in deciding which imaging modality or technique may best answer the clinical questions they have about a given case. “Referring physicians usually know what they want to find out—for example, whether a condition is present or to what extent it is present—but they aren’t especially well versed in how to find out,” he explains. “If that piece is missing, the relationship loses something.”
Noriko Salamon, MD, chief of neuroradiology at the David Geffen School of Medicine at UCLA and Ronald Reagan Medical Center in Los Angeles, says referring physicians appreciate that, when “doctors’ doctors” share advice about the best study to order, patients are diagnosed quickly and more precisely, as well as less expensively.
Without a focused consultation, “there are too many options,” Salamon says. “For example, a patient has neck pain, and the referring physician wants to do a scan. You may start from neck X-ray, or direct CT of the neck with and without contrast, or CT of the cervical spine. Or CTA of the neck, MRI cervical spine with or without contrast, or MRI of the neck with contrast. Or maybe the patient has blurry vision. Should the scan be brain MRI or orbit MR? Radiologists can help cut through all of that.”
Salamon also thinks radiologists must reinforce their identity as “doctors’ doctors” by discussing cases with other physicians. This can only enhance referring physicians’ perception of the value radiologists add along the continuum of care, she suggests.
Similarly, Cook advocates radiologist participation in multidisciplinary conferences while Krishnaraj advises affability and openness.
“If you want to optimize relationships with referring physicians by characterizing yourself as a ‘doctors’ doctor,’ don’t be critical of the questions you’re asked, no matter how redundant they may seem,” Krishnaraj says. “Put information in context. Make yourself available as a domain expert.”
Equally important, however, is functioning as the patients’ doctor.
“Patients are going to have questions about their studies that referring physicians cannot answer,” Gunn points out. “In a value-based environment, at a time when we need to have stronger relationships with referrers, it’s our job to answer them—and to do so directly, if at all possible.”
5. AI can play a real role in fostering productive relationships between radiologists and referrers.
Familiarity with artificial intelligence helps to optimize radiologists’ relationships with referring physicians in part because of the technology’s potential to enhance the quality of reports. The better the caliber of reports radiologists bring to referrers’ table, sources note, the greater the likelihood of stronger, more value-conscious partnerships between the two parties.
“AI can certainly assist radiologists in creating more simplified, logically organized—and therefore more easily understandable—reports,” Gunn says. “It could even be as simple as highlighting certain terms so as to provide referrers with a hyperlink” on which to click for more information.
Findeiss concurs. She adds that, for interventional radiologists at least, AI doesn’t merely offer significant potential to ease some of practitioners’ workload and allow them to focus on the clinical aspects of patient care. It also can provide practitioners with additional valuable insight into individual cases. This, in turn, takes to new levels the physician collaboration and communication that are the cornerstones of optimized referrer/radiologist partnerships.
For example, one application described in an abstract presented at SIR’s 2019 annual meeting would allow interventional radiologists to perform tasks like querying a smart speaker during a procedure to learn more about the case at hand, from patient data to inventory data. “There’s a lot of potential for these tools to improve the practice of interventional radiology for doctors and patients,” and these improvements can help reboot referrer/imaging provider relationships on a more productive foundation, Findeiss suggests.
To this Cook adds that radiologists, on the whole, must begin thinking of AI as “the next modality” while resisting the temptation to tell themselves they need not become intimately familiar with the technology because it doesn’t apply to their subspecialty.
“There will be AI for findings detection on imaging, AI for report-based tasks and AI for workflow optimization,” Cook says. “In a perfect world, AI will free us up to consult more with our referring colleagues and spend more time educating patients.”
But in order for this to happen, she emphasizes, radiologists must accept that, although they are unlikely to be replaced by AI, they cannot be complacent and assume it will not change their jobs—because it will.
“We need to participate in the process of change, safeguard the diagnostic process and not assume that AI will always get it right,” Cook concludes. “We need to be stewards of care, whether it’s assisted by AI or not. Strong relationships will get us there.”