I still vividly remember the protocol for a CT scan of the abdomen and pelvis from 1993. “Give two cups of barium to drink one hour prior to scanning, two cups 30 minutes prior to scanning and one cup on the table just before scanning,” it read. “Parameters included 5-mm scans with a 1.5-mm pitch helically, from domes of the diaphragm to the iliac crest with axial images through the pelvis.” These were the notes handwritten by our chief radiologist for each and every patient requiring the protocol. There were never any shortcuts taken or shorthand used; each protocol was painstakingly written.
After completing this protocol and printing the images, we would review the films together with the chief radiologist. There was time set aside to share comments about the patient’s disposition and concerns, which could ultimately change the diagnosis. I remember his disappointment one day when he asked me what happened to the contrast in the stomach. Embarrassed, I admitted I had been especially busy and forgotten the cup on the table. “How unfortunate,” he said, pointing out an area of interest to me. We had missed the opportunity to get a better glimpse, it turned out, and it could have been crucial to the diagnosis.
He then went on to explain that the reason he was so methodical in writing each protocol was that he hoped that each technologist would take the same care in following the protocol as he did writing it. After that day, I resolved to ensure I followed his protocols to the letter, no matter how hectic the schedule. We had a mutual understanding of what was important: don’t forget the cup on the table!
Fast forward to 2017. One-, two-, and four-slice scanners have been replaced with 128- and 256-slice scanners. These systems generate thousands of images to be acquired, reconstructed and transferred by the technologist, and then they are all reviewed, compared and reported by the radiologist. There are lab values to check, medications to be reconciled, and radiation doses to be monitored. Handwritten protocols have been replaced with a menu of protocol options that are accessible with the click of a button. Consequently, in most busy departments, radiologists and technologists seldom have the opportunity to personally interact ever since the advent of PACS. Conversations about quality are replaced with electronic options for placing remarks regarding image quality or technique, with little opportunity for a dialogue of what may have transpired. Lost is the opportunity to share anecdotes about the patient’s physical condition, state of mind, worries and concerns; these concerns are now condensed into one or two sentences in the technologist’s notes.
In addition to valuable details that could assist radiologists in their diagnoses, lost are the opportunities for conversations about friends, family and life outside of the hospital; the few chances to learn more about the personal side of one’s “work-family.” As human beings, we crave interaction with others, yet we often underestimate the power of a kind word or sympathetic ear; the joy in sharing life’s treasures of humor, sorrow, pride and vulnerabilities.
Studies have shown that relationships in the workplace are a critical driver of employee engagement. That sense of belonging is what drives teamwork, increased productivity, psychological well-being, and increased retention rates. But the ability for radiologists and technologists to relate, not only impacts levels of engagement, but also patient safety. A technologist who has a positive working relationship with a radiologist will feel responsibility and empowerment to address a possible misdiagnosis. Without that relationship, there could be fear of voicing what may be perceived as opposition.
The advances in technology that have led to more efficient communication, such as rapid access to images and reports, have also made communication less personal and harder to interpret at times. For example, a quick electronic note from a radiologist to address quality can be misread as terse or exasperated by the technologist. A hasty note from the technologist may lose the sense of criticality of the patient’s condition or may minimize difficulties in obtaining a high-quality exam.
To add complexity to feedback loops, there are differences in priorities and how people from different generations wish to communicate and receive important feedback. Generations in today’s workforce could range from the silent generation to millennials, with baby boomers and Generation Xers sandwiched in between. The silent generation may prefer feedback in a face-to-face conversation, while millennials may prefer an email or text. A baby boomer might be offended by the same communication given to someone from Generation X without issue. Given these differences, sharing feedback can be challenging, with added importance in whatever method to be given in a respectful way.
So how do we reclaim the benefits of personal interactions while struggling with decreased chances of encounters? Do we take lessons from Google or Apple and create centralized workspaces that are not only conducive to connecting with others, but require it? With increasing teleradiology options and decentralization of reading spaces, this may not be a valid option for many within the industry, but there are other ways to create opportunities for colleagues to connect.
Kaizen is a Japanese word that means “change for better.” It is a strategy used in quality management, which requires the participation of multiple members of a team in different functional roles. Cross-functional teams are organized to address a specific need for change, and each member of the team is responsible for big or small changes for improvement. Kaizen Events require the commitment of uninterrupted time—usually a minimum of three days—and energy, but are worth every ounce of effort. The results can be eye-opening for participants, who get to see the impact of small changes in processes. In other cases, team members can be completely unaware of the challenges and barriers faced by their colleagues until they are revealed through a dissection of the process.
A Kaizen Event is an effective and organized way to improve a process, but what can we do for everyday improvements? What is the answer for those that we cannot devote three consecutive days of protected time for radiologists, technologists, residents and others? Each modality has challenges to overcome and efficiencies to be gained. Cross-functional clinical practice councils that include technologists, nurses, radiologists, medical assistants, schedulers and supervisors can be an avenue to share thoughts and ideas on what needs to be improved and how to improve it. The dialogue from these practice council meetings is invaluable, as each member learns about the challenges up or downstream from their vantage point of the process. With this model, the team learns to challenge assumptions, walk in another’s shoes and solve problems together.
Whether through personal interactions, written communication, Kaizen Events, or clinical practice councils, increased communication in any form can help radiologists and technologists work together to improve the delivery of the highest quality care. Technology can truly be a force multiplier if potential pitfalls are addressed. Combining advances in technology—which allow for faster speed, better quality and stronger analytics—with the personal insights of the cross-functional team members, leaders can support workflows that are better for physicians, staff and, most importantly, our patients.
Paula T. Gonyea, MBA, RT (R) (CT), is director of radiology services at the University of Vermont Medical Center in Burlington.