Engaging Patients in Clinical Practice

Radiologists play a central role in the delivery of health care across all medical environments, and yet the public perception of what a radiologist actually does is often inaccurate. As a community, we radiologists have the opportunity to assume a more visible role in the daily administration of health care. Medical care standards evolve with time due to a combination of complex factors, including financial and political pressures, scientific discoveries, and cultural trends. Over the past decade, more attention has been placed on the value of patient-centered discussions. Here, the rationale for emphasis on improving communication with patients is discussed, and techniques for engaging patients comfortably in shared decision-making are presented.


Patient Safety Equals Satisfied Patients
In the current environment, patients have ample access to information through the internet, allowing for a thorough collection of assorted statements, whether accurate or inaccurate, about their symptoms, diagnosis, treatment, and quality of the medical centers in their area.The process of taking responsibility for one's own medical care in this way can feel exceptionally daunting.It is a process that boils down to securing a safe environment for one's own medical care.
Interestingly and importantly, there is a strong association between patient experience, patient safety and clinical effectiveness, as evidenced by a study reviewing over 5,000 publications related to patient safety and clinical effectiveness outcomes [1].These associations were observed over a range of disease areas, study designs, population groups, and outcome measures.The authors advise that "clinicians should resist sidelining patient experience measures as too subjective or mood-oriented, divorced from the 'real' clinical work of measuring and delivering patient safety and clinical effectiveness."Awareness of the patient's experience as he or she tries to relate to the medical environment will translate into patient safety.A radiologist may be primarily isolated in a reading room and dissociated from the patient.When the opportunity arises for communication of information relevant to a diagnostic study, either before or after it is performed, the radiologist as a medical professional must always consider that patients require emotional and psychological support, relief of fear and anxiety, and treatment with respect and compassion.Clear, comprehensible information, including transparency and full disclosure if something goes wrong, will translate into patient safety, whether it is an immediate effect upon an individual patient's perception of their own safety, or a long-term effect imparted by identification of a potential process requiring improvement.

Reaching Out to Patients
The need for clear communication with our patients begins with a simple task -clarifying for them who we are as radiologists.Gunderman and Mortell [2] point out that in a number of popular contemporary comedic and dramatic television programs set in hospitals with characters playing medical professionals and staff, there is no fair representation of a radiologist.These authors summarize that "by systematically excluding radiologists from the diagnostic equation, such programs contribute to a distorted view of medicine in which radiologists are either unnecessary or even simply nonexistent." Separate from the world of television, the American College of Radiology (ACR) has taken a leadership role to improve the perception of radiology on a national level.Through focus groups, interviews with Capitol Hill staff members, and through national surveys, the ACR documented that the public awareness of radiologists' degree of education and training radiologists is lacking; and, 2) the public is largely unaware that radiologists are medical physicians and experts in interpretation of diagnostic imaging.The ACR launched its Face of Radiology campaign [3] to educate the public about radiologists' contributions to the delivery of health care and to address common misconceptions that members of the public harbor about radiologists.Focus groups conducted by the ACR as part of this campaign showed that general attitudes towards radiologists and radiology are positive, and although the respondents widely indicated the radiologist is a trained professional, only 50 percent were aware that the radiologist is a licensed physician.Another interesting perspective gathered through these focus groups is that education of the radiologist's role in medical care shifted respondents' thinking about who should best perform interpretation of diagnostic imaging.Whereas initially, participants indicated their own private doctor was qualified and perhaps preferred, to assess less complex imaging examinations such as radiographs, most participants shifted their thinking after being informed about the training and role of the radiologist.Similarly, in a separate study investigating patient's perceptions of the role of the fellowship-trained breast radiologist in their medical care [4], 33% of survey responders changed their answers between two surveys, administered before and after educational material was provided about the role of the breast imager, supporting the impact of patient education about the role of the radiologist in their medical care.

Patients Want to Meet the Radiologist
The pace and demands of any given imaging center vary.Therefore, the expectation that the interpreting radiologist would be able to directly communicate the results of a diagnostic imaging study to the patient and family may not be realistic.However, if possible, establishing a means for the radiologist to directly convey imaging results to the patient is likely to enhance the patient's experience.One group [5] investigated the perceptions of 86 adult patients in an academic center and found that 98% of patients were willing and interested in having their study results directly communicated to them by the interpreting radiologist rather than their own physician.The majority of these patients strongly agreed (85%) or agreed (13%) that reviewing their CT or ultrasound with the radiologist was helpful.Patients were also surveyed about how their level of anxiety changed following the conversation with a radiologist: anxiety decreased in 48%, was unchanged in 37%, and increased in 15% of patients.

A Simple Way to Please: Listen
Generally speaking, patient surveys have shown that when communication is lacking, patients experience increased levels of anxiety, feelings of vulnerability, and discontent with their medical care [6].In an effort to involve patients in their medical care and reduce their feelings of anxiety, it is critical to keep in mind that talking with patients does not merely mean talking to patients.In a book by Buckman and Kason, the authors indicate that physicians interrupt their patients within 18 seconds of their talking [7].Buckman also points out that dissatisfaction with physicians' communication skills far outweighs any dissatisfaction with technical competence.The bottom line is physician empathy can considerably improve patient satisfaction.
We also need to remind ourselves to carefully avoid jargon.Many patients misunderstand a significant portion of what physicians communicate.For example, a study by Lobb, et al., reported that of 143 women diagnosed with breast cancer, 73% did not understand the term "median survival" [8].

Tools for Listening
Radiologists across the board can benefit from the numerous effective, hospital-directed campaigns aimed at reminding physicians and hospital staff to keep the patient's perspective and needs in mind with every interaction.The examples provided here all share the same themes of patient-focused conversation anchored in respect and validation.
The "Respond with HEART" mnemonic, utilized at Cleveland Clinic [9] reminds practitioners to Hear (listen attentively), Empathize (for instance, say, "I can see that you are upset"), Apologize ("I am sorry you were disappointed."),Respond ("What can I do to help?"), and Thank them for talking and for their time there.
The "Focus on K.I.D.S. First" script tool is specific to pediatric settings, utilized at Seattle Children's Hospital [10], and reminds practitioners and staff that the Kid is greeted first, then Introduce yourself and smile!Describe what will happen, and finally, Sum up the interaction and ask for further questions before leaving the room.
The "AIDET" mnemonic includes 5 fundamental components for successful patient appointments and is used widely across the country, including at Southern Ohio Medical Center and at the University of Washington School of Medicine [11].This tool reminds practitioners to keep the following five words in mind: Acknowledge, Introduce, Duration, Explanation, and Thank.Acknowledge-Greet the patient with a friendly smile, acknowledge the family members and friends.Introduce-Consistently introduce yourself by name and indicate your role in the appointment or procedure.Duration-Keep the patient and family updated on how long the appointment will take.Update them about delays.Let them know when results are available.Explanation-Inform the patient of what is going on.Ask if they have had this test before?Encourage them to ask questions.Address safety issues.Thank you -Share your appreciation of the privilege of caring for the patient and family.

Conclusion
Hospital campaigns oriented at patient satisfaction begin with useful lessons on effective communication between staff and patients.Radiologists should embrace any opportunity to be a visible part of patients' healthcare, keeping in mind the conversational tools summarized here.