Patient communication: Diagnostic confidence trumps severity

Disclosing radiologic findings directly to patients should be based on the radiologist’s confidence in the results, not on the severity of the findings, according to an article published in the March issue of the American Journal of Roentgenology.

Communicating only normal findings to patients has been a policy instituted by some practices with the idea that less potential harm can be done to patients if radiologists stick to reporting only the good news and leave more serious findings for the referring physician, according to Ian Amber, MD, of Pennsylvania Hospital, and Autumn Fiester, PhD, of the University of Pennsylvania, both in Philadelphia.

“Some radiologists remain tepid about the prospect of giving results directly to patients, either because of pressure from the referring clinicians or because they feel undertrained in how to communicate difficult news, whereas other radiologists view disclosure as a core obligation of their clinical practice,” wrote Amber and Fiester.

While clinicians remain divided on the issue of results disclosure, previous surveys have shown that 87 percent of patients want to know their imaging findings as soon as possible, regardless of who delivers the results and how severe they are, according to the authors. However, less than half of patients actually ask to discuss exam findings with the radiologist. By not communicating findings to these patients, radiologists are not fulfilling an ethical duty to meet patient needs, argued Amber and Fiester.

The primary arguments against disclosing severe findings are weak, according to the authors. They are based on the belief that patients will demand information that primary care physicians, and not radiologists, possess, which is often not the case.

It is also argued that patients will feel more comfortable with their family physician, but these strong patient-physician bonds are being established less frequently in the modern, fractured healthcare delivery system. “This claim harkens back to an idyllic past in which patients would be cared for over decades by the same general practitioner,” wrote Amber and Fiester. “Managed care, specialization in medicine, frequent changes in insurance coverage, and large group practices have all but ended this type of primary care relationship.”

Under the alternate paradigm described by the authors, patients would be asked their preference for results disclosure on the pre-imaging questionnaire. Radiologists would then consult a sliding scale of diagnostic confidence, which allows the radiologists to use his or her own expertise while at the same time respecting the referring physician and the importance of clinical correlation.

The diagnostic confidence scale put forth by Amber and Fiester has four categories of confidence:

• Highly suggestive – These are classic presentations of common conditions. Examples include pulmonary nodules with characteristic representing a hamartoma, and classic presentations of a hepatic hemangioma.
• Suggestive – This category represents findings that likely, but not definitively, establish a diagnosis. An example would be an ulcerated distal colonic mucosa seen on barium enema, because while it likely represents ulcerative colitis, a small percentage of patients with Crohn disease also present with such isolated colonic findings.
• Indeterminate due to lack of evidence – Incidental findings unrelated to the purpose of the study fall into this category. Many incidental lesions are benign, though additional evidence would be required to be more conclusive.
• Indeterminate and requires clinical correlation – Any conditions that require clinical history, laboratory results or further workup fall into this category. Amber and Fiester argued that it may be inappropriate to withhold such findings from the patient, though the duty for direct disclosure is weak.

“In an important sense, bad news is bad news,” wrote the authors. “Depending on its seriousness or severity, it will be upsetting, devastating, life altering, or life limiting…What makes the experience of hearing difficult medical information better or worse is not how long the patient has known the physician but how compassionately the news is delivered.”

For more information on patient communication, review this slide presentation provided to Health Imaging by Andrew J. Gunn, MD, of Massachusetts General Hospital in Boston.