Communicating results: Another perspective

By Stephen B. Strum, MD, FACP, member of ASCO, ASTRO, and of the International Strategic Cancer Alliance (ISCA), Ashland, OR

 Stephen B. Strum, MD, FACP, is Board Certified in both Internal Medicine and Medical Oncology. He has been a specialist in prostate cancer since 1983. Dr. Strum is a member of ASCO, ASTRO, and of the International Strategic Cancer Alliance (ISCA), Ashland, OR.

Almost all of us are patients at some time in our lives. Indeed, the quality of our lives and the time and manner of our demise is intimately related to whether our healthcare was wonderful, average, suboptimal, or downright dangerous. In cancer medicine or oncology, the testing that is done to establish the presence of cancer, determine its extent (stage of disease), and to discern if the treatment being given is working or not, are all crucial determinants of outcome. But for this physician involved in cancer medicine for a half century, it is obvious that, metaphorically speaking, healthcare is itself a sick patient with a dim prognosis.

The patient’s status is the biologic reality as determined through the sum of information that we acquire. Status is primarily determined through the patient’s history, physical examination, laboratory testing, pathologic evaluation, and radiologic imaging. Dr. Mirvis, in his editorial in the May 2012 issue of Applied Radiology, “Communicating results: Still a boondoggle,” addressed how the radiologist literally communicates with the healthcare practitioner (HCP) who has requested an imaging study. For that communication to be of real value in the patient’s care, it must convey meaningful, succinct, and usable results to allow the HCP to reach a correct diagnosis and provide optimal treatment.

While there are many cases where the interpreting imaging specialist should know what information is being sought through diagnostic imaging, there is no harm in the treating physician providing an informative and specific imaging request.

In today’s “healthcare,” the concept of objective and standardized reporting appears to have been, to a large extent, forgotten. In the United States and abroad, the imaging report is routinely a narrative by the radiologist that often contains phrases that are frustrating to the clinician, eg, “cannot rule out,” “may be,” “is consistent with, but not diagnostic of,” or “past studies are not currently available.” Additionally, objectified measurements are often missing when it comes to tumor dimension, or SUV on PET/CT studies, or standardization of the SUV with normalization to liver SUV. Commonly done studies, such as TRUSP (transrectal ultrasound of the prostate), most commonly performed by urologists, almost invariably do not comment on capsular invasion, involvement of the seminal vesicles, dimensions of hypo and hyperechoic lesions, and often even lack the prostate gland volume. Nuclear medicine studies too frequently fail to relate the change over time of lesions that should be identified as “index lesions,” ie, areas that are routinely focused on to determine the response to therapy or the status of a patient with known pathology.

When quantitative data are not provided or are camouflaged by imprecise language, the value of the report dissolves. When the commentary is filled with “hedges” and vagaries, the faith one has in the entire report wanes. All physicians look over their shoulders at the constant shadowy figure of the medico-legal bogeyman ever stalking us. All of us need to fight that ever present concern and say what we think without obfuscation. It is unforgivable how the legal profession, and by extension the lawmakers, have hampered the ability of physicians to do their jobs, but that is a drum I will beat another day.

More to the point, how can anyone intelligently direct patient care without baseline parameters and the results of therapy by quantitative observation over time? Is the patient getting better, remaining stable, or getting worse? How can medical doctors vary so wildly in their reporting that one report can be packed with pertinent details and another, on the same patient, can be pathetically lacking in useful data? What we have here is a horrendous problem in “useful” communication—it is the Cool Hand Luke, MD. At stake are the lives of those who have entrusted their care to us.

I have been frustrated for decades with the lack of a scientific approach to all realms of the medical record, and certainly radiologic reporting shares a top spot on the list of blatant reporting deficiencies. How about a workshop or task force to identify the key findings for a particular imaging study and create guidelines that highlight the most relevant information? This framework could be hospital specific and tailored by department. A narrative section can still be included to summarize key points. Also, whenever possible, relevant prior studies should be compared to the current examination for any interval change in pathology being followed—very typical in oncology. A helpful method to advance this cause would be a table with numbered “index” lesions so that a medical oncologist can easily determine the efficacy of the current antineoplastic regimen. The very same concept can be adapted to many other medical specialties. This same kind of thinking should apply to how MDs report their physical examination findings, how the pathologist reports the results of biopsies or other surgical specimens, and how laboratories report their findings.

How can we achieve these objectives? Personally, I do not think this will be driven by physicians, since most healthcare practitioners are more comfortable with the status quo than with change. At least some of us, recognizing this muddled and limited information exchange, can aim to more precisely codify the optimal parameters to address communication among the various components of our professional specialties. After all, what is the point of having a study performed unless the important questions are asked and answered to as great an extent as possible?

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Communicating results: Another perspective.  Appl Radiol. 

May 30, 2012

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