Hobson’s choice: The new ACR Practice Guideline for Communication

Dr. Raskin is a Neuroradiologist at the University Medical Center, Tamarac, FL, a Clinical Associate Professor of Radiology at University of Miami School of Medicine, Miami, FL, and Legal Counsel to the Florida Radiological Society, Tampa, FL.

The American College of Radiology (ACR) developed a Standard for Communication –Diagnostic Radiology in 1991.¹ Subsequent revisions in 1995, 1999, and 2001 further refined the Standard for Communication.^2-4 In the 2005 revision, the term “Standard” was changed to “Guideline” and the section on communication was greatly expanded.⁵ The last revision, Resolution 11, was approved at the 87th Annual Meeting and Chapter Leadership Conference in Washington, D.C., in May 2010, and became effective on Oct. 1, 2010.⁶ The 2010 ACR Practice Guideline for Communication of Diagnostic Imaging Findings contained few changes from the 2005 resolution. However, in order to better reflect reality and to be more consistent with recent case law, there was a substantive change concerning the final report.

The final report

Previously, the final report was considered to be the definitive means of communicating to the treating or referring physician. Evolving case law has consistently shown that radiologists cannot escape the duty to immediately communicate with the treating or referring physician when there is an unexpected finding on the imaging study.⁷ Consistent with this, the 2010 revision of the ACR Practice Guideline (PG) no longer considers the final report to be the definitive means of communicating to the treating or referring physician, but merely the definitive documentation of the results of an imaging examination or procedure. The final report is necessary, but not sufficient, for communicating urgent or unexpected findings. The radiologist can no longer rely on the final report to be the definitive means of communicating the results, forcing the radiologist to make a Hobson’s choice, a free choice in which only one option is offered. The phrase originates from Thomas Hobson (1544–1631), of Cambridge, England, who rented horses and gave his customer only one choice, that of the horse nearest the stable door.⁸

Direct communication

Communication with the treating or referring physician can take many forms, depending on the urgency of the situation and the seriousness of the imaging findings. However, the PG suggests 3 situations when direct communication may be necessary:⁶

1. When the findings suggest a need for immediate or urgent intervention;
2. When the findings are discrepant with the previous interpretation of the same examination, and failure to act may adversely affect patient health;
3. When there are findings that the interpreting physician reasonably believes may be seriously adverse to the patient’s health and are unexpected by the treating or referring physician.

This last situation is where radiologists have the greatest problem.⁹ There is an increasing onus being placed on radiologists to ensure that reports are communicated to the treating or referring physicians, especially when there are urgent or unexpected findings.¹⁰ Liability for inadequate communication is based on case law; the PG merely provides radiologists with the tools and information necessary to reduce their risk and liability for handling these communications.¹¹ The rapid proliferation of IT can facilitate better direct communication and reduce malpractice risk. Regardless of the method of communication, details of that communication with the treating or referring physician should be documented in the report or on other medical records, indicating the date, time, and person contacted, as well as the method of communication and the pertinent information exchanged.

Policy for communication

The revised PG again emphasizes that an imaging department’s policy on communication can be an effective tool to promote patient care, but to be effective any written policy must be followed and shared within the institution. Unfortunately, national studies show that as many as 20% of radiology practices do not have an established policy on communication of findings. Furthermore, insurance companies have documented that the treating or referring physician is not contacted on urgent or significant findings in up to 60% of malpractice cases.¹² Not surprisingly, half of these lawsuits are related to issues regarding communication and follow-up of important findings. Not only can documentation of your communication help you if there is an ensuing lawsuit, but it is in the interest of promoting better patient care. It also relates a contemporaneous time-line of the communication of the relevant imaging findings. Claims of difficulty in contacting the treating or referring physician will garner little sympathy from the public when they are able to reach any one of their friends in mere seconds with the push of a button or the touch of a screen; they will not accept that you can’t do the same. Although neither the ACR nor the courts consider communicating directly to the patient to be the standard of care, there is a growing trend in that direction.¹²

Lessons to be learned

The final report can no longer be considered the definitive means of communicating to the treating or referring physician. The role of the final report has changed from one of communication of findings to that of documentation of findings. Merely issuing a report that accurately describes urgent or unexpected findings does not ensure timely receipt or documentation of receipt. Direct communication with the treating or referring physician when there are unexpected findings is becoming the de facto “standard” for communication in radiology. Develop a written policy on communication of urgent and unexpected findings that is adhered to by everyone in your radiology practice. Reporting critical results also requires documentation that the results were actually communicated. This is necessary not only to promote good patient care, but to minimize your chances of being sued and losing. The choice is yours, but it’s the only option.

References

1. American College of Radiology. ACR standard for communication: Diagnostic Radiology (Resolution 5). Reston, VA: American College of Radiology; 1991:1-4.
2. American College of Radiology. ACR standard for communication: Diagnostic radiology (revised 1995, res. 10). Reston, VA: American College of Radiology; 1995:5-6.
3. American College of Radiology. ACR standard for communication: Diagnostic radiology (revised 1999, res. 27). Reston, VA: American College of Radiology; 1999:1-3.
4. American College of Radiology. ACR Standard for Communication: Diagnostic radiology (revised 2001, res. 50). Reston, VA: American College of Radiology; 2001:3-5.
5. American College of Radiology. The ACR practice guideline for communication of diagnostic imaging findings. (Revised 2005, Resolution 11). Reston, VA: American College of Radiology; 2005:5-9.
6. American College of Radiology. The ACR practice guideline for communication of diagnostic imaging findings. (Revised 2010, Resolution 11). Reston, VA: American College of Radiology; 2010:1-6.
7. Raskin MM. The perils of communicating the unexpected finding. J Am Coll Radiol. 2010;7:791-95.
8. Hobson’s choice. (n.d.). Collins English Dictionary, Complete & Unabridged 10th Edition. Retrieved December 19, 2010, from Dictionary.com website: http://dictionary.reference. com/browse/Hobson’s choice
9. Berlin L. Communication of the significant but not urgent finding. AJR Am J Roentgenol. 1997; 168:329-31.
10. Garvey CJ, Connolly S. Radiology reporting – where does the radiologist’s duty end? Lancet 2006; 367:443-5.
11. Lucey LL, Kushner DC. The ACR guideline on communication: to be or not to be, that is the question. J Am Coll Radiol. 2010;7:109-14.
12. Berlin L. Communicating results of all radiologic examinations directly to patients: has the time come? AJR Am J Roentgenol. 2007;189:1275-82.