A decade ago, retired Army Col. Jim Stapleton underwent a State Department physical that revealed a lump in his throat. He would not be going to Iraq for contract employment as planned, but instead would be fighting an unexpected foe at the Emory University School of Medicine’s Winship Cancer Institute in Atlanta: head and neck cancer.
Visualization of the head and neck (H&N) region is a complex and challenging area for imaging, according to Patricia A. Hudgins, MD, FACR, director of H&N radiology at Winship Cancer Institute. “The lesions are small, the anatomy is difficult to navigate, and everything is in close proximity to the brain. The risks are huge.”
Given the gravity, Stapleton wanted to learn about his squamous cell carcinoma from the person who could best see it — the radiologist. “Initially, my doctor talked to the radiologist and then relayed the information to me, but I wanted to talk to the radiologist directly,” he says. “I wanted to ask, ‘What’s that?’ on the images.”
Providing patients with an opportunity to interact directly with radiologists is exactly what Ashley H. Aiken, MD, associate professor in the neuroradiology division of Emory’s department of radiology and imaging sciences, had in mind when she envisioned an environment that would allow radiologists to take a more active, consultative role in the treatment of H&N cancer patients. To turn that vision into reality, Emory embarked on an initiative to add a patient consultation program right in the ENT clinic.
For years, radiologists and ENT surgeons at Emory had collaborated closely, including at tumor board meetings, laying the foundation for a strong relationship between the specialties. Radiologists were key team members who helped establish the algorithms for standardized patient care.
“When creating a patient consult program, we started by building relationships with referring doctors, and standardized protocols for interpreting and dictating images so all of the H&N radiologists read the same way,” explains Hudgins, who first began working in the ENT clinical space in 2010 in an integrated reading room. Radiology was able to integrate their reading space during an ENT clinic move and redesign, which enabled Hudgins and Aiken to advocate for an open, centralized location for image review workstations.
Today, Emory's neuroradiologists work side-by-side with ENT surgeons and health care providers, such as speech and hearing specialists. They share the clinical space, including five workstations for face-to-face treatment meetings with ENT surgeons, radiation oncologists, and medical oncologists.
In March of 2016, radiologists also decided to add direct-to-patient communication to the care pathway by utilizing the ENT patient exam room space adjacent to the clinic reading room (Figure 1). To create the patient consult program, the Emory team realized they needed to get a patient’s perspective to ensure they were delivering true patient-centered care.
Stapleton, who had been treated at the H&N clinic in 2007 and developed close relationships with his ENT physicians and radiologists, had volunteered to serve as radiology department liaison for a patient and family advisory board. Aiken then invited him to serve on a patient advocacy panel that focused on patient perception of the radiologist’s role. He also offered his unique perspective about the ideal way to communicate with patients during their consultations.
As a result, the team quickly determined that one of the most important aspects of that direct interaction was helping patients understand the role of radiologists. “When we first began consulting with patients, they didn’t originally think of radiologists as their doctors,” explains Aiken. “To overcome that perception, we start by introducing ourselves and saying, ‘We are your head and neck radiologists. We look at all of your scans before and after treatment to ensure that there are no deep abnormalities that your ENT surgeon cannot see.’ You can instantly see it makes patients feel better.”
Stapleton agrees. “There’s something powerful about meeting with an expert who’s interpreting the images of your anatomy,” he says. “I could point to the image on the screen and directly ask the neuroradiologist my questions and get immediate answers.”
Aiken says a direct, communicative approach to engaging patients will change the way radiologists — and all physicians — practice medicine in the future. To begin driving toward that future, Emory Healthcare has committed to learning from the patient experience, enlisting the help of former patients like Stapleton as patient advocates, to advise clinicians (including radiologists) on the best way to talk to patients about their care.
Before launching the ENT clinic, Emory radiologists worked with a multidisciplinary group of surgeons, radiation oncologists, and medical oncologists to create a template that reflected a consensus for next steps in managing patients undergoing surveillance for H&N cancer. In 2016, their Neck Imaging Reporting and Data System (NI-RADS) 1 was published to standardize templates for image reading and dictation. This helped quantify “big picture” recurrence and management concerns for radiologists to successfully engage — both with surgeons and in direct patient consultation, Hudgins explains.
Mihir R. Patel, MD, assistant professor of otolaryngology at Emory, helped radiologists identify which patients would be ideal for the direct patient consultation program: those being treated for H&N cancer and under surveillance with contrast-enhanced CT (CECT), or CECT combined with PET, with the case reported via the NI-RADS template. Due to regular communication regarding treatment images, radiologists have always been a part of the ENT clinic to some degree, Patel explains, so having them consult directly with patients was a “natural step.”
Here’s the collaborative process the Emory team designed to ensure a seamless patient consultation:
- After an H&N cancer patient has undergone definitive treatment (either surgery, chemotherapy, radiotherapy, or a combinationof these), he or she typically undergoes CECT combined with PET/CECT.
- The surgeon or nurse practitioner lets the radiologist in the clinic know when there is a patient who might benefit from a consultation.
- If needed, the radiologist spends a few minutes reviewing the images and discussing the plan with the surgeon. It is critical that the whole team knows the treatment plan to avoid sending a mixed message to the patient.
- The surgeon lets the patient know that a radiologist will be entering the consultation room to review the images and explain the findings.
- After joining the patient in the consultation room, the radiologist briefly explains his or her role in the patient’s care, reviews the images on a virtual desktop PACS, and gives the patient an opportunity to ask questions about anatomy, findings, and post-treatment changes – all in five to 10 minutes.
Is creating a patient consultation program in the ENT clinic as easy as it might sound? Not necessarily, says Richard Duszak, MD, FACR, professor and vice chair for health policy and practice in the Emory University Department of Radiology and Imaging Sciences, who advised the team on the practical implementation of patient consultations and the operational scope of the pilot program. “The concept of radiologists communicating results directly to patients is often considered foreign in radiology, with the exception of breast imagers and interventional radiologists,” he says. “Patients are increasingly asking us to do something that many of us haven’t been formally trained to do. Without support, infrastructure, and education, a concept like this could be doomed to fail.”
Fortunately, the Emory team was able to overcome these obstacles, largely by leveraging Hudgins’ and Aiken’s roles as onsite champions. Over the years, and enhanced by their onsite presence, Hudgins and Aiken had developed strong working relationships with both their referring physicians and their office staff members. Although Emory’s achievements were the result of a team effort that included active engagement of administrative and faculty leadership, clinical champions were vital for success.
The team had to overcome several other hurdles along the path to creating the patient consultation program. Aiken recalls that there was some resistance from both surgeons and radiologists regarding direct imaging consultation with patients. The main challenge was making time for the consultations.
“ENT providers feared that we would add work to their already busy schedules, but that wasn’t the case at all,” Aiken explains. In fact, Patel emphasized that with radiologist-patient interaction, he actually has more time available for other work.
“Having our neuroradiology team review the details of a surveillance scan helps patients who are feeling anxious about the progress of their disease. This helps us tremendously because I can spend more time with other newly diagnosed patients discussing prognosis and treatment,” Patel adds.
Radiologists were also worried about adding to their already full workloads, but Hudgins reports that after reading 35 to 50 H&N scans daily, her staff has become quite efficient with interpretation. As a result, the radiologists are able to work smarter and connect more intimately with patients. Fulfilling this niche with both speed and precision offers practices a huge opportunity to grow and market themselves as care providers, Hudgins notes. At Emory, the days of a faceless, nameless radiologist are long gone, she says. She also notes that radiologists’ morale has greatly improved as their role on the care team has deepened. “What we do matters,” she stresses.
Manpower can present challenges, so staffing appropriately also ensures that radiologists have time to develop good working relationships with referrers, coordinate logistics with ENT physician staff, and actually meet with patients, explains Duszak. “Our consensus reporting platform, NI-RADS, has helped a lot, because everyone is on the same page with diagnostic and management criteria and recommendations.”
According to Duszak, departments should get creative with staffing and workflow, since time in the clinic room means time away from image interpretation. By way of example, he suggests scheduling patient consultations on days when there are two subspecialty radiologists instead of one. He also notes the importance of each specialty staying in its own core of expertise. “Make sure roles are clearly delineated,” he says. “When a patient asks a radiologist what can be done to treat their cancer, the radiologist needs to refer the patient to their oncologist.”
Hudgins agrees that the team perspective resonates well with patients. “I tell them, ‘The Emory healthcare team has your back. We are caring for you as a group, and even though you might see just one or two doctors or providers, behind the scenes there is a whole team.’”
It is also vital to remember that not all radiologists are adept at delivering bad news, which is often missing from the standard radiology curriculum. “We need to educate radiologists on how to interact with patients and be prepared to break bad news,” Duszak says. “We also need to teach them how to provide next steps of the action plan and offer an element of hope at the end of the discussion.”
Adding the patient perspective, Stapleton advises radiologists refrain from inundating patients with medical jargon or giving bad news on Friday afternoon. Learn to go slowly, be empathetic, observe, and give undivided attention to each patient. Following the input of patient advocates like Stapleton, Emory operates on key principles that focus on communication with the patient and family.
Today, the patient consultation program in Emory’s ENT clinic is thriving. Three specialized neuroradiologists consult with an average of five H&N cancer patients each week in the ENT clinic. Radiologists generate about eight-to-10 biopsies a week through scan interpretation and have more opportunities with direct patient reporting to explain why the biopsy was necessary and how it will be done.
Emory neuroradiologists use onsite pathology and often relay results directly to patients and guide them on the next steps in their care. “We’ve redefined the role of the radiologist. As we become more involved in the ‘softer side’ of radiology, we’re watching our referrals and services expand,” Hudgins says.
Most importantly, both radiologists and surgeons agree that direct radiologist-patient interaction has enhanced the care provided to patients. “The program really works because we’re collaborative, and we share space. The patient sees that radiologists are key and that they help educate them,” Patel says. “Our neuroradiologists help educate patients about their disease, why certain imaging tests were ordered and performed, and the effects of their treatment on that disease. This is our opportunity to help patients and their families understand and take ownership of their care.”
To gauge patient response to the program, the Emory team conducted a before-and-after survey. The most interesting finding, says Aiken, is that after consultation, 93 percent of patients wanted to review future exams directly with the radiologists. Patients also had a much better understanding of management, imaging results, and the radiologist’s role in their care.
Learn more about what Emory researchers discovered about patient perception of radiologist involvement in their care.
Today’s patients are more proactive, asking detailed questions about different imaging options and expecting tangible specifics about their diagnoses, adds Hudgins. “Usually, patients want to talk to the radiologists after they’ve been to their clinic session. There’s something powerful about looking at their images and having them explained to them.”
Stapleton, who experienced that power firsthand, remains committed to supporting the H&N team in their approach to patient-centered care — both through his patient advocacy role and via a less formal duty: pastry delivery man. Each Tuesday at 6:30 a.m., he brings breakfast for the multidisciplinary tumor board members, who discuss every H&N patient seen in the last week. “They saved my life,” Stapleton says. “This is my small way of thanking them. I’m impressed that they meet this early in the morning. It just shows their tremendous dedication to their patients.”