Negotiating Expertise: PACS and the Challenges to Radiology

Renegotiating Expertise: PACS and the Challenges to Radiology

Allison A. Tillack, MA

UCSF Medical Scientist Training Program UCSF-Berkeley Joint Program in Medical Anthropology

Richard S. Breiman, MD

UCSF Department of Radiology

Purpose of Study

  To examine how the adoption of PACS has/has not impacted:   Professional relationships among radiologists and clinicians   The role of the radiologist as a member of the patient care

team

What Is Medical Anthropology?   A subset of sociocultural anthropology:

  “examines patterns and processes of cultural change, with a special interest in how people live in particular places, how they organize, govern, and create meaning” (AAAnet.org)

  Medical Anthropologists are interested in how the health of individuals and larger social groups are impacted by inter-personal relationships and cultural and social norms

What is Medical Anthropology?

  Qualitative

  Primary research method is Participant-Observation:   “involves placing oneself in the research context for

extended periods to gain a first-hand sense of how local knowledge is put to work in grappling with practical problems of everyday life” (AAAnet.org)

  Ethnographer is embedded into study population— allows development of relationships of trust, movement beyond rhetoric offered to a perceived ‘outsider’

Why Use Medical Anthropology/Qualitative Research Methods?   Particularly good for investigating research questions about

complex, emergent situations

  Generates detailed, rich data connected to specific contexts

  Can highlight differences between what people say and what they do

  Helps generate important themes, patterns, hypotheses for future research

Study Goals

  Characterize nature of changes in clinician-radiologist relationships post-PACS

  Suggest possible causes/impact of these changes

  Develop suggestions for enhancement of radiologists’ role in clinical medicine

Methods

  A pilot project

  3 months of observation of the daily practices of a small sample of radiologists and a community of clinical specialists (N=40)   Included interactions in reading rooms, during multi-

disciplinary conferences and tumor boards, and on rounds

Methods

  Semi-structured interviews with 10 radiologists and 5 clinical specialists focusing on:   Perceptions of radiologists’ roles before and after PACS   Perceived changes in nature/substance/frequency/place of

radiologist-clinician interaction pre- and post-PACS

Methods

  Extensive archival review of relevant scientific and popular literature

  Radiology, JACR, society bulletins, society websites   NEJM, JAMA, Lancet

  New York Times, Washington Post, Wall Street Journal

Data Analysis

  Verbatim interview transcripts and field notes (written record of daily observations/interactions of ethnographer) were analyzed for recurrent themes and patterns

  These themes/patterns were then correlated with relevant literature

  Special attention was paid to discrepancies between what people said and what they did

Results

  All study radiologists (broad range of levels of experience) expressed belief that they interact much less frequently with clinician colleagues after adopting PACS, and that very few clinicians now visit reading rooms (as compared to rate of visits before PACS adoption)

  All study radiologists voiced a high level of concern about what this reduction in interactions will mean for radiology in the future and for patient care

Results

  For example, one senior radiologist said:   “We [radiologists] knew all the clinicians intimately

before. And then with PACS, this intimacy disappeared. Before [PACS], I knew the face, name, wife’s name, and kids’ names of all the clinicians, but now I don’t know who you are if you joined the medical staff after we got PACS. Now we’re operating in a void, because there’s no history of the patient on the written image requests. Before, when a clinician showed up, I could ask them and find out what’s really going on with the patient.”

Results   Observations of and interviews with clinical specialists in the

study indicate that attending specialists and a large majority of fellows and senior residents believed that:   PACS allowed them to see images frequently enough to develop

significant expertise in interpretation   They were unlikely to seek out the opinion of a radiologist unless they

already had a solid professional relationship with that radiologist and felt they could “trust” that radiologist’s interpretation

  At the study site, images were not embedded in radiology reports. Often, the specialists would look at the image and not the dictation, preferring to rely on their own ‘read’ and clinical knowledge of the patient

Results

  For example, a senior clinical specialist commented:   “In the acute setting when someone has a stroke and is in the

emergency department, we have our residents look at the images on PACS and then a senior person, a stroke attending like myself or one of the fellows, views the image as well, and then makes a decision about emergent treatment. We make a lot of decisions from home… we have our web-based PACS that we can look at from home, so I wake up at 1 AM and stagger down to the computer and look at the thing, and then tell folks what we’re going to do.”

Results

•  Trust was something that both study radiologists and clinicians frequently talked about both informally and formally   Difficulty of establishing/maintaining trust between

radiologists and clinicians post-PACS

Discussion   Anthropological studies have shown the importance of social

interaction in establishing/maintaining jurisdictions of expertise and professional trust

  Expertise is knowledge based, but also interactional and performative

  Without opportunities to create and reinforce relationships of professional trust and displays of expertise in image interpretation with which to ‘convince’ their clinician colleagues of their expertise, radiologists are at risk of losing their status as imaging experts

Discussion

  As medical care becomes increasingly sub-specialized, trust among clinicians is more important than ever   Relying on others for the production/interpretation of

information (i.e., lab tests, imaging, physical exam, etc) involves risk

  To work as a patient care team requires trust in the competence of others

Discussion

  PACS has revolutionized medical imaging and has had many positive impacts on radiologic practice

  But…   PACS has also disturbed the mechanisms by which

radiologists formerly established trust and communicated their expertise to clinicians, which has led to a marginalization of the radiologist as a member of the patient care team

  What can radiologists do to combat/reverse this trend?

Discussion

  Some radiologists are already taking action:   Embedding reading rooms in clinical areas

  Becoming more visible through multi-disciplinary conferences (seeking out clinicians and patients outside the reading room)

  Focusing more on providing clinically relevant information to clinicians, faster… asking clinicians directly what they need, how radiology can help them

  Taking on role of patient advocate (especially for radiation safety, reducing number of unneeded scans)

Discussion

  This isn’t just a problem of less communication, but the kinds of communication and the ways communication takes place

  A key question for future research: how can trust and expertise be established/maintained using alternate modes of communication (email, phone, IM, etc.)?

Avenues for Future Research

  Sociologists have been investigating how trust is established without personal interaction or knowledge in virtual communities   Example: eBay—how do people conduct business via the

internet (and establish trust) with people they’ve never met?   A particularly successful technique uses positive (as opposed to

negative) reputation systems

Ongoing Research   Pilot project helped to shape Ms. Tillack’s current dissertation

research

  Combines both qualitative (ethnographic) and quantitative approaches

  Study is now multi-sited (in a different geographic region); includes a large academic medical center, a community hospital, and pre-PACS health care clinic

  Also includes observation/interviews with multiple specialist communities (ER, Neurology, Orthopedic Surgery, Hospitalists)

Special Thanks:   Dr. Breiman and the UCSF Radiology Department

  Dr. Sunshine and the ACR

  Dr. Borgstede and the U. Colorado, Denver Radiology Department

  Drs. Adele Clarke, Ian Whitmarsh, Sharon Kaufman, Department of Anthropology, History, and Social Medicine (UCSF)

  The UCSF Medical Scientist Training Program

Questions? Comments? Suggestions? Want to Share Your Perspective?

  I would love for you to contact me!   Email: [email protected]