negotiating expertise: pacs and the challenges to radiology
TRANSCRIPT
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]