by Nikolas Sanoudos MSc AVS RVT ARDMS Senior Vascular Scientist, Newcastle Upon Tyne Hospitals NHS Trust in Newcastle, United Kingdom
It is now a commonly-held belief that patients have the right to be the ultimate decision makers when choosing among their healthcare options. Healthcare providers agree that patients need to be informed. The underlying assumption is that patients will make their decisions based, in part, on the results of their diagnostic examinations. What the healthcare community has not yet achieved consensus on is who should do the informing.
In the United States and some other countries, sonographers are not permitted to provide results to patients, instead deferring those conversations to the interpreting radiologists or the referring physicians. My experience for the past 30 years has been in vascular labs in Greece and in the United Kingdom. In the UK, band 7 sonographers are permitted to sign and communicate the results. Nevertheless, the question of whether we should do so is still being debated. So far, there are no standardized professional guidelines nor consistency in recognizing sonographers' professional status.
To begin the conversation, below are pros and cons to four approaches of how sonographers might deal with the question of informing patients of their results.1
1. Don't tell.
Pros: Those who prefer this approach provide several reasons. Patients have no pre-existing
relationships with the Ultrasound department whereas they probably do with the referring physicians; therefore, the patient would be more comfortable hearing the results from the physician. In addition, the sonographers may not be familiar with the patient's complexity of disease, and because they are not medical doctors, they are ill-equipped to answer patients' questions about disease prognosis and therapies. At times, discrepancy can exist between the complexity of the results and the patient's ability to comprehend them so the technologist might ask the radiologist to talk to the patient.
Cons: The American Medical Association Code of Medical Ethics clearly states that patients have the right to know.
2. Tell if asked.
Pros: If a patient wants to know the results of the study and is told, uncertainty and anxiety will be eased immediately rather than making the patient wait for days or weeks to meet the referring physician. The sonographer is the most expert to point out the findings on the images and talk about what they mean. No one understands the imaging examination as well as the sonographer. One of the best investments the field can make in its own future is increasing the commitment of sonographers to communicate directly with patients.
Cons: Every patient request cannot always be granted. In this case, however, doing so provides an opportunity to give patients something they naturally want and need and thereby helps to build a stronger relationship with the patient.
3. Ask to tell.
Pros: Some patients may not even know that finding out the results immediately is an option. Older patients may simply assume that they cannot get the results. Especially in the case of language and cultural barriers, an offer by the radiology personnel (operating where necessary with an interpreter) may go a long way toward easing patient anxiety and enhancing trust in the institution and healthcare system. One of the best ways is, at the end of an encounter, to ask patients if they have any questions.
Cons: There are, of course, practical considerations. In a busy department, explaining results to every patient may delay the examinations. According to U.S. practice, 2 it was found that the average time necessary to inform patients of normal results was approximately two minutes. In the case of a minor abnormality, five minutes was required. When the abnormality was severe, the time required was eight minutes. While in many practices only a small minority of patients are likely to have a severe abnormality, this still can be a substantial drain on time. Sonographers need to be organized to provide timely information.
4. Always tell.
Pros: If all patients are informed of their imaging results, failures to communicate results are eliminated. Furthermore, it may reduce the rate of error in the communication of results. Referring physicians spend less and less time with their patients. Also, many use nurse practitioners as surrogates to provide various patient-care functions, including giving patients the results of their examinations. Who is more expert to communicate the results than a sonographer? The purpose is to empower patients' autonomy and enable them to make informed choices from the moment they learn their result.
Cons: In the case of a patient who does not want to be informed, the patient's preference must be respected. Informing all patients will be time consuming (as mentioned before). Also, sonographers need to be trained on how to present abnormal findings.
Suggestions to consider when developing a policy on informing patients.
In developing a departmental policy on informing patients of the results of imaging studies, sonographers should bear several points in mind. First, such policies should be uniform throughout a healthcare organization so that divergences in practice from one department to another are minimized. Second, it is probably good for sonographers to inform patients of normal results, to alleviate unwarranted anxiety. When the findings are uncertain, sonographers can tell the patient that there are many images to interpret and that, rather than render a hurried opinion, they want to sit down and go over them carefully to make sure not to miss anything. If patients still want to know, however, they have the right to wait or to receive a phone call once more definitive conclusions have been reached. When patients ask questions to which sonographers do not know the answer, it is best to say, "I don't know the answer, but I think your referring physician will." When unexpected or alarming findings are encountered, they should contact referring physicians to find out how they would like to handle the situation.
It is beyond doubt that effective communication is imperative for the delivery of high-quality patient care. At the heart of effective patient communication is an understanding of the patient's ability to comprehend and cope with the information being communicated. Patients want good news. Often patients fear the worst. Anxiety, expressed or not, must never be trivialized. Respect the patient and all their needs: for dignity, modesty, and hopeful and helpful information. Many patients fear that they will be left to make decisions for which they are unprepared. They need guidance, not dictation in decision making.
Our work is becoming more technical and sophisticated. It is my opinion that this increases the need for more independence and education for sonographers in addition to clear professional guidelines and a stronger emphasis on sonographers, as experts in their field, communicating the results of diagnostic-imaging studies to their patients.
Acknowledgments: Dr Alison Mackie C.Sci., C.RadP., MSRP, MBNMS, FIPEM
Head of Medical Physics Unit. University Hospital of North Durham. Durham UK.
1Should We Inform Patients of Radiology Results? J. Nathan Smith, BSN, MS, and Richard B. Gunderman, MD, PhD, MPHRadiology May 2010 Volume 255, Issue 2
2Disclosure of results of sonographic examinations to patients by sonologists. Ragavendra N., Laifer-Narin SL , Melany ML , Grant EG . AJR Am J Roentgenol 1998;170(6):1423–1425. CrossRef, Medline