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  • 1.  Communication

    Posted 07-31-2020 15:14
    Good paper.

    Could a conference or other inclusive discussion taking into consideration the cost of good communication in all walks of medicine to prevent error, death and injury?

    And who to lead this?

    Rob Bell, M.D.
    Sent from my iPhone

  • 2.  RE: Communication

    Posted 07-31-2020 17:22
    Mark, Thanks for calling our attention to this paper. Interesting discussion and one cannot disagree with a plea for better communication, but several issues were not adequately addressed in this paper. The one of most interest to me is what the radiologist actually said in the preliminary (if there was one) and final reports. To say as is stated in the paper, "CT showed adenopathy in the abdomen (Figure 1a). The radiologist read this as "probable lymphoma.'" may be doing a disservice to the reading radiologist if the report actually followed the guidelines in the 2014 ACR PRACTICE PARAMETER FOR COMMUNICATION OF DIAGNOSTIC IMAGING FINDINGS (see below). On the other hand, if that quote was the actual report or an accurate rendition of its contents, then it's not hard to see things going south from there through a series of Reason's Swiss Cheese holes.

    The ACR practice parameter describes the process in some detail starting with deciding what study to order through the performance of the procedure to the final report. The section on Diagnostic Imaging Reports describes in detail what the report should contain. Here is what sections 3 & 4 say:


    3. Body of the report
    • a. Procedures and materials: The report should include a description of the studies and/or procedures performed and any contrast media and/or radiopharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or complication should be recorded.
    • b. Findings: The report should use appropriate anatomic, pathologic, and radiologic terminology to describe the findings.
    • c. Potential limitations: The report should, when appropriate, identify factors that may compromise the sensitivity and specificity of the examination.
    • d. Clinical issues: The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical question, this should be stated explicitly.
    • e. Comparison studies and reports: Comparison with relevant examinations and reports should be part of the radiologic consultation and report when appropriate and available.
    4. Impression (conclusion or diagnosis) 

    a. Unless the report is brief each report should contain an "impression" or "conclusion."

    b. A specific diagnosis should be given when possible.
    • c. A differential diagnosis should be rendered when appropriate. (emphasis mine)
    • d. Follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate. (emphasis mine)
    • e. Any significant patient reaction should be reported.

    (I do quarrel with the latitude implied by the bold italics "when possible" and "when appropriate".  I would prefer leaving those words out and substituting explanatory language when not included.)

    In my nearly 40 years of emergency medicine practice, radiology reports conforming to this kind of "guideline" were the exception rather than the rule. Admittedly this guideline was not in force 40 years ago either. And many of the reasons for truncated radiology reporting is the same as for the compromises in clinical practice across all areas of medicine - production pressures, cognitive deficits and biases, workarounds, distractions, lack of adequate time to think, etc, etc. More and better verbal communication would likely be a great help to improving practice, but in the real world, a good written report of a study would be a great start.

  • 3.  RE: Communication

    Posted 07-31-2020 18:44

    Hi all,

    I have been following the discussion related to hospital discharge communications and ambulatory follow-up.

    I have been part of an AHRQ funded workgroup looking at hospital discharge and follow-up ambulatory care.

    Even though this project was focused on reducing unwarranted re-admissions, during the project we identified poor communication between transitions in care as a major problem.

    The AHRQ has posted several articles about our findings that you may find interesting.

    Also, we have a paper under review at the Annals of Family Medicine (hopefully it will be accepted and published soon).


    Designing and Delivering Whole-Person Transitional Care



    Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions



    Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care Final Report





    Ted E. Palen, PhD, MD, MSPH

    Diplomate American Board of Internal Medicine

    Diplomate Clinical Informatics American Board of Preventive Medicine

    Senior Investigator | Institute for Health Research | Kaiser Permanente Colorado (KPCO)

    Physician Reviewer, KPCO Member Appeals | Colorado Permanente Medical Group

    2550 S Parker Rd, Suite 200 | Aurora, CO 80014 | ( 303-636-2406 | cell 303-514-8126 | 7 303-636-2945

    Email: Ted.E.Palen@kp.org

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