Volume 10 Issue 11 - January 2013
                       
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Radiology Consultation Clinic
     
  The Radiology Consultation Clinic is a pilot program that provides an opportunity for patients to consult directly with a radiologist

  Its goal is to support the patient, referring physician, and primary care physician

  Patients may benefit from a better understanding of the risks of incidental findings and the importance of follow up, the implications of imaging findings, or the risks of exposure to ionizing radiation

  Initial experience in the clinic is limited but has been appreciated by patients and their referring physicians



Incidental Findings
Reviewing Re-Staging Scans in Cancer Patients
Radiation Risk and Choice of Imaging Modality
Further Directions
Scheduling
Further Information
References


Figure 1. Dr. Dushyant Sahani (a staff MGH radiologist in Abdominal Imaging) is shown here in pilot radiology consultation clinic.
Figure 1. Dr. Dushyant Sahani (a staff MGH radiologist in Abdominal Imaging) is shown here in pilot radiology consultation clinic.

Consultation with referring physicians has always been an important role for radiologists although direct patient consultation is not a common practice. This changed at the MGH more than a decade ago when the Radiology Department opened an Interventional Radiology Clinic. Providers refer patients to interventional clinicians. These interventionalists use this clinic to consult with patients and, if appropriate, discuss treatment options. The radiologists become part of a team, together with the patient, surgeon, or other medical specialists, in the decision to select surgery, image-guided interventions, or other care. One interventional radiologist made the point that patients are not referred in for a procedure, rather they are referred to the providers for a consultation that potentially might result in the procedure. Then, if a patient chooses to undergo inverventional therapy, a radiologist will perform the procedure and provide longitudinal therapy including follow-up care. These may include follow-up visits in the interventional radiology clinic.

More recently, the department has begun a Radiology Consultation Clinic as a pilot program for patients who wish to learn more about imaging techniques and the implications of imaging findings. This new program has given radiologists the opportunity to allay fears and to explain confusing terms, discuss radiation risk, or discuss the advantages and disadvantages of imaging methods such as CT or MRI. The goal is to support both the patient and their referring physicians. Patients have been pleased that they were able to speak with a radiologist and have reported feeling more in control of their diagnosis and treatment.

There are two principle situations in which both the patient and their doctors have found the clinic to be helpful. First are patients with incidental findings on an imaging examination unrelated to the findings. Second are patients who are receiving imaging to follow up after a diagnosis of cancer and wish to better understand the results of their scans.

At this time, all patients receive their imaging results directly from their clinical provider before the patient comes to the Radiology Consultation Clinic. The purpose of this clinic is not for the delivery of radiology examination results.  However, a number of patient preference surveys have shown that a majority of patients would like to receive their results as soon as possible, find that waiting for the radiology results to be difficult, and do not show preference regarding whether a radiologist or other provider delivers them.


Incidental Findings
Pulmonary and adrenal nodules are common incidental findings that occur in about one percent of patients who undergo CT or MRI. Most of these nodules are benign, as are other less common incidental findings such as pancreatic cysts although there is risk that they are cancerous.

Many of these incidental findings are found in images that were ordered by providers other than the patient’s primary care provider (PCP), including those from outside institutions. Often, these referring physicians or outside providers do not convey their findings or their implications to the patient.

Instead, the incidental findings are typically reported to the patient’s PCP, with a note to say that the findings need follow-up care. At times, the patient first learns about the incidental findings in a letter, together with information that follow-up is necessary. Without further details on the significance of the findings, this information can provoke needless anxiety.

In many cases, PCPs do not feel well prepared to understand and convey the risks associated with incidental findings and may not be aware of up-to-date recommendations on imaging follow-up. In contrast, radiologists may be more knowledgeable about the risk of an incidental finding. They are also well versed in the recommended protocols for follow-up imaging to establish a diagnosis. Therefore, Mass General Imaging offers the opportunity for a patient to consult with a radiologist in the Radiology Consultation Clinic to better understand the implications of incidental findings and the follow-up recommendations.


Reviewing Re-Staging Scans in Cancer Patients
The review of re-staging scans is another situation in which patients have felt that they benefit from consultation with a radiologist. This perceived benefit was clearly expressed in a recent article published in the Journal of the American College of Radiology, written by a patient who has been in our clinic.

Prior to coming to the clinic, she had found that a post-operative review of her images with her surgeon, who showed her that her tumor had shrunk and her lung was re-expanding, had helped her by giving her the gift of hope. Later, when she had the opportunity to consult directly with a radiologist, she wrote that she benefitted from a review of her imaging findings and clarification of terminology in radiology reports. The clinic review helped her understand her condition and gain a sense of deeper purpose and understanding in how she could participate in her own treatment and recovery.


Radiation Risk and Choice of Imaging Modality
There have been several recent reports about the radiation risk associated with CT scans, which have led to increased anxiety for many patients who might benefit from a CT scan. The Radiology Consultation Clinic offers the opportunity for patients to discuss their options and understand the risks and benefits of exposure to radiation in their individual situation. Patients can learn about the suitability of other imaging examinations, such as MRI or ultrasound and, in many cases, radiologists can alleviate anxiety and help the patient select the most appropriate imaging modality on an individual basis.


Further Directions
Given the early pilot nature of the program, a limited operational context exists. At this time, two radiologists have been donating their services and have been making use of space and personnel that are formally assigned to interventional radiology. In this pilot proof of concept stage, neither patients, patient’s insurance, nor referring clinicians are being charged for this service. As the program grows, formal allocation of time, space, personnel and other resources will likely be required.


Scheduling
Physicians who wish to refer patients to the Radiology Consultation Clinic should contact Debita Pomare, Patient Services Coordinator, at 617-726-8488 for an appointment. Radiologists are available for consults lasting up to 30 minutes and will document all clinic visits via a standard consultation note that is recorded in the electronic medical record. Virtual visits via videoconference are in development and may be available in mid 2013.


Further Information
For more information about the Radiology Consultation Clinic, please contact Garry Choy, MD, Emergency Radiology and Cardiac Imaging, 617-724-4270 or Dushyant Sahani, MD, Abdominal Imaging and Intervention, Massachusetts General Hospital, 617-726-3937. For more information on the Radiology Interventional Clinic, please contact Joshua A. Hirsch, MD, Vice Chief of Interventional Care.

We would like to thank Drs. Choy, Sahani, Hirsch, and Susan E. Bennett, MD, Internal Medicine, Massachusetts General Hospital, for their assistance and advice for this issue.




References

Basu PA, Ruiz-Wibbelsmann JA, Spielman SB, Van Dalsem VF, 3rd, et al. (2011). Creating a patient-centered imaging service: determining what patients want. AJR Am J Roentgenol 196: 605-610.

Ollivier L, Apiou F, Leclere J, Sevellec M, et al. (2009). Patient experiences and preferences: development of practice guidelines in a cancer imaging department. Cancer Imaging 9 Spec No A: S92-97.

Webster NJ (2012). Healing images. J Am Coll Radiol 9: 610.



©2013 MGH Department of Radiology

Janet Cochrane Miller, D. Phil., Author
Raul N. Uppot, Editor


 
 
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