Adding value within medicine’s new paradigm: the pediatric radiologist
In the face of uncertainty regarding the future of medicine, radiologists are seeking a new paradigm for their field, one that enables collaborative and patient-centered care. We are looking for ways to add value within the ever-more-fragmented environment of health care. The pediatric radiologist provides a clear example of how to provide meaningful care in a way that enables our colleagues.
Now more than ever, radiologists face pressure to maintain visibility within patient care. Yet at the same time, many radiologists are experiencing increasing administrative pressures that demand productivity and efficiency. In response, some have suggested that radiologists need more focus, and that outside distractions during image interpretation — phone calls, conversations, etc. — keep us from doing our best work . Others have called for a rebranding effort, claiming that we need to refresh our image with our fellow physicians and with the lay public, highlighting accessibility and collaboration.
Both reactions articulate something important and emphasize different levels of value that radiologists can bring. If radiology is to add value that emphasizes patient-centered and family-centered care, it won’t be the result of working alone. We must strengthen the relationships that bridge the silos of hyper-specialized medicine.
Many subspecialized areas within radiology are making progress implementing so-called Imaging 3.0 initiatives [2, 3]. However, perhaps none is so uniquely positioned as the pediatric radiologist to highlight how the radiologist’s value is far broader than the generation of a report. Our scope is comprehensive, yet specialized, caring for families as much as individuals .
The example of the pediatric radiologist emphasizes the vital importance of the roles of consultant, collaborator and patient advocate. It is through these three roles that we see the particular value of strong relationships, with fellow health care providers and with our patients. The center of these relationships is the reading room.
The pediatric radiology reading room often serves as a focal point for multidisciplinary care, drawing together physicians from the far corners of the hospital. These physicians come to the reading room not because of a nameless and faceless radiologist, but rather because of relationships built on confidence and trust.
Relationships with unique individuals provide something different from what is contained in a report. They go far beyond a transfer of data, allowing for true collegiality. We refer to “colleagues” because we recognize more than a co-worker. Our connection is not an incidental by-product of working in the same physical space. Rather, we are united by a common purpose — sustaining the health and the life of a person — and the term “colleague” implicitly recognizes interdependence as key to our mission.
Some might argue that the fast-paced model of modern health care can no longer sustain such time-consuming human interaction. Interruptions to workflow have been identified as an obstacle to efficiency. Yet it is worth considering how often each of us has seen the care of a patient be delayed and compromised by the improper use of imaging, with inadequate exams and incomplete indications leading to less-than-helpful diagnostic results. It is worth asking how many hours or days of delayed diagnosis and misguided treatment could be avoided with a meaningful 5-minute conversation.
The reading rooms of the past did this well, serving as important destinations for rounding medical teams each morning . Many senior radiologists recall working their way through the alternator with visiting clinical teams, providing opportunities to enhance one another’s understanding of a medical problem and work together to develop the solution. Without the benefit of consultation and the resulting inter-disciplinary discussions, the true value of medical imaging might be obscured.
Beyond encountering us in the midst of our work, another opportunity in welcoming diverse caregivers to the reading room is that they will encounter one another. Impromptu patient care conferences frequently break out spontaneously in the reading room, allowing us to contribute to and learn from one another in a more comprehensive manner.
The “reading-room-as-watering-hole” model, seen especially clearly in the example of the pediatric radiologist, provides a space to build relationships among caregivers who might otherwise only come together in the electronic medical record. We can serve a purpose of adhesion, helping to unify the many parts of the care team. Such a confluence of physicians and the new ideas and decisions arising from this teamwork inevitably result in a clear winner — the patient.
Consider the following recent case: a young child, diagnosed at another location with an abdominal mass, was referred to the children’s hospital for surgical management. Although outside imaging had been thought to demonstrate a renal mass, the inpatient pediatrics team chose to come to the reading room to discuss the case and the images. The pediatric radiologist suspected that the images were not truly characteristic of a tumor, and repeat ultrasound confirmed this suspicion. While in the reading room, they encountered a pediatric urologist, who recalled seeing a similar case the prior year and was able to add confidence. This informal care conference, facilitated by visiting the reading room, resulted in a determination that the child’s “mass” was in fact pyelonephritis, requiring not surgery but simply antibiotics.
Excellence in the care of our patients depends upon our ability to function as collaborators. The value of our contributions depends upon whether someone is listening to our ideas. In other words, “adding value” presupposes strong relationships with the entire health care team and an environment of trust.
Although an emphasis on interdependence and trust has not always been a hallmark of medical training, our patients expect and depend upon our ability to work closely and collaboratively as a team . The radiologist can enable teamwork among physicians, by serving to unite diverse specialists around a common vision. Radiology quite literally provides vision to other caregivers by revealing the hidden.
If we are serious about patient-centered care and reinforcing the value of medical imaging, there is no more worthwhile work than strengthening the collaborative model in radiology and in medicine. The advent of decentralized imaging through the implementation of picture archiving and communication systems (PACS), although a boon for efficiency, has had the unintended consequence of increasing isolation, and this has certainly presented obstacles to the collaborative model .
Increasingly advanced technologies seem to keep us even further apart. However, they need not make obsolete the concept of collaboration. In fact, the integration of machine learning into our specialty can be a valuable reminder that our non-interpretive skills are not really “skills” at all — they are relationships. Despite continual changes brought by the digital revolution, the radiologist can once again bring together the health care team.
Nowhere are these themes on better display than in the reading room of the children’s hospital. Far from a peripheral service, the radiologist functions at the very core of health care. At our best, we have the potential to bring together an increasingly disparate and subspecialized cadre of caregivers for the betterment of patient care, as in the case of the child with pyelonephritis. The example of the pediatric radiologist reminds us of how much we depend on other caregivers, and they on us, and how the health of our patients depends on this collaboration.
Our distinct ability to see allows us to offer a benefit that can go beyond cataloguing structures absent and present, benign and malignant. We can assist in making medical care more patient-centered . As advocates, our relationships with the medical care team and with the patient can offer direction and clarity where these are lacking. More than most subspecialists, the pediatric radiologist encounters all body systems and organs. We frequently provide diagnosis for both anatomical and physiological dysfunction, and we might be involved in the care of multiple distinct pathologies within a single child.
For a child with the sequela of spina bifida, pediatric radiology might first perform a head ultrasound to assess the degree of hydrocephalus, then examine the integrity of that child’s ventriculoperitoneal shunt via radiographs. Later that day, the same child might have a voiding cystourethrogram performed in the fluoroscopy suite. Each request comes from a different part of the hospital — neonatology, neurosurgery, urology — and they are drawn together by radiology. What might have been disconnected and separate episodes of care can be brought back to center around the patient through the uniting effect of the radiologist.
The ability to be a true advocate presupposes strong collaborative relationships and that we are functioning as consultants. For example, consider a pregnant woman recently seen at our hospital, with dilated fetal bowel noted on prenatal ultrasound. The woman was referred for advanced imaging, and the pediatric radiologist who performed fetal MRI found signs of a closed-loop obstruction, concerning for volvulus. This was discussed in the reading room with a group of physicians that included maternal–fetal medicine and pediatric surgery. As it happened, the woman went into preterm labor the very next day. The surgeons, already aware of the newborn’s situation, confirmed the obstruction in discussion with the very same pediatric radiologist, and went immediately to surgery, resulting in a reduction of the volvulus and successfully salvaged bowel.
When radiologists speak of changes for the future or emphasize the need for an “Imaging 3.0,” perhaps we can recapture something that we once knew and have neglected. The solution to a fresh challenge does not always have to be novel. It might be that lessons from our past are particularly well-suited to answer concerns for our future. Despite a shifting landscape in health care and technology, what we must control is the strength of our relationships.
The pediatric radiologist, acting as consultant, collaborator and advocate, can serve as an exemplar on the specific means by which we contribute value. When our colleagues in medicine are asked what a radiologist is, the answer must not be report-generator, not guardian of imaging apparatus, nor even advocate of technology. Instead we are, and must be known to be, uniting health care for the sake of the patient.
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