teaching the art of verbal consultation
TRANSCRIPT
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OPINION
© 2009
eaching the Art of Verbal Consultation
ugue Ouellette, MD, Ara Kassarjian, MD, Theresa C. McLoud, MDiciidectaleTlteitaccAmsuoisrtef
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etween 8,800 and 18,600 Ameri-ans die every year from prevent-ble medical errors in diagnosisnd communication [1]. Improvedommunication, whether written orerbal, among referring physiciansan decrease patient mortality [2].
Most routine radiologic inter-retations are communicated to re-erring physicians through writteneports. In addition, preliminaryerbal communications often oc-ur. Verbal consultation is typicallyeserved for cases in which radiolo-ists’ opinions are most likely toave an important impact on pa-ient management. Despite its clin-cal importance, very little has beenublished regarding the art of ver-al consultation and the educationequired for radiology trainees tocquire such skills.
Radiologic training programs typ-cally develop curricula that representhat educators in any given institu-
ion want radiology residents toearn. There are 2 types of curricula.
e are familiar with the formal cur-iculum composed of written goalsnd objectives, assigned readings, lec-ures, and case conferences [3]. Caseonferences, or “hot seat” confer-nces, traditionally have been used toecreate verbal consultation scenar-os. This type of teaching is extremelyffective in the development of resi-ents’ observational and analyticalkills and in enhancing the knowl-dge bases of individual residents4,5]. Although valuable and interac-ive, these exercises are more con-rolled and less complex then actualnteractions that occur during verbalonsultations.
The second type of curriculum ishe informal curriculum. The in-
ormal curriculum consists of learn- m006 American College of Radiology1-2182/06/$32.00 ● DOI 10.1016/j.jacr.2005.09.008
ng experiences outside formalhannels. This type of curriculums more difficult to impose or mon-tor. Yet it is a large part of the ra-iology residency training experi-nce in all programs [6]. Verbalonsultation education is part ofhe informal curriculum. It is a rel-tively pure form of case-basedearning, a model preferred in sev-ral medical and law schools [6,7].ypically, students are given real-
ife situations that they are requiredo solve. The process is mediated byducators. In this learning model,nteractivity is considered impor-ant for optimal learning [8]. Inddition, verbal consultation edu-ation conforms best to theonstructivist model of learning.ccording to the constructivistodel, learning is a predominantly
ocial process [9]. Learners and ed-cators negotiate an understandingf subject matter through practicen real situations [10]. Verbal con-ultation occurs sporadically andesults in a complex social interac-ion not only between learners andducators but also with teams of re-erring physicians.
In an informal curriculum,rainees are likely to conclude thatearning what their educators do is
ore important than learning whathe trainees are told to do [6].herefore, teaching verbal consul-
ation is best done by providing ef-ective examples of this skill. Theollowing is an outline of elementse consider important in optimalerbal consultation in radiology.
First, a referring physician re-uests a verbal consultation. Theeferring physician’s first impres-ion is important as with any hu-
an interaction. The radiologist Ohould understand that such a re-uest typically occurs when thepinion of the radiologist has anmportant impact on clinical deci-ion making. We believe that verbalonsultation should be regarded asn important component of radiol-gy practice and education. Unfor-unately, the added time and effortre not financially compensated.
It may be helpful to consider thetructure and sequences of eventshat occur during a typical clini-ian-radiologist consultation. Of-en, the referring physician startshe consultation with a summary ofhe patient’s symptoms and signs,ollowed by the clinical questionshat have led to obtaining theadiologic investigation. Radiolo-ists sometimes have to prompt cli-icians to give this information.The radiologist then reviews the
maging study for abnormalities. Ifhe study entails only a few images,uch as in a plain radiographic ex-mination, the search pattern maye carried out simultaneously withhe description of the study typend findings. If the study containseveral images, such as a computedomographic or magnetic reso-ance imaging examination, the ra-iologist will scroll though all
mages rapidly to detect major ab-ormalities. First, the radiologistescribes positive findings, fol-
owed by negative findings of clini-al significance. Then, incidentalndings may be quickly reviewednd discarded if irrelevant. Thehorter the description is, the moreonfident the radiologist seems [11].
The radiologist should avoid ed-torial or “uncertain” speech styleshen describing imaging findings.
ne way to minimize this effect is9
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10 Opinion
y starting every sentence withThe” or “There is” during the de-criptive portion of the verbalonsultation. Sentences describingubtle or uncertain findings shoulde constructed in the followingashion: “There is a questionable,”There is a suggestion of,” or “Iuestion the possibility of.” In ourxperience, this speech style in-reases clinicians’ confidence in ra-iologists without an alteration inonsultation content. It also helpsadiologists construct short, effec-ive descriptions. Sentence formatsuch as “I think,” “There may be,”nd “I wonder if” should bevoided. Comparison with previ-us examinations is often carriedut after the description of find-ngs. If the description is long, auick summary of findings is ap-ropriate before discussion of theiagnosis of diagnostic possibilities.he summary may be omitted if
he description of findings is veryrief.With regard to the impression,
here may be only one possible di-gnosis (an “Aunt Minnie”), whichhould be stated. More often, how-ver, the imaging findings requireifferential diagnoses. Such shoulde as organized as possible. Urgentr important diagnoses should beiscussed first [11]. The communi-ation of differential diagnoseshould include a very short list ofhe statistically likely choices givenhe imaging findings, integrated
ith the clinical information from mhe clinician. It is helpful to com-it to a single diagnosis as beingost likely, and the most effective
ifferential diagnoses consist of 3ntities or fewer. Although listingore than 5 diagnoses increases the
ikelihood of mentioning the cor-ect one, it decreases the usefulnessf the verbal consultation. Whenppropriate, the radiologist shoulde frank about not knowing the di-gnosis. Knowledge that the find-ngs are atypical may be useful tohe clinician. Although the diagno-is may not be obvious or may beompounded by contradictory im-ging findings, the radiologist maye able to advise with confidencehe next appropriate step in thelinical management of the patient.
Recommendation for furthermaging, biopsy, or interventionalrocedures is advised whenever ap-ropriate. The radiologist shouldolicit any further questions andake time to answer them. Overime, a working relationship is es-ablished between the clinician andhe radiologist.
In summary, verbal consultations a crucial component of radiologyractice. It is requested by a clini-ian when a radiologist’s opinion isost likely to affect his or her ap-
roach to the management of pa-ients. Teaching radiology verbalonsultation is part of the informalurriculum and is done predomi-antly using a constructivist learn-
ng model. In this learning environ-
ent, trainees are more likely torioritize learning what their edu-ators do over what educators tellhem to do. Teaching effective ver-al consultation skills is best doney example.
EFERENCES
1. To err is human: building a safer health caresystem. Washington, DC: National Acad-emy Press; 1999.
2. Williamson KB, Steele JL, Gunderman RB,et al. Assessing radiology resident reportingskills. Radiology 2002;225(3):719-22.
3. Collins J. Curriculum in radiology for resi-dents: what, why, how, when, and where.Acad Radiol 2000;7(2):108-13.
4. Shaffer K. Radiology education in the digi-tal era. Radiology 2005;235(2):359-60.
5. Collins J, Garofalo RS, Albanese MA. Resi-dent conference at the viewbox: an experi-mental approach. Acad Radiol 1996;3(11):962-7.
6. Williamson KB, Gunderman RB, CohenMD, Frank MS. Learning theory in radiol-ogy education. Radiology 2004;233(1):15-8.
7. Maudsley G. Do we all mean the same thingby “problem-based learning”? A review ofthe concepts and a formulation of theground rules. Acad Med 1999;74(2):178-85.
8. Hutchinson L. Evaluating and researchingthe effectiveness of educational interven-tions. BMJ 1999;318(7193):1267-9.
9. Vygotsky L. Mind in society: the develop-ment of higher psychological processes.Cambridge, Mass: Harvard University Press;1978.
0. Lave J, Wenger E, Situated learning: legiti-mate peripheral participation. Cambridge,UK: Cambridge University Press; 1990.
1. Hall FM. Language of the radiology report:primer for residents and wayward radiolo-gists. Am J Roentgenol 2000;175(5):1239-
42.heresa C. McLoud, MD, and Ara Kassarjian, MD, are from Massachusetts General Hospital, Boston, Mass.ugue Ouellette, MD, Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, Yawkey 6406, Boston, MA2114; e-mail: [email protected]