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0:44

Today we're honored to welcome Dr. Janine katzen

0:47

for a lecture on patient-centered care and

0:50

breast Imaging Dr. Katzen is a breast imager

0:53

in the director of breast Imaging fellowship program at Cornell

0:56

medicine New York Presbyterian Hospital where she

0:59

has practiced for over 10 years.

1:01

At the end of the lecture, please. Join Dr. Katzen in a Q&A

1:04

session where she will address any questions you may have on today's topic.

1:08

Please use the Q&A feature to submit your question at any

1:11

time during the lecture.

1:13

With that said we are ready to begin today's lecture Dr. Katzen.

1:16

Please take it from here.

1:18

Thank you very much for that nice introduction and welcome everyone.

1:21

I'm really excited to have the opportunity to speak with you

1:24

regarding patient-centered care in breast Imaging and

1:27

providing the greatest value to those that we serve.

1:32

The objectives of this talk are to First clearly

1:35

Define what is patient-centered care?

1:39

and next to address what patient-centered care looks

1:42

like specifically in the setting of breast Imaging

1:46

And finally, we're going to review possible future directions of

1:49

patient-centered care.

1:52

So as a little bit of a background.

1:55

Healthcare delivery payment models have shifted over the

1:58

past decade.

2:00

There's been a move away from fee for service towards

2:03

value-based payment models. And what does that mean? It

2:06

basically means that it's supposed to focusing on the volume

2:09

of studies that were reading the number of studies

2:12

that we can turn out. There's a real focus on the value of

2:15

our reports and of our interaction with our multiple

2:18

multidisciplinary colleagues, we focus

2:21

on higher value care increased teamwork

2:24

integration and care coordination and

2:27

really there's been a major cultural framework

2:30

shift over the past decade from

2:33

physician-centered or institution-centric medicine

2:36

to patient-centered Medicine, you know, we've switched

2:39

from that dogmatic practice to a real interactive relationship with

2:44

our patients.

2:47

Okay, so what is patient-centered care and you'll

2:50

see there's not one real line item

2:53

here. It's a multifaceted definition which

2:56

includes a focus on engagement with

2:59

patients and their families and their overall support

3:02

system.

3:04

Effective communication this is so key shared

3:07

decision making and that means shared decision-making

3:10

between us and our patients but also

3:13

between us and the multiple healthcare providers

3:17

that are caring for this patient.

3:20

coordination and integration of care again working with patients their

3:23

families and members of the multidisciplinary

3:26

team

3:28

cultural competence our patients come from

3:31

a large variety of backgrounds and we

3:34

have to understand where they're coming from.

3:37

Education is so key. You will hear me say this

3:40

multiple times throughout the lecture, but I myself

3:43

and much more likely to adhere to a recommendation if

3:46

I understand the rationale behind that recommendation so

3:49

education is so so important.

3:52

And finally emotional support, you know, we're not

3:55

just, you know, giving the medical information, but we're providing the

3:58

emotional support that comes along with the information that

4:01

we're conveying.

4:04

So this is a schematic from the New England Journal of Medicine. And again, this

4:07

also represents that patient-centered care

4:10

is multifaceted.

4:12

We want the missions and values aligned with the patient's goals

4:15

and we have to recognize that not all patients goals are

4:18

the same and not all patients goals will

4:21

be the same as what our goals would be.

4:24

Care is collaborative involving us patients and

4:27

their support system involving the

4:31

technologists who we work with involving everyone of

4:34

the Care team and it should be accessible.

4:38

We want to focus on the physical comfort and emotional

4:41

well-being of our patients.

4:45

Patient and family viewpoints are respected and

4:48

valued yesterday. I had a

4:51

patient who came in she said do you mind if I take notes while we're

4:54

discussing I said, of course not tell me when you're ready and she took

4:57

out her notepad and she told me that last week she had seen a

5:00

physician who wouldn't allow her to take notes and I think that

5:03

person could really benefit from listening to this lecture today.

5:08

Every day, I have technologists who come into my

5:11

room and they say is it. Okay, if the patient has her husband come in or

5:14

is it okay if the patient has her friend come in and the answer is always

5:17

yes, we have to remember that when patients come into

5:20

our office frequently. They're nervous. They're anxious about what the

5:23

results are going to be and when they have that

5:26

heightened sense of anxiety, it can be difficult to

5:29

hear what we're saying. So by having a family member

5:32

or someone from a support system who's

5:35

with them and can help them to process that information

5:38

later on family should be welcome in

5:41

the care setting.

5:42

And finally full transparency and fast

5:45

delivery of information.

5:47

And this has really significantly changed

5:50

over the past year and a half with the 21st century

5:53

cures act which I'll address later but patients

5:56

are now basically getting their Radiology reports immediately

5:59

if they have access to the patient portal and we

6:02

have to be aware of this in our daily practice.

6:07

So the American College of radiology recognized the

6:10

importance of patient-centered care and created

6:13

the Imaging 3.0 program to focus on

6:16

these initiatives.

6:18

Of patient and family centered care. They recognize that

6:21

our roles are now moving beyond the reading room. They

6:24

move Beyond image interpretation. And there's

6:27

again a shift in focus from the volume of

6:30

studies read to the value of the care that we're providing

6:33

to our patients and to other members of

6:36

the healthcare team.

6:40

And so what does success for patients look

6:43

like with this initiative?

6:46

First is increased patient access and we're

6:49

going to talk about this a lot later on in the

6:52

lecture. We have to make sure that patients can get in to CS.

6:56

Increased education again, if a

6:59

patient understands the rationale behind our recommendation

7:02

and understands what is coming they're much

7:05

more likely to adhere to these recommendations.

7:09

We want our patients to have direct access to us

7:12

to be able to discuss results with us.

7:16

And finally increased access to medical records and reports.

7:21

We don't only want success for our patients. We want success

7:24

for ourselves as well. We all want to lead fulfilling careers

7:27

and in patient-centered care, what does

7:30

success for Radiologists look like

7:32

We should be a central part in the patient care

7:35

team when I was deciding what sub-special to

7:38

tea to go into one of the reasons that I chose Radiology was

7:41

because as much as I loved interacting with patients and and

7:44

performing a physical exam and and garnering the history,

7:47

it was really when I was down in the reading room that I

7:50

frequently was able to figure out what the diagnosis was

7:53

and Radiology is a central component of

7:56

that so we should be Central in the patient care team.

8:01

We should have confidence in practicing evidence-based medicine.

8:05

And ultimately this will lead to decreased burnout

8:08

and increased career satisfaction.

8:13

So ACR Imaging 3.0 program focused

8:16

on Radiology overall.

8:18

But what does patient-centered care look like

8:21

in breast Imaging?

8:24

And I'm going to focus on five main points here. The first

8:27

is access which is critically important.

8:31

followed by scheduling

8:34

communication

8:36

the multidisciplinary team approach

8:40

And finally future directions.

8:43

and first access

8:45

so you cannot discuss access and breast

8:48

Imaging without addressing the significant

8:51

Health disparities that currently exist in breast

8:54

screening.

8:57

There are increased breast cancer mortalities and

9:00

morbidities among racial and ethnic minorities.

9:04

Women from lower socioeconomic status and Rural

9:07

communities and amongst uninsured women.

9:11

African-American women are more likely to be diagnosed at

9:14

a younger age.

9:16

Be diagnosed at a later stage and our

9:19

41% more likely to die from their breast cancer.

9:25

So this study looked back at over 385,000 women

9:28

between 2015 and 2019.

9:33

And they looked back at screening exams to see who was getting to almost

9:36

synthesis and who was getting too deep digital

9:39

mammography.

9:40

And what they found were that African-American women compared to

9:43

women of other races were less likely to

9:46

receive two or more screening exams. And

9:49

we all know that mammography screen mammography

9:52

saves lives. What's also important

9:55

to note is that more consecutive exams further decreases that

9:58

mortality so consecutive exams

10:01

are

10:03

Extremely important in reducing mortality associated with

10:06

breast cancer in addition African-American

10:09

women were less likely to receive tomosynthesis and

10:12

we know that tomosynthesis can increase cancer

10:15

detection rates. It can increase

10:18

positive predictive values and it also can decrease recall

10:21

rates leading to less time away

10:24

from work less time away from child care. And so

10:27

this is really important. They also found that African-American women

10:31

Were more likely to be slightly older at

10:34

the time of that first screen. And if you

10:37

remember from the slide before African American

10:40

women are more likely to be diagnosed at a younger age. So this

10:43

is definitely problematic.

10:47

In order to increase access we have

10:50

to be aware of what current impediments

10:53

exist to screening mammography.

10:58

First is the perceived cost and so really

11:01

we have to educate patients about this.

11:04

Then there are the perceived harms and these are many, you know

11:07

patients are concerned about the radiation exposure concerned about

11:11

false positive results recalls from screening concerned about

11:14

the necessity for biopsy. And again,

11:17

this is where education really comes in. We

11:20

are the best equipped to educate our patients

11:23

and the providers about the

11:26

risks and benefits and that these harms are

11:29

really minimal compared to the benefits associated with screening mammography.

11:34

Lack of insurance is an impediment to screening a

11:37

huge one is the perceived confusion

11:40

within the healthcare Healthcare Community and

11:43

I would even say we should remove the word perceived because

11:46

there is confusion within the Healthcare Community. There are

11:49

three major screening guidelines

11:52

recommendations that exist the American College

11:55

of radiology and the Society of breast Imaging recommend that

11:58

all women should have a risk assessment by age 30 and then

12:01

average risk women should have annual screening mammography

12:04

starting at age 40

12:06

Several years ago the American Cancer Society changed

12:09

their recommendations saying that every woman should begin

12:12

getting screened at 45 and get annual screening

12:15

until 55 and then consider every other year after 55

12:18

and the 445. They should have the opportunity to

12:21

get screened if they desire and finally the

12:24

United States preventative Services Task Force recommend screening

12:27

every other year is starting at age 55. So

12:30

there is confusion within the Healthcare Community. So it makes

12:33

sense that our patients are confused as to what is the appropriate

12:36

recommendation.

12:39

Fear of diagnosis is a real real thing. You'll

12:42

see within your patients. You know, I think we've all seen patients

12:45

who will come in with a very large mass and when

12:48

they finally get in here they say yeah. I knew it

12:51

was happening. I was just too scared to come in. So we have to

12:54

recognize that this is something that our patient space

12:57

and finally challenges with accessing care, you

13:00

know, there can be Transportation issues time

13:03

away from childcare time away from work.

13:06

All of these things can be impediments to screening and

13:09

we need to be aware of them so that we can address them

13:12

and increased access

13:15

And we also should be aware of what the motivators are

13:18

for screening. Right what brings patients in and

13:21

the two things that have been shown to be motivators are recommendations

13:24

by Healthcare Providers. Again, this is where our

13:27

role is Educators come in to educate our referring

13:30

providers as to

13:33

the importance of screening mammograms and why we recommend what we recommend and

13:36

also reminder letters have been proven to be

13:39

effective as a motivator for screening.

13:44

So what is the role of the breast temperature I've

13:47

alluded to it before so you will

13:50

see it here education education education, you

13:53

know, we are the ones who are best equipped to

13:56

educate all of those around us about

13:59

the importance of screening mammography and breast

14:02

Imaging.

14:04

And so who do we educate we educate the referring providers?

14:07

You know, why do we recommend risk assessment starting

14:10

at age 30? Why do we recommend the

14:13

screening intervals that we do? Um,

14:16

you know, it's not just about mortality benefits about life

14:19

years gained, you know, one of the arguments about against screening

14:22

mammography, is that of overdiagnosis, but

14:25

if you think about it,

14:28

If you have a patient who's has a breast cancer at

14:31

44, no one is saying you shouldn't get screened. Right?

14:34

So the breast cancer is present at 44 you're gonna find it

14:37

if you start Imaging at 40 if you start Imaging at 45

14:40

years you start Imaging at 55 so over diagnosis

14:43

really shouldn't be a concern and the rates of

14:46

overdiagnosis are the least in those patients between 40

14:49

and 50.

14:51

So that should not be an issue with starting screening mammography

14:54

at age 40, but it's our role to educate others about

14:58

this in addition to educating a referring providers. We

15:01

have to educate our patients on these same topics

15:04

about screening intervals what they should be and why

15:07

we recommend them and about risk assessment.

15:12

And finally, we have to educate ourselves. We have to consistently educate

15:15

ourselves about the needs of the diverse population.

15:20

We have to constantly check in with our own unconscious biases.

15:25

And also be aware of patient perspectives, you know, our patients

15:28

have so much to teach us. We just have to be willing to listen to them.

15:34

So this study looked at how a breast Imaging campaign could

15:37

address screening access and the

15:40

goal was basically to increase mammography screening. And

15:43

so what did they do schedulers reached out

15:46

to patients to book exams?

15:49

Radiologists added appointment hours, which is really key and

15:52

a mobile mammography went out unit went

15:55

out into the community to increase access to screening

15:58

and following these initiatives what they found was that

16:01

there was a 39% yearly increase

16:04

in screening mammography and the monthly mammogram

16:07

orders increased year over year.

16:11

So there are interventions we can take that can really have a true

16:14

impact.

16:19

However, mobile mammography units are not the only thing that can

16:22

go out into communities. We can go out ourselves and

16:25

educate lay public audiences and a

16:28

study that looked back at Radiologists going out

16:31

into the community regarding cancer screening Imaging.

16:34

So this was not just breast cancer this involved Imaging screening

16:37

regarding breast cancer prostate cancer

16:40

and colon cancer found that 95% of

16:43

participants demonstrated an increased

16:46

understanding

16:48

importantly 86% felt more involved with

16:51

their care

16:52

and 87% felt more prepared to

16:55

undergo the screening test. So again, this reiterates that

16:58

you're more likely to follow a recommendation if

17:01

you understand the rationale behind it.

17:05

There are some key points to remember education is

17:08

really key to increasing access. Ask breast

17:11

images. We are the best equipped to

17:14

address screening mammography.

17:17

And it's really important to remember to use plain

17:20

language a 2015 study.

17:24

Looked at all of the available internet-based patient education

17:27

materials and found that 0%

17:31

None were written at or below the sixth

17:34

grade level which is what is recommended by the US Department of

17:37

Health and Human Services. So this is so important to

17:40

remember in our printed materials and our conversations with patients

17:43

and in our online materials.

17:50

Okay.

17:50

So we've convinced everyone they need to come in. We need

17:53

to make scheduling.

17:55

As easy as possible for our patients

17:58

and how do we do this? So we should have a variety of tools

18:01

available to schedule appointments.

18:04

Open Access scheduling which is scheduling via a

18:07

patient-piece portal or an application

18:10

or or the internet.

18:13

Allows patients to log on themselves and schedule at a time.

18:16

That is a appropriate for them.

18:19

Not only does this improve operational efficiency because

18:22

you don't have as many people manning the phones and having to to

18:25

schedule live. It also has been

18:28

shown to decrease patient wait times.

18:31

But we also have to recognize that not all patients are comfortable with

18:34

these interfaces. So we need to help Alternatives available

18:37

such as the phone which many patients

18:40

are more comfortable with and also the old-fashioned way

18:43

of just making the next appointment at the time you check out of your current appointment. So

18:46

when patients come in for their screening and they're on their way out having

18:49

the opportunity for them to book the following Year's exam

18:52

at that time.

18:55

Having expanded hours is extremely important,

18:58

you know.

19:01

Coming in for an appointment requires time away

19:04

from work time away from child care. And so having a variety

19:07

of times available for

19:10

our patients is highly valuable and can

19:13

increase access and so pre-pandemic at

19:16

our practice. We actually instituted a shift

19:19

that went from noon until 8 pm.

19:22

And this enabled patients to come in after work hours and

19:25

I will say from the radiologist perspective when we first

19:28

heard that it was rolling out. None of us were thrilled but

19:31

when it actually was implemented we ended up doing it

19:34

maybe once every two or three weeks and it actually was quite nice

19:37

to have the morning where we could make our own appointments and

19:40

then serve patients later on. So it was

19:43

mutually beneficial for the patients and for ourselves. I'm

19:46

having weekend hours to do screens and

19:49

also Diagnostics when possible helps to

19:52

increase access and gives more variety of

19:55

options for our patients.

19:58

Reducing patient wait times is

20:01

also imperative. And so what does that mean? That means

20:04

when a patient calls in for their screening exam, you don't want to have to

20:07

have them wait for eight months. And honestly, this has been a little bit of

20:10

an issue since the pandemic because there was a backlog of

20:13

cases but it's something to be conscious of and

20:16

to strive towards reducing patiently times

20:19

and we should be conscious of what they are at any given time

20:22

in our practice. We also really want to minimize time

20:25

between when a patient gets recalled from a screening

20:28

exam and they come in for their Diagnostic Imaging.

20:31

His patients are very anxious knowing that

20:34

they have to come back in and minimizing that

20:37

wait time. It is greatly impactful.

20:40

And finally, we want to decrease the amount of time that they

20:43

spend in our office.

20:46

Patients perceived wait time while in the office has a

20:49

great impact on their perception of the

20:52

care that they received. There are also some things that

20:55

we can do while they're in our practice.

20:57

Having available Wi-Fi is really beneficial pre-pandemic

21:00

having food or

21:03

drinks available was greatly

21:06

appreciated and in our practice, we actually have these little coloring

21:09

books with colored pencils that patients can sit

21:12

and use while they're waiting to help pass the time.

21:17

So talking about scheduling.

21:20

This study looked back at racial disparities in diagnostic

21:23

delay among women who were diagnosed with

21:26

breast cancer and they looked back at 730 women

21:29

who were diagnosed with a screen detected cancer and

21:32

measured delays. They looked at the time between

21:35

the screening and diagnostic exams

21:38

between the times between the diagnostic exam

21:41

to biopsy and overall the

21:44

total delay.

21:45

And what they found was is that the total delay was

21:48

greater in black women at 42 days compared to 26 days

21:51

in white women. They also found longer delays

21:54

in women residing in lower Associated socio-economic neighborhoods.

21:59

and an uninsured women

22:03

and really important to note here is that women who experienced total

22:06

delay of greater than 45 days had a

22:09

1.6 gold increased odds of

22:12

breast cancer mortality. So it really is important

22:15

to get our patients in as quickly

22:18

as possible.

22:21

Okay, so moving on to the third point which is

22:24

communication and I tried to order this in a way

22:27

that made sense that the flow made sense. But if I had to pick one item

22:30

here that was of the utmost

22:33

importance. It's communication because without effective communication

22:36

nothing else really comes together.

22:41

So we all know communication is a really key component of breast

22:44

Imaging 93% of breast

22:47

imagers report communicating abnormal Diagnostic Imaging

22:50

results. I think we can all recognize

22:53

that breast Imaging is really at

22:56

the Forefront of

22:59

patient facing Radiology subspecialties

23:03

effective communication has

23:05

impact on

23:06

our experience when they're here with us.

23:08

It can impact pain and anxiety experienced at

23:11

the time of biopsy.

23:14

And importantly effective communication can really lead to improved patient

23:17

outcomes.

23:20

Additionally effective communication is associated with

23:23

decreased malpractice claims.

23:28

Patient provider communication may

23:31

be the strongest modifiable factor in screen.

23:34

Adherence. Remember when we talked about motivators for screening provider

23:37

recommendations was was one of the two that

23:40

fell into that category.

23:43

And greater adherence to screening recommendations is dependent

23:46

on provider enthusiasm and encouragement. We

23:49

have to address patient barriers be

23:52

aware of them and address patient barriers and again thorough explanation

23:55

of techniques when patients understand the

23:58

rationale, they're more likely to follow our recommendations.

24:05

In addition there are benefits to Radiologists.

24:08

Through effective communication. So burnout

24:11

is characterized by combination of exhaustion depersonalization

24:14

feeling a lack

24:17

of connection and also feeling a lack of accomplishment.

24:21

Burnout is prevalent amongst Radiologists within

24:24

the United States.

24:26

A 2015 study demonstrated that radiology was

24:29

among the top five Medical Specialties experiencing burnout.

24:34

A 2020 study that was done before the

24:37

pandemic demonstrated that 79% of academic Radiologists

24:40

were experiencing at least one symptom of

24:43

burnout.

24:45

And a 2001 2021 study that

24:48

specifically looked at breast imagers and the

24:51

impact of the pandemic on breast imagers found

24:54

that 68% were experiencing anxiety.

24:58

And the level of distress was noted to be higher among

25:01

younger respondents.

25:04

females

25:05

those with greater Child Care needs and those with

25:08

greater Financial loss.

25:12

There is hope though direct relationship. There's a

25:15

direct relationship between the ability to build rapport

25:18

with our patients and job satisfaction and as

25:21

breast images, we really do have the ability to

25:24

build rapport with our patients and effective communication is

25:27

a key component of that.

25:31

The acgme recognized the importance

25:34

of communication and introduced it as a core competency

25:37

in 2012.

25:40

And despite the fact that 93% of

25:43

breast images.

25:45

State that they convey abnormal Diagnostic Imaging results to

25:48

our patients.

25:49

62% were still willing to undergo

25:52

further communication training. I think we recognized the

25:55

importance of communication in our interactions with

25:58

our patients and with the members of

26:01

the multidisciplinary team.

26:04

And in 2021 the updated breast Imaging

26:07

Fellowship curriculum listed proficiency and

26:10

communicating with patients as the first item under non-interpretive

26:13

factors.

26:18

So critical components of communication is

26:21

the capacity to listen.

26:25

And this includes eliciting feedback from our patients in

26:28

our practice. When we do

26:31

Diagnostic Imaging the patients come into our office the

26:34

office that I'm sitting in right now and they have a discussion with

26:37

us. They get dressed after their exam and they and they come in and we give

26:41

them the findings and we have time to discuss and frequently the

26:45

patients will give me feedback and I thank

26:48

them for you know, it's really valuable. Sometimes they give positive

26:51

feedback. I had a patient this morning who said she was just so happy with

26:54

the care and everyone was so nice to her and we also have negative

26:57

feedback sometimes and that negative feedback is really

27:00

important because it gives us the perspective of patient that we

27:03

might not be seeing and that is really highly valuable

27:06

and allows us to adjust our practice in a

27:09

way that can change the experience for our

27:12

patients. And so whenever a patient comes in and gives me negative feedback.

27:15

I listen to them. I thank them I email the

27:18

practice manager.

27:19

We have 18 breast imagers here. So, you know,

27:22

I'm only getting a small fraction of the patient experience. But if I

27:25

send it to our practice manager and we all do that, then she

27:28

Garners like the full picture and we can enact changes

27:31

based on the feedback that we're getting

27:34

from our patients in addition our practice

27:37

and many practices send out post exam

27:40

surveys to our patients and there's a list

27:43

of questions many of which are on a likert scale but we

27:46

also have free text opportunities on there so that we

27:49

can really get detailed information

27:52

on the patient's experience and again enact

27:55

changes in our practice based on the feedback. We're

27:58

getting from our patients and this is just a diagram showing, you

28:01

know, overall satisfaction throughout the years and I

28:04

think it's interesting to see this drop here was during the year of

28:07

the pandemic this or the height of the pandemic. This was 2020 and we're

28:10

heading in the right direction coming back from that.

28:14

I am not even going to attempt to

28:17

give a communication lecture here. There's no way

28:20

I could do that in the given time that we have but there

28:23

are certain components that are really important in communication.

28:26

It's important to greet the patient by the

28:29

name, you know, our nonverbal communication is definitely limited

28:32

by the necessity to wear masks in the

28:35

office. But I hope that if I smile they can still see some

28:38

smile lines forming around my eyes and and see the

28:41

changes in the eyes. It's important to make eye contact to

28:44

clearly introduce ourselves and say what our role is if we

28:47

happen to be working with trainees to introduce the

28:50

trainees as well and their role and

28:53

to give an accurate expectation of

28:56

any future testing or exams if we're

28:59

recommending them if we're recommending a biopsy to

29:02

clearly explain what they can expect how long they're gonna be in

29:05

the office what the procedure entails when they

29:08

can expect their biopsy results how they will expect the brides to

29:11

result, you know, giving as much detail as possible is really

29:14

Helpful for patients to know what to expect

29:17

and at the end of every encounter.

29:21

I encourage questions and I actually attended a

29:24

communication course several years ago, and there was one

29:27

Pearl that I took away I used to say to patients at the

29:30

end of our encounters. Do you have any questions?

29:33

And I got this tip in this Communications course that instead

29:36

of saying that what I say now is what questions

29:39

can I answer for you and it's a really subtle change

29:42

that I think that it leaves it

29:45

a little bit more open-ended for patients to take a

29:48

second to pause and to think they really do have any questions.

29:56

Okay, moving on to the multidisciplinary

29:59

team approach which is a huge

30:02

component in patient-centered care.

30:07

Radiology is frequently the entry point for patients with newly diagnosed

30:10

cancer. They come in for a screen. They then

30:13

come in for a diagnostic mammogram Diagnostic

30:16

Imaging we recommend the biopsy and

30:19

many times. We are

30:22

the ones who perform the biopsies and who get that diagnosis

30:25

for them. And so we have to recognize this role

30:28

and take it. Seriously. We have the capacity to

30:31

initiate that multi-disciplinary team for the

30:34

patients.

30:35

When possible having a centralized physical

30:38

location for all members of that

30:41

multidisciplinary team is very helpful.

30:45

for us our medical oncologist

30:48

radiation oncologists

30:51

oncologic surgeons plastic surgeons are all located

30:54

on one floor. So patients can move from

30:57

one office to the next throughout the day and I

31:00

really think that facilitates a positive patient

31:03

experience.

31:05

Also patient Navigators are extremely important.

31:09

They've been shunned to improve screening rates.

31:12

To decrease time to follow up. So decreasing those

31:15

delays that can really have an impact on patient outcomes.

31:19

And decrease loss to follow up.

31:22

when we

31:24

Perform a biopsy and it yields a

31:27

cancer diagnosis. We email and nurse navigator

31:30

from the surgical team. They then

31:33

reach out to the patient directly and help

31:36

them integrate their care moving forward and

31:39

I think for patients with a new cancer diagnosis. This is

31:42

really helpful, you know, a lot of the anxieties

31:45

is not knowing where to go next and

31:48

having someone guide them through this process of

31:51

you know, you can see this person at this time and and help them

31:54

take the next steps. I really think can be very helpful and kind

31:57

of alleviate some of the anxiety that comes along with

32:00

that diagnosis.

32:02

Multidisciplinary conferences

32:05

are imperative. You should

32:08

involve all members of The Care team and I've listed some

32:11

here. This is definitely not a comprehensive list, but it

32:14

can include Radiologists.

32:16

Pathologists surgeons that includes breast

32:19

surgeons and plastic surgeons medical oncologists

32:22

radiation oncologists psychiatrists and

32:26

mental health professionals geneticists members

32:29

from OBGYN and fertility

32:32

preservation, you know for our younger patients who want to

32:35

preserve fertility. It's really important to have this

32:38

option available for them.

32:41

And multiclinary conferences have a true

32:44

impact. They've been reported to change the management and

32:47

up to 36% of patients. It's really

32:50

part of that collaborative care that we discuss

32:53

with patient-centered.

32:56

care

32:58

And finally future directions and you know when I

33:01

was choosing to go into Radiology one of the things that really excited me was

33:04

that we were always going to have the potential to learn new

33:07

technology and they were always going to be new opportunities

33:10

to look into new technology and new tools

33:13

to use to image patients and what I didn't recognize

33:16

and that I really come to value in recent

33:19

years is that it's not only the technology that's continuously

33:22

evolving with Radiology. It's the

33:25

care that we take of patients and so a lot

33:28

of future directions involved improving patient care,

33:31

and I think that's a really exciting area.

33:37

So here at Cornell, we have a radiology consultation service

33:40

called. Why care while Cornell

33:43

Imaging consultation and radiologic expertise. It

33:46

was really established to promote patient-centered

33:49

care and shared decision

33:52

making

33:53

It was originally established in 2013 and

33:56

this coincided with when

33:59

dense breast notifications had to pure

34:02

and lay letters here in New York. And at

34:05

that time we anticipated that patients would get this new information

34:08

in their layers and not really know what to

34:11

do with it.

34:13

So starting in March of 2013 at the

34:16

end of all of the lay letters we included included this paragraph

34:19

that said we encourage you to speak with your physician concerning additional

34:22

options available for you. If you

34:25

still have questions our Radiologists are available to

34:28

discuss dense breast Imaging considerations and

34:31

to speak with someone. We put the phone number here and I'm

34:34

going to draw your attention to what we said back then

34:37

which was speak to your physician. And if

34:40

you still have questions, then we can speak to you because we have evolved

34:43

since 2013.

34:46

And so then they look back at what happened in

34:49

the first year of this service. So

34:52

again in March of 2013, we

34:55

started putting this paragraph at the

34:58

end of our lay letters in that first year. There were

35:01

over 7,000 women who received the dense breast

35:04

notification and 152 consultations

35:07

were performed 150 of

35:10

those were patient initiated and to

35:13

were referring provider initiated.

35:17

And all of these consultations were performed by a

35:20

registered radiology assistant or one of

35:23

our 13 breast images at the time.

35:26

of the consultations that were performed 91 were

35:30

performed for women with dense breast tissue and nine percent

35:33

were for women with general questions about breast

35:36

density or general questions about breast Imaging

35:42

out of these consultations the great majority 150

35:45

out of 152 prefer to

35:48

phone consultation again, this was

35:50

Pre-video consultations pre-video

35:53

visits and so the majority preferred to

35:56

just have a phone conversation.

35:59

And the great majority of these consultations were performed by the

36:02

registered radiology assistant. The meantime

36:06

of consultation for the Radiologists was relatively brief

36:09

five minutes interestingly for our ra

36:12

it was much longer over 30 minutes.

36:18

And we wanted to assess you know, how did patients

36:21

respond to this was this helpful for them? And so we asked four questions

36:24

at the end and it was do you feel sure about

36:27

the best choice for you? Are you clear about

36:30

which benefits and risks matter most to you? Do you

36:33

know the benefits and risks of each option and finally, do you

36:36

have enough support and advice to make a choice? And

36:39

I think that if you're looking at you know, which of these

36:42

were really trying most to accomplish with this service. I think

36:45

number four was was of the

36:48

four the most important and 78% felt that

36:51

the answer was yes to this question.

36:54

For the other three questions the positive response

36:57

rate ranged from about 70 to 76

37:00

percent and I think that in some ways this might represent

37:03

the confusion. We were all feeling at this time. You know, what should

37:06

we recommend to our patients know that they're getting this dense breast notification.

37:09

I think we've reached some more clarity at this

37:12

point. So I'd like to think that if we if we distributed the survey

37:15

at this point, we would have even higher positive response

37:18

rates.

37:20

So this consultation service has continued on patients

37:23

still get a statement at the end of their

37:26

reports, and we wanted to

37:29

see you know, what was the utilization of this consultation service

37:32

during the initial phase of the covid-19 pandemic?

37:37

And so basically initially we looked back from the first

37:40

six months of 2020 compared to the

37:43

first six months of 2019.

37:47

And what we found was that the consultations did increase in

37:50

the first half of 2020 compared to 2019. I

37:53

think what's also interesting to note is that if you remember

37:56

in that first year from 2013 to 2014 and one year,

37:59

we had 152 consultations. This looks

38:02

at half of a year at six months and we had over

38:05

1,600 consultations. So

38:08

the consultation service definitely has grown over time.

38:12

And then we further rope down the time period to

38:15

between March and June because beginning

38:18

in March, we stopped performing all screening mammograms

38:21

and we were continuing to perform diagnostic mammograms

38:24

predominantly in symptomatic patients.

38:27

And so we wanted to you know look back at this

38:30

time period when a lot of patients were not coming in what was

38:33

the utilization of the service and what

38:36

we found was is that in this period during 2020 compared

38:39

to 2019. There was a 16.5% increase

38:42

in utilization of the consultation service

38:45

and I think it's also important to remember that

38:48

Diagnostic Imaging studies a lot of you know Radiology volume

38:51

plummeted, but this consultation service

38:54

still had a lot of value for our

38:57

patients and 37% of these consultations addressed

39:00

code related concerns.

39:07

So moving on to the 21st century cures

39:10

act remember a huge aspect of patient-centered

39:13

care is direct access to reports

39:16

and information. So this act requires

39:19

no delay in access to clinical

39:22

information and that includes our Radiology reports.

39:25

It was implemented in 2000 April 2021. It

39:28

was originally supposed to be implemented a little bit earlier, but it

39:31

was delayed because of the pandemic.

39:33

Um, and before this time many locations

39:36

had a built-in delay and release of the Radiology

39:39

reports in 2021 study reported

39:42

that 42% respondents had

39:45

a delay of four days or longer before the Radiology

39:48

reports were released into the patient portal.

39:52

And over half sent them to the referring provider first and

39:55

the rationale behind this was allow the referring provider time to

39:58

review the results before the patient has access to

40:01

it.

40:03

Another study looked back at patient

40:06

and physician preferences again. This was before the Act was

40:09

implemented and this single institution surveyed

40:12

patients in the Outpatient Center setting and

40:15

also referring Physicians and they basically looked and

40:18

said what do patients and Physicians want as far as

40:21

report release.

40:23

And when looking at patient preferences when patients were told that

40:26

their results could be normal or abnormal. They 82%

40:29

wanted results by the

40:32

Radiologists the same day.

40:34

However, if they were told they were going to have abnormal results

40:37

that number went down but still 58% did

40:40

not want to wait to see the report even

40:43

if they knew the results were going to be abnormal.

40:48

This was in contrast to position preferences.

40:51

So 64% of Physicians did not

40:54

want a discussion directly with the patient and one of

40:57

the reports sent to the office.

40:59

And 88% did not want to report sent directly to the

41:02

patient.

41:04

Well, the ship has sailed on that patients are now getting their reports

41:07

basically immediately if they are accessing their patient

41:10

portal.

41:11

And so, you know,

41:14

there are definitely challenges associated with this patients

41:17

have increased anxiety. And in

41:20

my practice what I've seen as patients are really anxious when they get

41:23

the recall screening report to their patient

41:26

portal when they come in for their Diagnostic and I actually have the discussion

41:29

with them several patients has said to me, you know, can I give you

41:32

some feedback it really is very scary getting that

41:35

report in your patient portal. You see the work Distortion you Google Distortion.

41:38

It says, you know, it almost certainly is cancer. They have

41:41

a difficulty interpreting the reports. They don't know what to do with

41:44

that knowledge and then they have to wait because a recalls, you

41:47

know, just identifying a potential issue then they have to come in for the

41:50

diagnostic imaging and I think that does result in

41:53

a lot of anxiety for the patients.

41:56

And this honestly puts a lot of burden on the referring providers

41:59

because most of our patients have a more direct

42:02

relationship with the referring provider. So they're more likely

42:05

to reset reach out to them as opposed to reaching out

42:08

to us.

42:10

However, there are also some benefits that

42:13

can be associated with immediate report release. I think

42:16

it places an impetus for clear and

42:19

concise reports.

42:21

You know, we all have our buy Red's lexicon which assists with keeping

42:24

us organized and some have proposed putting

42:27

in a lay paragraph at the end of

42:30

our reports to make it more understandable for

42:33

our patients.

42:36

one of the

42:38

most common causes for malpractice in

42:41

Radiology is delayed reporting

42:44

of abnormal results. And so with

42:47

this immediate report release there is decreased medical

42:50

legal risk. We also Garner greater

42:53

trust with our patients. They know exactly what we're saying, right? They

42:56

see exactly what we're saying in the reports. So they know

42:59

that we're not hiding for them. And then there is the opportunity for more

43:02

patient Radiologists interaction. They're seeing

43:05

our names on the reports. They know how to reach out to us directly.

43:08

And so we have changed the verbiage at

43:11

the end of our reports since 2013. And now

43:14

what our Reports say is our Imaging experts are

43:17

available to speak with patients and medical practitioners who

43:20

have questions regarding breast Radiology exams and

43:23

results and to schedule a consultation. Please contact us contact

43:26

us at this number or at this email address. So again,

43:29

we want to give options about which Patients Preferred

43:32

to reach out to us, but also there's been

43:35

a real shift and if you remember in 2013, we said

43:38

speak to your provider and then if you want to you can come

43:41

to us, but now we say, you know, we're available to

43:44

speak to patients and medical practitioners. So everyone can come directly to

43:47

us. We are more.

43:50

Forward facing we want to have the opportunity to speak with our

43:53

patients and medical practitioners.

43:57

Okay, so shifting gears a little bit here. You know,

44:00

I think that when we talk about Radiology artificial intelligence

44:03

is definitely top of mind a lot

44:06

of times and I think the true clinical impact is still to

44:09

be determined but it almost certainly involves breast

44:12

Imaging.

44:14

In one way or another and likely, you know,

44:17

if this frees up some of our time will be able to rededicate our

44:21

time to more of these high value patient interactions.

44:28

So this was a study that came out of Boston and I

44:31

think that you know, one of the Silver Linings

44:34

from the pandemic is that we realized that virtual visits

44:37

definitely have utility.

44:40

And benefit for our patients.

44:42

There's definitely increased convenience. It requires less

44:45

time away from the office time away from other obligations. No transportation

44:48

is required and there is

44:51

this opportunity to review Imaging reports and

44:54

imaging images with

44:57

our patients directly.

44:59

So what they did was they basically patients

45:02

were in the office with their primary care

45:05

physician and they were able to review images and

45:08

and discuss the results

45:11

over 10 minute period of time the visits

45:14

were limited to 10 10 minutes and it was

45:17

mostly abdominal and Neuro Imaging reports that

45:20

they reviewed but then they looked back at both patient and

45:23

provider satisfaction and what they found was that

45:26

91% would like to have the consultation again, so it

45:29

was definitely valuable 88% demonstrated improved understanding

45:32

of their condition.

45:34

And 92% reported an improved patient care

45:37

experience and that's the goal. Right? We're trying to improve patient-centered

45:40

care. So I think that this does have

45:43

the potential for really high value in the future.

45:46

The same group looked back and and basically looked and

45:49

saw what happens if we do synchronous visits, you know, if we have the patient

45:52

is remote and the referring physician is remote

45:55

and the radiologist is remote and they were able to carry on

45:58

the exams this way as well, but they did

46:01

note that they had some difficulty with recruitment.

46:06

So here we started a breast Imaging

46:09

virtual visit visit service and

46:12

you know, it's a little bit different in breast Imaging and

46:15

that we discussed diagnostic results with our

46:18

patients live. So they're here and they get the results live and

46:21

also a lot of times screening patients

46:24

are like if my exam is negative great. That's wonderful.

46:27

I don't need to discuss it. I'll see you next year but there

46:30

are some patients who could benefit from this. I think that

46:33

you know some patients with Diagnostic Imaging again, when

46:36

they're in the office, they're very nervous. It's hard to process the

46:39

information. Sometimes they could benefit from where you reviewing

46:42

the images.

46:43

For patients who we recommend biopsy for same thing.

46:46

A lot of times they could want to review the images and for

46:49

those patients who get a cancer diagnosis. They might want to review the

46:52

images. Once they know what the biopsy has yielded.

46:55

In in addition patients who have breast MRI

46:58

do not have the opportunity to discuss the results

47:01

live with us. They get their exam when we read it on a

47:04

little bit of a delay. So they might benefit from having

47:07

these videos visits and finally, you

47:10

know, we get a lot of interpretation of

47:13

outside films and when patients come

47:16

in from an outside Center and occasionally, we recommend additional Imaging

47:19

and sometimes patients might want to review that as well. So I

47:22

do think that there is some utility for the

47:25

potential of video visits with our patients, but

47:28

I will tell you that we started the service

47:31

and and we also have had difficulty with recruitment. So

47:34

we are going to start hanging these flyers

47:37

and see if it's helpful and see if the patients think it

47:40

would be a value.

47:43

So going back to the original just objectives. The

47:46

goal was to clearly Define patient-centered care.

47:49

And again, it's multifaceted. There's

47:52

not just one line item definition. It involves

47:55

many different aspects and focusing on the patient as a

47:58

whole person focusing on

48:01

the patient experience experience and the value of

48:04

the care that we are providing to them.

48:07

What is patient-centered care and breast Imaging look like

48:10

education education education. We

48:13

really need to educate our patients and our

48:16

providers and ourselves consistently and constantly work

48:19

on it.

48:20

Effective communication with the patient and their support

48:23

system and remember that we are very frequently the

48:26

ones who initiate that multi-disciplinary care team.

48:29

And finally possible future directions, you

48:32

know, we consistently have to search for novel and

48:35

innovative ways to care for and connect with

48:38

our patients. And I think that this is going to be a huge area of growth

48:41

within radiology and within breast Imaging

48:46

So in conclusion, we have to continue to

48:49

educate our referring providers ourselves and

48:52

our patients in order to improve access as perimeters

48:55

were uniquely positioned to provide high

48:58

quality patient-centered care. It's really a privilege that

49:01

we have.

49:02

Patient feedback is one of the greatest available resources for enhancing

49:05

patient-centered care.

49:07

We serve as the entry point for the multidisciplinary care

49:10

team and it's a privilege that we're fortunate to have our

49:13

rules will likely evolve in the future and it's

49:16

something that we should be open to.

49:18

And it's important to continue to create novel ways to

49:21

create high value care for our patients.

49:25

These are my references and this is

49:28

my email address. Please feel free to reach out

49:31

at any point.

49:34

Okay.

49:36

So now I am going to go into the Q&A.

49:46

So one of the questions is how is it

49:49

practical to implement this on a very busy Clinic with

49:52

a lot of patients and I hear you.

49:55

I think that a lot of us are feeling very short

49:58

staffed right now feeling stretched very thin and I

50:01

think the answer is is we do the best

50:04

we can we have compassion for our patients. We

50:07

try to put ourselves in their shoes. And and

50:10

we do the best we can to support them. What

50:13

are some do's and don'ts for the

50:16

mammographer or the radiology technician who is taking the image if

50:19

you could clarify

50:22

That question that would

50:25

be great. Just so I know

50:28

exactly what you're referring to.

50:31

How does one become a registered radiologist assistant? This

50:34

is a really good question. There is a program here in

50:37

the United States that are radiologist assistants

50:40

go through and I don't

50:43

know the details but it is a specific program for them.

50:46

And why was the RAS consultation so

50:49

much longer? So this is a really good question and I thought

50:52

about this as well. So I think that

50:56

Many times the rra did the

50:59

initial consultation with a patient and sometimes

51:02

the patients wanted to speak to the radiologist. So the ra

51:05

would go through and discuss all of the important points with the

51:08

patient. And basically when we came and we would just kind of wrap everything

51:11

up and answer any outline questions that had not yet

51:14

been addressed. So I think that that enabled us

51:17

to have shorter shorter consultations.

51:24

Did we get the percentage of minorities that requested

51:27

the service? You know what I honestly am not

51:30

sure if we did but if you email me

51:33

I will I will get

51:36

you that information if we did keep track of it and I'm happy. I'm happy to get back

51:39

to you and the consultations are not charged. This is

51:42

something that we do to provide a service to our patients and it

51:45

is not charged.

51:50

This is a great question does our

51:53

resident training.

51:58

Also need to adapt to our role in patient-centered care and

52:01

I think the answer is yes. I think that you know patient-centered care.

52:04

Like I said initially it's a cultural shift.

52:07

I think that it's a shift

52:10

in medicine. I think that honestly the pandemic

52:13

had an effect all all of these things have

52:16

enabled us to have more compassion for not only

52:19

our patients but for everyone else around us, so I think

52:22

that educating our residents about

52:25

patient-centered care is really important and

52:28

I I think that we should all try to do this and you

52:32

know, if we incorporate it into our

52:35

practices, which I think many of us are doing then the

52:38

residents will I think appreciate that as well.

52:42

And then the final question here is what you

52:45

advise for community-based.

52:47

cancer screening program

52:50

tomosynthesis and sonography versus fulfilled digital

52:53

mammography and sonography, you

52:56

know the American College

52:59

of radiology the last time I checked so I should

53:02

double check. This is that they said they don't you know,

53:05

they said Thomas what this is can be a useful adjunct.

53:09

But they don't come out quite yet and fully recommend it and

53:12

I think that really what we should do is the best we can

53:15

right. I think that we should serve our patients

53:18

the best we can we at this practice.

53:21

We are not a community-based practice for a large academic center, but

53:24

we performed almost synthesis on all screening

53:27

exams unless the patient declines and we

53:30

leave ultrasound up to the referring provider.

53:34

you know, if you're looking at additional cancer

53:37

yields screening breast MRI is going

53:40

to detect a lot more additional cancers and women with dense breasts than

53:43

ultrasound is but that comes with an increased cost and intravenous

53:46

contrast and you know,

53:49

they all come with

53:53

their own

53:56

Issues that you have to deal with it, and so I think that you know, we do the best

53:59

that we can for our patients.

54:03

With what resources that we have.

54:06

And then there's a question any thoughts on how to

54:09

get younger staff interested in mammography and

54:12

breast Imaging in general.

54:16

As many technologists are retiring and I

54:19

think this is such an important question. I

54:22

completely agree. I think

54:25

you know we are

54:28

really feeling the challenge of some of

54:31

the workforce retiring and I think

54:34

The only answer I have is really what I addressed here

54:37

is that we really do have a privilege

54:41

to have these interactions with these patients and

54:44

to serve these patients and I think you know recognizing.

54:49

This privilege and and communicating it with everyone and

54:52

reinforcing. You know, the joy that we can get

54:55

from serving these patients in positive patient interactions and

54:58

the

55:02

The sense of satisfaction that comes from helping these patients really can

55:05

excite the younger generation and

55:08

I think it falls on us to to encourage pursuing breast

55:12

Imaging and mammography and and to communicate and

55:15

educate on the benefits.

55:18

And so again in low resource settings, which I

55:21

think a lot of people are feeling right now with few

55:24

Radiologists and a high workload. How can this

55:27

really be possible? And again, I'm going to reinforce what

55:30

I said before. I think that we do the

55:33

best we can um in whatever

55:36

circumstance that we're in and I think that's really, you know, all that

55:39

we can be asked to do and remembering that you know

55:42

patients are concerned and remembering the patient's perspective

55:45

and just having compassion. I

55:48

I think you know that really

55:51

goes a long way and all of our interactions with

55:54

our patients.

55:56

All right. I think you answered all of those questions. Thank you

55:59

so much for your time, and that was a great talk. I learned

56:02

a lot and thanks to all for your participation in our

56:05

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