Sunday, July 8, 2012

Do We Know What We're (not) Talking About?

The Gist:   Communicating with patients can be tough, particularly with regard to the risks and benefits of medical imaging.  Feel uncomfortable discussing risks of ionizing radiation with patients? You're not alone, especially since uncertainty abounds; however, you can educate yourself by listening to SMART EM's CT Consent podcast and your patients using these bedside aids - card from Academic Life in EM and this awesome radiation risk calculator!

Providers often don't discuss medical treatment or testing with patients in a meaningful way.  According to the study referenced below, Emergency Physicians could be leaders in this field, with regard to medical imaging.

The paper:  Patient and Health Care Provider Discussions About the Risks of Medical Imaging: Not Ready for Prime Time  Stickrath C, Druck J, Hensley N, Maddox T, Richlie R. Arch Intern Med. 2012;():1-2. doi:10.1001/archinternmed.2012.1791

  • E-mail questionnaire to providers (4th year medical students, residents, attendings) at public university
  • Low response rate (41%) to get n=348 (not all surveys returned were complete so some of the numbers for individual variables were <348)
  • Most respondents (71%) reported discussing radiation risk of imaging with patients less than 1/4 of the time.
  • EM residents and 4th year medical students only group that at least half of respondents reported discussing radiation risk with patients at least half the time. n=40 medical students and 33 residents, so a small sampling.
  • Over half of respondents reported never mentioning the possibility of incidental findings on scans
  • Only 27% (81 of 300) of providers felt comfortable educating patients on the risk of ionizing radiation from imaging 
What's the deal?
  • Providers are limited by time and extremely variable degrees of health literacy in the patient population.  In EM, critically ill patients, including trauma patients, may not be responsive (able to participate in the conversation) and may not have the critical time for discussion.  Consider engaging the high risk medical patients, those with renal colic, chronic abdominal pain, etc, in conversations regarding the risk of imaging.
  • The lack of provider comfortableness in discussing risks of ionizing patients is something that can be easily changed through education and practice.  A balance exists in which one seeks to inform the patient and reduce potential harms without scaring the patient out of necessary imaging.  
  • The information stemming from this article mostly revolves around radiation, but there are certainly other issues with imaging such as: 
    • Contrast induced nephropathy (CIN). For more on this, check out the CT consent podcast from SMART EM and this super quick segment on Keeping Up With EM from Vanderbilt. Basically, CIN is caused by renal vasocontriction and tubular injury and has a reported variable incidence from 0-50%.  Risk factors include: renal insufficiency (Cr >1.5), diabetic nephropathy, reduced renal perfusion  (heart failure, hypovolemia, etc), PCI, lots of contrast (1).
    • Incidental findings.  These can cause problems in two ways.  First, it's easy to get lured into thinking that a finding on a scan is the cause of a patient's ailment or, alternatively, that a clean scan means that there's no organic cause for the ailment.  This may cause one to miss the actual problem.  Secondly, patients may become excessively concerned over anatomic variants picked up on a scan.  I will never forget a patient, status-post MVC with surgery to fix multiple fractures, clutching a CT report, frightened about the cyst (physiologic) on her kidney. 
I want to be able to initiate these conversations with patients.  Me too, that's why there are more resources on how to educate oneself for these conversations (and some links to bedside aids) here
1.  Rudnick M, Tumlin J.  Pathogenesis, clinical features, and diagnosis of contrast-induced nephropathy.  UpToDate.  May 2012

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