Table 3.

Influencers of Patient Outcomes in Imaging Testing Settings and Exemplary Excerpts

Patient-provider communication
“It's really driven by the time that you have. Most of the patient encounters are now 15 minutes, some only 10 minutes. You want to discuss the most important things, and while often there isn't any more time available to go into any more depth, and sometimes I feel that it's appropriate, because sometimes patients get lost in the depth, and then they may not focus on the bigger picture… My personal goal is to make the best use of the time that I'm given. I'm not into should I get 20 minutes, or not get 20 minutes. My goal is to try to give them as much information as possible at a level they can understand in the time that's allotted.”–PCP 03
“It's hard because there are so many different kinds of imaging. For example, sometimes little cysts are found in the kidneys, or on an ultrasound, sometimes a small cyst is found that's thought not to be clinically significant. Because there's so many little things that can be found that may or may not be significant, it's a little difficult to discuss those possibilities before you actually do the test.”–PCP 04
“They [imaging tests] can create a lot of anxiety and sometimes my own clinical decision-making process at that point depends to some extent on my personal comfort with ambiguity and the patient's comfort with ambiguity. If I'm comfortable with it and the patient's comfortable with it, then it's something that we can wait, maybe do follow-up study a few months down the line, or whatever. If I'm comfortable with it, and the patient is going to be lying awake at night worrying, then I'm going to be more likely to go ahead and pursue at that point. So, it involves the discussion with the patient.”–PCP 16
“I think in general, because there's not a lot of risk. I mean there are risks, but we don't see bad things happen very often … Then, I think some of it is “oh, the radiology department will tell them, they'll double check, they'll make sure, they'll up their XYZ medicine before they get their tests,” so I think it's a lot of someone else is gonna do that.”–PCP 12
Inadequate knowledge
Providers
“The cost thing, I frequently just simply do not know what something ultimately is going to cost. There's so many variables in terms of insurance, and slides, and discounts, and all this kind of stuff. That's not discussion … I don't tend to get into the weeds with my patients on things like that. If it's somebody who's got major concerns, then I send them to talk to one of our financial people, before they go get the test done.”–PCP 16
“Talking about the risks of the procedure. Again, when you're trying … Even then, it's actually really hard quantify what that risk is. What does it mean when you say you're going to get extra radiation from your CAT scan to your head. Is that more than taking an airplane flight and that kind of stuff and you have that kind of ambient radiation that you have. That's actually really hard to quantify. Part of it is we don't know. We actually can't … I can't even say, I don't know exactly from a radiation standpoint what the risk is. It becomes a little bit more abstract.” –PCP 02
Patients
“And I think I probably overestimate their [the patient's] understanding as does probably every provider. I do try sometimes … if my alarm is raised, that maybe someone who doesn't understand, I sometimes do have them teach it back to me. So, tell me what you're going to do or what is the benefit. Or sometimes I'll write it out for them in terms of instructions. So those are probably the big ones I would use.” –PCP 01
“Selective hearing; that people hear it but don't hear it, forget it. There's a lot of information in a visit.”–PCP 04
Balancing Risks & Benefits
“How do you balance the risks and benefits of the imaging study with the benefit that you're going to get in terms of diagnosing things? Because not all the tests are obviously a hundred percent accurate. Right. So, you may find something that isn't the problem or you may not find the problem even though you've done the test. So, letting people know that it doesn't always show up on this type of test or that.” –PCP 07
“So that's something I am working on, is whittling those who don't need imaging. But then also asking myself “is this imaging going to change the plan? Like, will it make me give antibiotics or am I already going to do that? Do they need a referral to orthopedics, or you know that kind of thing?”–PCP 08
Patient Expectations
“I think patients have the false understanding that if they get this imaging then they'll see the thing that's causing them this problem they're having… Everybody wants an MRI. So you might end up spending a lot of time trying to tell people why they don't want the test. People really don't understand the downside of the test. They don't understand false positives and procedures that can follow. Even if you explain all that, they still are like oh, I'm not worried. They just don't worry about it. That's one of the more frustrating things. I can't really think of anything that would make it easier.”–PCP 05
“It [the test] can falsely reassure them. “Oh the imaging was negative, that means I'm fine.” There might be something going on which is not yet big enough to show on imaging. Imaging only looks at anatomy, which is a structure. It doesn't look at physiology, which is the function and so it could be falsely reassuring as well.” –PCP 03
  • CAT, computerized axial tomography scan; MRI, magnetic resonance imaging; PCP, primary care provider; XYZ, form of speech; placeholder for a medication name.