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1 The Russell H. Morgan Department of Radiology and Radiological Sciences, The
Johns Hopkins Medical Institutions, 601 N. Caroline St., JHOC Rm. 3254,
Baltimore, MD 21287.
2 Department of Medicine, Division of Pulmonary and Critical Care Medicine, The
Johns Hopkins Medical Institutions, Baltimore, MD 21287.
Received June 25, 2002;
accepted after revision August 22, 2002.
Address correspondence to J. C. Scatarige.
Abstract
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MATERIALS AND METHODS. We surveyed 450 pulmonologist members of the American College of Chest Physicians. The self-administered questionnaire sought information about the radiologists and imaging facilities to which these clinicians referred patients for high-resolution CT of the lungs. The participants rated their satisfaction with the radiology services, estimated the number of patients referred for high-resolution CT per month, answered questions about certain attitudes and utilization practices, and provided general demographic information.
RESULTS. Completed surveys were received from 230 pulmonologists practicing in 43 states. Satisfaction with high-resolution CT services was rated as follows: very satisfied (35% of respondents), satisfied (49%), and indifferent or dissatisfied (16%). A higher rating was found in pulmonologists in academic practice, in those who believed that the radiologists desired as much clinical information as possible, and in those who believed that two or more members of the radiology group were interested in high-resolution CT. Among satisfied pulmonologists, confidence in the radiologist's high-resolution CT interpretation was very important. Physician satisfaction was not significantly associated with the size of the radiology group or the number of monthly referrals for high-resolution CT.
CONCLUSION. Pulmonologists in the United States appear to be satisfied with the high-resolution CT services provided by the radiologists in their communities. Satisfaction with radiology services might be further increased if radiologists expressed greater interest in high-resolution CT and pertinent clinical information and improved their interpretive skills.
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Referring physicians rely heavily on the observations and opinions expressed in the radiology report [13, 14, 15]. Measuring referring physician satisfaction is important, because doing so provides an indicator of the perceived accuracy of interpretation and the clarity of the written communication from the imaging consultant [13, 16]. Difficulties in communication between clinicians and consultants may ultimately affect patient care [17].
Pulmonologists are referring physicians with whom the radiologist frequently consults concerning patients with suspected diffuse lung disease. Pulmonologists have expertise in the clinical diagnosis and management of diffuse lung disease. We believe that they are the clinicians best able to assess the radiologist's skills and performance.
In this article, we describe our efforts to measure the level of satisfaction of pulmonologists in the United States with the high-resolution CT services provided by radiologists. In addition, we tested hypotheses that the level of satisfaction would be determined by practice type, perceptions about the radiologists providing the high-resolution CT services, and certain beliefs and practices of the referring pulmonologists. For example, we had hypothesized that satisfied pulmonologists would refer patients to radiologists in large radiology groups whom they believed to be competent and interested in the high-resolution CT technique and would request more high-resolution CT examinations per month from those radiologists.
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Survey Instrument
The Joint Committee on Clinical Investigation, the institutional review
board of The Johns Hopkins Medical Institutions, approved the study design and
survey instrument. The goal of our survey was to examine the utilization
practices and attitudes of pulmonologists in the United States concerning
high-resolution CT of the lungs in diffuse lung disease. Some data from this
survey have appeared in other reports
[18,
19]. The questionnaire
contained the following six sections: a definition of high-resolution CT; and
questions regarding satisfaction with radiologists providing CT services and
current utilization practices, awareness of clinical guidelines concerning
idiopathic pulmonary fibrosis, perceptions of the clinical value of
high-resolution CT, barriers to using the technique, and general demographic
and practice data. The 13-page survey consisted primarily of close-ended
questions.
As part of the development process, the survey was reviewed for clarity by academic pulmonologists in Baltimore, MD, and by several pulmonologists in private group practice in Norfolk, VA. The final version of the survey incorporated several suggestions from these physicians. We estimated that completing the survey would require about 9 min.
Physician Satisfaction
The pulmonologist's attitudes concerning the radiologists' providing
high-resolution CT services were examined in the second section of the survey.
Satisfaction was measured on a five-point Likert-type scale. The response
choices included very satisfied, satisfied, indifferent, dissatisfied, and
very dissatisfied. The last three categories were considered unfavorable
responses from the radiologist's perspective and were combined for ease of
analysis.
Additional questions were posed to identify certain attitudes, practices, and demographic factors that determined satisfaction. Respondents were asked whether the radiologists to whom they referred patients for high-resolution CT seemed interested in the technique and in having pertinent clinical history. Respondents were also queried about their reliance on the written high-resolution CT report, their own ability to interpret the examinations, the number of patients they referred for high-resolution CT each month, and the size of the radiology practice to which they referred their patients. Questions requiring a subjective response, such as agreement with or frequency of a certain practice, had a five-point response scale (strongly agree, agree, not sure, disagree, strongly disagree). The two responses at each end of the scale were usually combined for ease of analysis and interpretation.
Survey Process
In late September 2001, the 450 pulmonologists received by first-class mail
an introductory letter explaining the survey and our goals. Two weeks later,
the survey and a stamped return envelope were forwarded to each selected
individual, followed 1 week later by a reminder letter. Those physicians who
did not respond by November 15, 2001, received by mail a second survey and a
stamped return envelope. All surveys were returned to the principal
investigator by first-class mail.
Data Analysis
Statistical analysis was performed using SAS version 8.2 software (SAS
Institute, Cary, NC). All survey results were evaluated in the aggregate and
expressed as a proportion. Respondent age was expressed as a mean. The
chi-square test was used to compare the satisfaction ratings reported by the
respondents with their attitudes concerning the radiologists, their
utilization practices and beliefs, their practice type, and the year they
completed their pulmonary fellowship. Associations with a p value of
0.05 or less were considered statistically significant.
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Respondent Demographics
The mean age of respondents was 49 years (range, 32-68 years) and 92% were
men. Ninety-eight percent had completed subspecialty training in the United
States. Most were in private group or academic practice
(Table 1). More than two thirds
spent more than 75% of their work time in patient care activities and, of this
clinical time, more than 75% was devoted to pulmonary and critical care
medicine. Ninety-eight percent of respondents had referred patients to an
imaging facility for high-resolution CT during the preceding 12 months.
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Satisfaction Rating and Demographic Factors
When asked to rate their level of satisfaction with the high-resolution CT
services provided by the radiologists to whom they refer their patients, the
subspecialists responses were very satisfied (35%), satisfied (49%), and
indifferent or dissatisfied (16%) (Table
2). No physicians indicated that they were very dissatisfied.
Pulmonologists in academic practice were significantly more likely to indicate
that they were very satisfied with high-resolution CT services than those in
private group practice (57% vs 27%, p = 0.0001). Only 2% of
university-based pulmonologists were indifferent or dissatisfied, whereas 23%
in private group practice described themselves as such. Finally, those who
finished their fellowships before 1990 were more likely to be satisfied with
the radiologist's services than those completing training more recently.
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Satisfaction Rating and Perceptions About Radiologist Providers
Higher levels of physician satisfaction were associated with a belief that
the radiologists desired as much clinical information as possible and that two
or more members of the radiology group were interested in high-resolution CT
(Table 3). No significant
association was detected between the satisfaction rating and the size of the
radiology group to which the subspecialist referred patients.
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Satisfaction Rating and Beliefs and Practices of Referring
Pulmonologists
Most pulmonologists believed that it was very or extremely important to
have confidence in the high-resolution CT report from the radiologist, and
those who believed it was important tended to be more satisfied
(Table 4). Most pulmonologists
also reported that they always or frequently relied on the high-resolution CT
report; those who did were nearly twice as likely to be very satisfied as
those who seldom or never relied on the report. Most respondents did not rate
highly their own proficiency in high-resolution CT interpretation: 71% rated
themselves as good, fair, or poor (Table
4). Those with a high self-reported rating tended to be more
satisfied than those with a low rating, although the differences were not
statistically significant. Finally, no significant differences were observed
between the monthly volume of patients that a pulmonologist referred for
high-resolution CT and the reported level of satisfaction.
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Our data suggest that most of the pulmonary specialists we surveyed are satisfied with the high-resolution CT services provided by radiologists in their communities. Eighty-four percent of the respondents described themselves as satisfied or very satisfied, and only 6% expressed dissatisfaction. Previous reports have emphasized the importance physicians attach to the clarity of and meaningful content in the written radiology interpretation [13, 14, 15]. That radiologists appear to be meeting those expectations is encouraging. We are aware of one other nationwide survey that questioned internists, surgeons, and pulmonologists about their use of and attitudes toward thoracic CT and high-resolution CT [20]. In that report, however, referring physician opinions concerning satisfaction with radiology services and written reports were not specifically measured.
Our study found that pulmonologists in academic practice, as a group, were more likely to be satisfied than those in private group practice, and the latter were more likely than other groups to express indifference toward or dissatisfaction with the radiologists providing high-resolution CT services. These differences have several possible explanations. Pulmonary subspecialists in private group practice may demand more from or have higher expectations of their radiologists. To our knowledge, no data exist to either support or refute this hypothesis. Another explanation is that academic radiologists may deliver a higher level of interpretive expertise than their peers in private practice. Finally, the academic setting itself may provide an atmosphere that facilitates consultation and interchange between the clinician and the imager. Pulmonologists may associate this environment with a higher level of satisfaction.
Pulmonary subspecialists who expressed satisfaction tended to rely on the radiologist's report and to place more importance on their confidence in the high-resolution CT interpretations than those who reported indifference or dissatisfaction. This finding again confirms the high value clinicians place on the quality of the radiology report. Satisfaction may also be an indicator of unfamiliarity with high-resolution CT or its interpretation. Supporting this is the association we observed between satisfaction and completion of pulmonary fellowship before 1990. Because the use of high-resolution CT did not become widespread until the late 1980s, subspecialists completing fellowships before 1990 would have had less exposure to the technique during training.
Two perceptions about the radiologists providing high-resolution CT
services were strongly linked to referring physician satisfaction. The first
was a belief that the imagers desired as much clinical information as possible
from the referring specialist. Pulmonologists appear to respond positively
when they believe, first, that the clinical data they provide are valued and,
second, that radiologists recognize the importance of clinical history in
increasing confidence when a diagnosis is based on high-resolution CT findings
[9,
11]. Pulmonary subspecialists
were also more likely to be satisfied when radiologists in the practice
appeared interested in high-resolution CT of the lungs. Our survey did not
explore whether the radiologists had advanced training in thoracic radiology
or cross-sectional imaging. Perhaps the satisfied clinicians equate the
perception of interest in high-resolution CT of the chest with interpretive
expertise. Although pulmonologists referring to large radiology practices
(
11 radiologists) were slightly more likely to be very satisfied than
those referring to smaller groups, the differences were not statistically
significant. This finding suggests that the qualities pulmonologists associate
with satisfaction (interest in high-resolution CT, interest in clinical
information, interpretive expertise) can be found in small and medium-size
radiology practices in which subspecialization is not feasible.
We were surprised by the lack of association between the level of satisfaction and the monthly volume of patients referred for high-resolution CT. We had expected that high-volume referrers would be more likely to report satisfaction. No such trend was shown. Presumably, referral volume is determined by other factors (e.g., proportion of patients with diffuse lung disease in the practice) and may not be directly linked to physician satisfaction.
We acknowledge several limitations in this study. The first is survey response bias. The pulmonologists who chose to participate in our survey may be more familiar with high-resolution CT or may view the technique more favorably than the nonresponders. Second, we intentionally limited our survey to pulmonary subspecialists in the United States. Our results may not be applicable to other physicians such as general internists, oncologists, or thoracic surgeons who also request high-resolution CT examinations, or to physicians in other countries. Third, difficulty with the physician's recall may render estimates of the number of referrals per month and the number of members of the radiology group inaccurate. Finally, our survey measured physician perceptions about the radiologists and their practices. These perceptions may or may not accurately reflect reality. Do radiologists who appear interested in having as much clinical information as possible from the referring pulmonologist in fact value these data? Our survey cannot answer this question.
In conclusion, pulmonologists practicing in the United States appear to be satisfied with the high-resolution CT services provided by radiologists in their communities. The overall high level of satisfaction among the pulmonologists is encouraging. Our results suggest that physician satisfaction with imaging services might be further enhanced if radiologists expressed greater interest in high-resolution CT of the lungs, sought as much clinical information as possible, and improved their interpretive skills.
Acknowledgments
We thank Lynne Marcus, vice-president for membership of the American
College of Chest Physicians, for her generous assistance in preparing the
membership database and John T. Bowers, III, of the Sentara Medical Group of
Norfolk, VA, for his helpful review of the physician survey.
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