chapter 3

3 Caring and Communication

Your character is constantly radiating, communicating. From it, in the long run, I come to instinctively trust or distrust you and your efforts with me.

STEPHEN COVEY

Learning Objectives

After completing this chapter, the reader will be able to perform the following:

• Identify the nature of care and its ethical and legal implications.

• Provide examples of the impact of communication on imaging.

• Define human care, professional care, and communication.

• Explain care and communication as a context for imaging practice.

• Develop a more caring and communicative demeanor.

• Identify what health literacy is and how it affects imaging.

• Implement the legal aspects of caring and communication.

Key Terms

caring

existential care

health literacy

professional care

Professional Profile

While practicing and teaching radiologic technology for more than four decades, I have observed the results of both ethical and unethical conduct. We are not perfect; mistakes occur. But an informed commitment to ethical principles greatly diminishes the likelihood of errors.

I have served as an expert witness in several cases of medical malpractice that involved unfortunate incidents in medical imaging departments. In one case a patient suffered permanent, incapacitating brain damage because of administration of the wrong intravenous fluid in an emergency situation. This could have been avoided if the technologist had followed orders and obtained the correct solution. A second opportunity to avoid this same error was missed because of incomplete and unvalidated communication between the technologist and the physician.

It is clear that communication is both vitally important and potentially perilous in the practice of health care. Those who are guilty of gossip, thoughtless sharing of confidential information, inaccurate reporting, or incorrect medical recording often cause serious consequences for the patient as well as professional or legal problems for themselves. I participated in another case in which the family of a patient who died of natural causes sued the hospital based on careless, unfounded remarks by a technologist, which were overheard in the imaging department.

We are all tempted to take shortcuts when we are in a hurry, but lack of compliance with safety procedures places both the patient and the imaging professional at risk. I have been called to consult in two cases where patients were injured in imaging departments because of falls. In both situations, injuries occurred when technologists were rushed and failed to make the effort to be careful. Because they were preoccupied with their own concerns, they did not place a high value on the well-being and protection of their patients.

When providing testimony about the actions of an imaging professional, I compare the person's actions to the code of ethics of the applicable professional organization. I also review the organizational policies and procedures that relate to the situation. Patients rightfully expect their health care providers to be educated in ethical principles and aware of the rules that apply to their care. When principles and rules are not conscientiously applied, unmet expectations raise concerns and resentments, even when no harm is done. These resentments increase the likelihood of a lawsuit. When patients have confidence in those who care for them, lawsuits are rare.

Ruth Ann Ehrlich, RT(R), Senior Instructor, Radiology

Western States Chiropractic College Portland, Oregon

ETHICAL ISSUES

Caring and communication are essential for life and growth; they are crucial ingredients in the imaging professional's ability to serve the needs of self and others. Caring and communication require the developmental strengths of trust, autonomy, initiative, identity, justice, industry, and intimacy, all of which play a role in discussions of ethics and ethical problem solving for the imaging professional.1

Health care professionals, including imaging professionals, refer to the therapy and other services they provide in their practices as care. Care is shown to the patient through appropriate communication. Therefore caring and communication are the primary tasks of the imaging professional. A caring attitude should influence the imaging professional's feelings and ethical problem solving arising from interactions and communication with patients. This chapter defines caring and communication, describes their ethical implications for imaging practice, and provides methods to help the imaging professional develop a more caring and communicative demeanor.

Eleanor McMartin explains that the imaging professional plays an important role in maintaining patient autonomy by projecting a caring attitude through appropriate communication.

DEFINITION OF CARING

Caring is defined as a function in which a person expresses concern for the growth and well-being of another in an integrated application of the mind, body, and spirit designed to maximize positive outcomes. Expressions of caring include feelings of compassion and concern, a philosophy of commitment, an ethical approach to problems, altruistic acts, conscious attention to the needs and wishes of others, protection of the well-being of others, nurturing of growth, and empathy and advocacy. Because caring plays such a vital role in human interaction, an appreciation of caring is fundamental to an understanding of human nature.2

CARING

Caring is a function of the whole person in which concern for the growth and well-being of another is expressed in an integrated application of the mind, body, and spirit that seeks to maximize positive outcomes.

Such activities as listening, providing information, helping, communicating, and showing respect are expressions of caring.3 Other caring activities include touching, nurturing, supporting, and protecting (Box 3-1).4 Caring is a universal phenomenon, although expressions, processes, and patterns may vary among cultures.5

Caring is essential in the development of the imaging professional.6 Radiographers must be caring individuals, part scientist and part humanist. Humanism entails the provision of existential care, a more abstract form of care arising from an awareness of common bonds of humanity and common expressions, fates, and feelings.7 Care may occur as a product of the rapport between imaging professionals and patients. Unfortunately, this is not always the case8:

EXISTENTIAL CARE

Existential care is compassion arising from an awareness of common bonds of humanity and common expressions, fates, and feelings.

In radiology, particularly, the administrative focus is on reducing costs by increasing productivity. The efficiency of virtually every radiology department in this country is based on how many exams its technologists can complete per hour. This emphasis on speed means that radiologic technologists often must spend less time than they would like getting to know each patient. This can have a detrimental effect on patient satisfaction. Patients who are treated like bodies on a mechanized production line are bound to go somewhere else the next time they need health care. Patients who perceive a lack of genuine concern and empathy are the first to complain about their care and ask for their records to be transferred to another facility.

Box 3-1 Expressions of Caring

Advocacy

Altruism

Commitment

Compassion

Concern

Courage

Ethical behavior

Monitoring

Nurturing

Protection

Empathy and Empathetic Care

The empathetic imaging professional is sensitive to the needs of others and strives to meet those needs. Building a respectful rapport between the health care provider and the patient portrays the ability of the provider to connect as a human being.

EMPATHY

Empathy is the ability to recognize and to some extent share the emotions and state of mind of another and to understand the meaning and significance of that person's behavior.

The connection must not merely be a reaction to the patient's distress. Empathy is not sympathizing or feeling sorry for the patient. It is a constructive and objective response that allows the imaging professional to provide high-quality patient care.

Communication

Communication is a symbolic interaction: when one person says something to another and that person responds. There has to be at least one response to one initiation, creating a tie of communication. Human communication is how an individual interacts with another. This may be through symbolic interaction or language or both. It is transactional and affective in nature. Human communication is not static, and it involves human feelings and attitudes, as well as the delivery of information. Health communication is narrower in scope than human communication. It is a subset of human communication that is concerned with how individuals in a society seek to maintain health and deal with health-related issues.

The key elements of communication regarding imaging are the speaker or sender (the imaging professional), the language spoken or body language (explaining the procedure and asking for information), the environment (the imaging department), listening (to the patient or to peers, physicians, etc.), and feedback from the receivers.

Care as an Ideal

Philosophically, care is an ideal analogous to beauty, truth, and justice; although it is sought after, it can never be fully attained or perfect in human expression. Imaging professionals are not capable of providing perfect care. In striving for the ideal, however, the imaging professional may occasionally come close to achieving it and in so doing provide great benefits for the patient. One danger in discussing ideals is viewing them as achievable and measurable commodities; this leads to the idea that those who fall short of achieving ideal care should be ashamed.7 This misperception may lead imaging professionals who consider caring to be a vital part of their professional practice to feel guilty, selfish, or discouraged when they are unable to give more time to their patients.9

Obstacles to Caring

Imaging professionals face a variety of obstacles to providing caring treatment:

•Scarcity of time

•Technical priorities

•Impact of personal life

•Lack of training in caring for patients who are critically or terminally ill

•Lack of communication

•Societal pressures

•Lack of faith in self

All these obstacles lend themselves to personal and professional ethical dilemmas. Imaging professionals who feel inadequate as a result of any of these obstacles may have difficulty feeling or expressing caring.

Imaging Scenario

A patient who has a family history of breast cancer and has found a lump in her breast arrives at a mammography imaging center. She is frightened and emotional. She has read a great deal of literature about breast cancer and knows it is one of the leading causes of death in women. Her mother and sister died painful deaths at early ages, and she is frantic to learn her diagnosis. The breast imaging center has been informed that it needs to complete procedures more rapidly to allow a greater number of mammograms to be performed per day. This pressure for speed has elevated the stress of the mammographers. Moreover, unexpected emergencies and procedures that call for additional views have been causing backups in the waiting room, increasing the anxiety of patients anticipating their examinations. Such a backup occurs on the day the patient arrives, and by the time her procedure begins, she is almost hysterical and has difficulty following the mammographer's directions. Her inability to hold still and endure the compression necessitates retakes of the films. By the time the woman is finished with the examination, she is angry and vows never to return to the breast imaging center. Her anger may even prevent her from following through with future mammograms.

Discussion questions

• What problems have occurred in this scenario?

• Whose problems are they, and what are the possible solutions?

• What impact has caring and communication or the lack of either had on the ethical dilemma facing the mammographer?

Obstacles to Communication

Obstacles to communication also exist and are intertwined with the obstacles to caring. Some obstacles may come from the sender or the receiver. If the patient or the imaging professional is thinking about other things, this may interrupt the flow of communication in the information-gathering process. Noise, temperature, or other distractions in the imaging environment may present an obstacle in the communication process. Distance and the inability to see or hear are obvious obstacles between the imaging professional and the patient. The relationship between the patient and imaging professional as it is affected by roles, personalities, values, and ethical differences may also influence the communication process.

PROFESSIONAL CARE

Professional care is characterized by the application of the knowledge of a professional discipline, including its science, theory, practice, and art. It is complementary to human caring. Imaging professionals must possess human caring before they are able to provide professional caring. Human and professional caring are both activities of the whole person (although activities are only a portion of caring). The interaction of compassion, knowledge, and the experiences and emotions of the whole person gives rise to human and professional caring.7

PROFESSIONAL CARE

Professional care is the application of the knowledge of a discipline, including its science, theory, practice, and art.

Clearly, professional expertise unaccompanied by human compassion is not enough to serve all the needs of the patient: “If we fail to motivate that feeling (empathy and compassion) and the earnest desire within our student to help our fellow man, we will have created the equivalent of human robots.”10 Such an emphasis on skill at the expense of caring and empathy produces a “patient care gap” in which the patient is ignored as the “scale tips toward science and technique.”11

Caring in the Imaging Sciences

The professional and human caring practiced by imaging professionals is based on individual and institutional values. Adherence to a set of values and the use of ethical problem solving help the imaging professional to develop a more caring demeanor. The three strengthen one another. Without values, caring and ethics in the imaging health care environment are without foundation and force. In turn, a strong commitment to caring requires a fusion of feeling, thought, and action, all of which aid the technologist in coping with stress and solving problems ethically. Taken together, caring, values, and ethical problem solving give meaning to professional practice, create the possibility of ever-improving care, and enhance patient comfort and feelings of safety.2 For example, cardiac ultrasonographers who have the ability to make their patients comfortable find them more willing to comply with directions, leading to an examination with greater diagnostic success.

Caring brings together all the resources of the imaging professional. When imaging professionals care for patients by performing imaging procedures, monitoring equipment, and meeting patient needs, they do more than provide therapy; they become a part of the patient's life.

Caring in the imaging sciences also involves an appreciation of the universal patterns of human experience. As imaging students enter educational programs, they are exposed through their patients to the universality of pain, loneliness, suffering, fear, and looming death. Human caring and professional caring require compassion for the suffering endured by patients and an understanding of the ways in which people construct and draw meaning from their lives. This unending activity of inventing, restructuring, and reinterpreting is universal, even though the outcomes are personal. Compassionate imaging professionals respond to the universal appeal made by suffering human beings by caring. The potential for this response is also universal.7

Imaging professionals see patients in all phases of life and all conditions of health and disease. Because the nature of their practice requires care for a diverse patient population, imaging educational programs incorporate classes to develop skills in caring. Professionals in other modalities, however, may not have as much continued and direct contact with a wide variety of patients and therefore may not be as prepared to care. This disparity may be an obstacle to providing the safe, comfortable environment patients require.

Careful monitoring of radiologic equipment is an activity that shows caring by ensuring the autonomy, comfort, and safety of the patient. Quality control specialists exhibit caring by spending as much time as necessary monitoring imaging machinery. Imaging professionals also show caring for their patients by ensuring confidentiality, obtaining informed consent, thoroughly explaining procedures, and taking complete and accurate histories. Nuclear medicine technologists exhibit human and professional caring by explaining the significance of the radioactive material being injected into a patient receiving a therapeutic dose.

Figure 3-1

A caring demeanor can be expressed through helping, nurturing, and offering support.

From Gurley L, Callaway W: Introduction to radiologic technology, ed 6, St Louis, 2006, Elsevier.

Developing a More Caring Demeanor

Caring is an attitude that may be developed and learned (Figure 3-1). Courses in professional caring have been part of the radiologic sciences curriculum for some time. Education in human caring and human relations skills, however, is a somewhat newer addition. To enhance caring, imaging professionals must strengthen and integrate their mental, physical, and spiritual capacities. By learning all they can about professional practice and human interaction, loving more, and being more creative and generous in spirit, imaging professionals can improve their ability to evaluate and solve ethical and technical problems. Self-analysis and rating of caring abilities provide further insights into strengths and weaknesses in caring.

Imaging programs can use a variety of means to instill a desire to increase caring skills in students:

•Communications classes that address body language and the importance of listening

•Critical thinking classes that focus on recognizing, analyzing, and evaluating ethical dilemmas

•Discussions of films that illustrate caring scenarios (e.g., The Doctor)

•Empathy rotations that require students to become patients for a day and participate in a variety of imaging patient activities

•Role modeling by instructors and staff technologists, including student evaluation

•Discussions among classmates about experiences with hospitalization and health care providers, emphasizing the ways in which caring influences outcomes

•A review of patient interviews in which care needs are identified and the department's response to those needs is evaluated

•Review and discussion of educational and professional materials dealing with issues of caring

Improving Communication

Not only must imaging professionals evaluate their caring and improve this all-important ability, they also must continue to improve their communication skills. To do this, they must want to objectively evaluate and change their communication styles. The next step is trying to change. Active listening is an important key to improving communication between the imaging professional and the patient. Active listening requires not only hearing the patient, but also watching the patient's body language, observing the patient's physical presentation, asking open-ended questions, and waiting for responses and feedback from the patient. The true active listener strives to recognize and understand the patient's needs. Investment of time and effort is imperative in the ongoing improvement of communication in imaging.

EXAMPLES OF CARING AND COMMUNICATION

Each of the following scenarios provides an illustration of caring and communication. They demonstrate the ways in which this essential human quality is finely honed by professional training and expressed humanly rather than perfectly. The scenarios depict imaging professionals engaged with the whole of their professional knowledge, as well as their human spirit.12

Imaging Scenario

Jane Smith is a radiographer in charge of portable imaging, and one of her patients is a young man who is an illegal immigrant. He was in a car accident and has a serious head injury. He has no family in the United States. The patient has been unconscious since his accident. Smith is quite concerned about the well-being of this patient, and though she does not condone his illegal status, she does not feel it is relevant to the situation. She realizes that she must monitor every change in the patient's condition when she is taking his radiographs. She watches all the monitoring equipment carefully. She also uses all her physical assessment skills to detect any complications that may arise. She talks to him in an attempt to stimulate his mind and penetrate his coma while performing radiographic procedures. He cannot talk to her, however, and may not even be aware of her care. Nonetheless, the imaging professional feels it is her duty to use her whole person on behalf of the patient's well-being … to care.

Discussion questions

• What else could the imaging professional do to communicate with the patient?

• How could she provide the maximum support for the patient's autonomy?

Modified from Creasia JL, Parker B: Conceptual foundations: the bridge to professional nursing practice, ed 3, St Louis, 2001, Mosby.

Imaging Scenario

Mike Jones, a radiation therapist, is the primary therapist for a 53-year-old grandmother who has advanced cancer. She is in pain and aware that her prognosis is poor. While Jones is positioning her, she says to him, “Are you a religious man, Mike?” Actually, Jones does not consider himself a particularly religious man, and furthermore he has a great deal to do this morning. He is inwardly annoyed at being called on to enter into this patient's suffering. This morning, at least, he would rather attend to other things. He is a human being and not capable of providing perfect care. However, he recognizes that religion is not the issue here; rather, the patient is seeking a human connection and comfort in her fear.

Jones sits down beside the patient to signal his intention to be fully present for her and enter into her experience, not because he plans to stay a long time. Human interaction need not always take a long time. Speaking truthfully, he says, “My own religion has its ups and downs—does yours provide you some comfort now?” The question is gentle and undemanding. The patient may choose to speak briefly about her religion and remain silent about other concerns. However, she may also choose to accept and respond to his gentle acknowledgment of her need for comfort. She replies, “I know that I haven't much longer to live. I long to watch my grandson grow up a bit longer and offer more support to his parents. My comfort is in knowing that the Lord does things in His own good time and that He will provide for my children.” Jones takes her hand for a moment and says, “Your faith that the Lord will provide for your children seems a comfort to you now indeed.” His answer is brief and tacitly accepting of everything she has said. He waits to see if she needs any further support, and she pats his hand and says, “Well, you have others to take care of. Thank you so much.”

Discussion questions

• If the radiographer is not a religious person, how can he comfort and communicate with this patient concerning her situation?

• What other hospital personnel could be called on to help this patient?

• What types of educational activities could help prepare a student imaging professional for this type of situation?

Modified from Creasia JL, Parker B: Conceptual foundations: the bridge to professional nursing practice, ed 3, St Louis, 2001, Mosby.

LEGAL ISSUES

Caring and communication are the cornerstone of the art of medicine. When the relationship between care provider and patient is marked by mutual trust and open communication, a major step has been taken toward patient satisfaction. Evidence shows that clear, two-way conversation is a key element in the prevention of patient dissatisfaction and malpractice claims. This section discusses health literacy, the lack of which causes almost half the population to be unable to understand what their health care provider is telling them. Once imaging professionals understand health literacy and its impact on the profession, they will understand that inability to communicate health care information effectively to patients has implications for risk management and litigation.

HEALTH LITERACY

A serious and growing problem is affecting the ability of health professionals to deliver care: low levels of health literacy. To quote the movie Cool Hand Luke, “What we have here is a failure to communicate.”

HEALTH LITERACY

Health literacy is the ability to read, understand, and act on health care information to make effective health care decisions and follow instructions for treatment.

Health literacy is the ability to read, understand, and act on health care information in order to make effective health care decisions and follow instructions for treatment. Many factors contribute to a person's health literacy, but the most common is the individual's general literacy, or ability to read, write, and understand written material. Other factors include the person's amount of experience with the health care system, the complexity of the information being presented to the person, cultural factors that may influence decision making, and the way the material is communicated.13

Research in adult literacy has been done mainly in general literacy. The most recent data available come from the 2003 National Assessment of Adult Literacy (NAAL), which measured the English literacy of America's adults.14 Participants in this assessment were scored at four levels according to their ability to understand prose, documents, and quantitative data (Table 3-1).

At the lowest level of literacy skills, termed Below Basic, individuals possess only the most simple and concrete literacy skills. This level, when averaging the components of prose, document, and quantitative testing, represents 16% of the adult population.

At the second level, termed Basic, individuals possess only skills necessary to perform simple and everyday literacy activities. This level, when averaging the components of prose, document, and quantitative testing, represents 28% of the adult population.

Together, the Below Basic and Basic Levels include 44% of the population, almost half of U.S. adults. What this means is that one out of five American adults reads at or below the fifth-grade level and the average American reads at the eighth- to ninth-grade level. Yet most health care materials are written above the tenth-grade level. In contrast, persons at NAAL levels of Intermediate or Proficient have sufficient literacy skills to permit full functioning in society.

Imaging professionals commonly see patients who have trouble reading and understanding health information. If almost half of the adult U.S. population has limited or marginal general literacy skills, these individuals are likely to have limited health literacy skills as well. Even persons with adequate literacy skills may have trouble understanding and applying health care information, especially when it is explained in unfamiliar technical terms. Patients may be articulate and appear well educated and knowledgeable, yet fail to grasp disease concepts or understand how to carry out medication regimens properly.13 The patient's inability to understand may not be obvious to the health professional. Patients are generally under stress and concerned about their health when receiving medical information, which exacerbates their inability to take in this information.

The Institute of Medicine, in their 2003 report “Priority Areas for National Action: Transforming Health Care Quality,”15 has identified health literacy and self-management as a priority area for national action in transforming health care. John Nelson, MD, then president-elect of the American Medical Association, said, “Limited health literacy is a huge obstacle standing between millions of America's patients and the health care they need.”16 Because low health literacy has been identified as a barrier to good care, the American Medical Association Foundation and other organizations have done much work to improve the way health care providers communicate with patients.

Table 3-1 Overviews of the Literacy Levels in the National Assessment of Adult Literacy

Level and Definition

Key Abilities Associated with Level

Sample Tasks Typical of Level

Below Basic

Indicates no more than the simple and concrete literacy skills

Average score 215∗

Locating easily identifiable information in short, commonplace prose texts

Locating easily identifiable information and following written instructions in simple documents such as charts and forms

Locating numbers and using them to perform simple quantitative operations, such as addition, when the mathematical information is very concrete and familiar

Searching a short, simple text to find out what a patient is allowed to drink before a medical test

Signing a form

Adding the amounts on a bank deposit form

Basic

Indicates skills necessary to perform simple and everyday literacy activities

Average score 242∗

Reading and understanding information in short, commonplace prose texts

Reading and understanding information in simple documents

Locating easily identifiable quantitative information and using it to solve simple one-step problems when the arithmetic operation is specified or easily identifiable

Finding in a pamphlet for prospective jurors an explanation of how people were selected for the jury pool

Using a television guide to find out what programs are on at a specific time

Comparing the ticket prices for two events

Intermediate

Indicates skills necessary to perform moderately challenging literacy activities

Average score 304∗

Reading and understanding moderately dense, less commonplace prose texts as well as summarizing, making simple inferences, determining cause and effect, and recognizing the author's purpose

Locating information in dense, complex documents and making simple inferences about the information

Locating less familiar quantitative information and using it to solve problems when the arithmetic operation is not specified or easily inferred

Consulting reference materials to determine which foods contain a particular vitamin

Identifying a specific location on a map

Calculating the total cost of ordering specific office supplies from a catalog

Proficient

Indicates skills necessary to perform more complex and challenging literacy activities

Average score 420∗

Reading lengthy, complex, abstract prose texts, as well as synthesizing information and making complex inferences

Integrating, synthesizing, and analyzing multiple pieces of information located in complex documents

Locating more abstract quantitative information and using it to solve multistep problems when the arithmetic operations are not easily inferred and the problems are more complex

Stating in writing an argument made in a lengthy newspaper article

Comparing viewpoints in two editorials

Interpreting a table about blood pressure, age, and physical activity

Computing and comparing the cost per ounce of food.

Modified from Hauser RM, Edley CF, Koenig JA, Elliott SW (Eds): Measuring literacy: performance levels for adults, interim report, Washington, DC, 2005, National Academics Press; and White S, Dillow S: Key concepts and features of the 2003 National Assessment of Adult Literacy (NCES 2006-471), Washington, DC, US Department of Education, National Center for Educational Statistics.

∗ Average score is the average of the Prose, Document, and Quantitative scores for each level.

Imaging professionals must communicate with patients to obtain maximal results. They can benefit from tips to communicate better and be assured that patients understand (Box 3-2).13 These ideas are simple to implement and can make a huge difference in patients' level of understanding. In addition to the suggestions in the box, others include sitting down to talk with the patient, making eye contact, and establishing that the patient can hear the health professional. When the teach back method is used, it should be done in a way that does not intimidate the patient. Examples of questions to ask are, “When you get home, what are you going to tell your wife you have to do to get ready for this exam?” and “Can you tell me when you are to come back for your next film?” The professional can also note his or her responsibility for the communication by saying something like, “I'm not sure I did a very good job explaining. Why don't you tell me what you understand?” Patients should never be asked, “Do you understand?” because they will always say yes and the health provider will have no idea what it is they understood.

Legal Side of Health Literacy

Poor communication between patients and clinicians is a major factor leading to malpractice lawsuits. In fact, attorneys estimate that a clinician's communication style and attitude are important factors in nearly 75% of malpractice suits.17 The most frequently identified communication errors are inadequately explaining diagnosis or treatment and communicating in such a way that patients feel that their concerns have been ignored (Box 3-3).13

Although the data in the preceding paragraph were gathered for physicians, they hold true for all health care providers who deal with patients. Few hospitalized patients complete their stay without having some contact with the imaging department. In addition, a steady flow of outpatients go through the imaging department. Imaging professionals have the opportunity and the responsibility to improve interpersonal communication with patients. By doing so, they will also be decreasing risk for themselves and their facility.

Box 3-2 Six Steps to Improve Interpersonal Communication with Patients

1. Slow down. Communication can be improved by speaking slowly and by spending just a small amount of additional time with each patient. This will help foster a patient-centered approach to the clinician-patient interaction.

2. Use plain, nonmedical language. Explain things to patients as you would to a family member.

3. Show or draw pictures. Visual images can improve patients' recall of ideas.

4. Limit the amount of information provided, and repeat it. Information is best remembered when it is given in small pieces that are pertinent to the tasks at hand. Repetition further enhances recall.

5. Use the teach back or show me technique. Confirm that patients understand by asking them to repeat back your instructions.

6. Create a shame-free environment. Make patients feel comfortable asking questions. Enlist the aid of others (patient's family, friends) to promote understanding.

From Weiss B: Health literacy: a manual for clinicians, Chicago, 2003, American Medical Association Foundation and American Medical Association.

Box 3-3 Clinician-Patient Communication Problems Involved in Malpractice Lawsuits

Explanation of diagnosis is inadequate.

Explanation of treatment is inadequate.

Patient feels ignored.

Clinician fails to understand perspective of patient or relatives.

Clinician discounts or devalues views of patients or relatives.

Patient feels rushed.

Data from Vincent C, Young M, Phillips A: Why do people sue doctors? A study of patients and relatives taking legal action, Lancet 343:1609, 1994; Hickson GB, Clayton EW, Githena PB, Sloan FA: Factors that prompted families to file medical malpractice claims following perinatal injuries, JAMA 267:1359, 1992; and Hickson GB, Clayton EW, Entman SS, et al: Obstetricians' prior malpractice experience and patient satisfaction with care, JAMA 272:1583, 1994.

CARING

Caring may not appear to be a topic with many legal implications, and strictly speaking this is true. A review of the many legal issues previously discussed, however, reveals that patient care does indeed have legal aspects. No federal or state statutes define or mandate caring; no complainant will attempt to make a prima facie case of “not caring.” Because of this lack of legal guidance, imaging professionals must use a commonsense approach when caring for patients. Patients are more likely to file a malpractice suit when they are unhappy with the “care” they received, so caring has a practical aspect.

Researchers from Harvard University reviewed more than 31,000 New York hospital records from 1984 to determine the incidence of injuries resulting from medical negligence.17 This study found that the incidence of adverse events caused by negligence during hospitalizations in New York in 1984 was 3.7%. In studying the litigation data for the same year, the researchers also found that 8 times as many patients suffered an injury from negligence as filed a malpractice suit, and that about 16 times as many patients suffered an injury from negligence as received compensation. Another study of 645 physicians from 1992 to 1998 found a direct correlation between malpractice suits and unsolicited patient complaints, indicating patient dissatisfaction.18

The preceding data indicate that most patients injured as a result of negligence do not file malpractice claims. Patient dissatisfaction, however, is a major factor linked with the filing of medical malpractice claims. In general, patients do not consult an attorney unless they are unhappy with the “care” they receive.

Caring, then, may be the single most important thing the imaging professional can do to minimize the risk of litigation. Imaging professionals can do their best to ensure that their patients understand the procedures and are able to give truly informed consent. Imaging professionals can also do their best to follow procedures with the goal of obtaining maximal studies, providing minimal radiation exposure, and keeping patients safe.

Probably the most important benefit gained in caring for patients is the patient's knowledge of the professional's care. As stated earlier in this chapter, imaging professionals must be part scientist, part humanist. Imaging professionals who share their humanist side with patients by caring not only communicate compassion but also go a long way toward minimizing the risks of litigation.

Imaging Scenario

A 40-year-old man who was injured on the job is brought to the emergency room with a fractured pelvis and internal injuries. He is conscious and is scheduled to have a vascular examination. The radiologist speaks to the patient and obtains informed consent. The imaging professional, in trying to explain exactly what the patient will be experiencing, has some reservations about whether the patient really understands what is happening. However, the schedule that day is swamped, the patient is obviously severely injured and needs a diagnosis for treatment, the special procedure room is open, the consent form has been signed, and the radiologist and staff are ready to begin the procedure. During the vascular examination the patient suffers heart failure and cannot be revived.

At a later date the family questions the informed consent process and brings suit against the hospital and the imaging professional. It is brought into evidence that the deceased patient was hard of hearing and could not read. The family believes that his inability to understand and recognize the danger of the vascular procedure was a deciding factor in his death. They also believe that the persons involved in the consent process should have recognized this and dealt with the informational procedure in another manner.

Discussion questions

• How does health literacy enter into this situation? Were there signs the physician and imaging professional should have seen indicating that the patient did not understand?

• What were the obstacles to caring and communication?

• What ethical and legal dilemmas were involved in this unfortunate situation?

• What should the imaging professional have done?

Apology Statutes

When errors happen, studies indicate that it is not necessarily the medical error itself that causes patients and families to sue, but the response to it.19 A study published in the Journal of the American Medical Association in 2003 reported that after an error occurs, patients want information about why it happened, how the consequences will be mitigated, and what is being done to prevent recurrence. They also want emotional support—including an apology.20

Sixteen states have passed legislation giving a physician the right to provide a compassionate statement or say “I'm sorry” to patients at the time of an adverse outcome without threat of litigation.21 These statutes allow an honest and open dialog when a medical error, accident, or unanticipated outcome occurs without the apology being taken as an admission of guilt. Open communication between patients and their health care professionals about their care decreases the likelihood that a patient will file a lawsuit.21 Empirical evidence shows that the use of a compassionate statement has lowered the litigation costs at the University of Michigan Hospital System, the Children's Hospitals and Clinics of Minnesota, and the Veterans Affairs Medical Center in Lexington, Kentucky.21 Because not all states have this legislation, imaging professionals should ask their facility's risk management department whether their state has such a statute and how they should handle situations when errors occur.

SUMMARY

• Caring and communication are crucial in the development of the imaging professional. They are essential to the treatment provided in the imaging environment and the ethical problem solving required to provide high-quality imaging services.

• Caring is a function of the whole person in which concern for the growth and well-being of another is expressed in an integrated application of the mind, body, and spirit that seeks to maximize positive outcomes. Existential care is compassion arising from an awareness of common bonds of humanity and common expressions, fates, and feelings. Professional care is the application of the knowledge of the discipline, including its science, theory, practice, and art.

• Human and professional caring in the imaging sciences provides safety and comfort for patients, involves imaging professionals in their patients' lives, and enhances patient autonomy, confidentiality, and informed consent.

• Empathy is the ability to recognize and to some extent share the emotions and state of mind of another and to understand the meaning and significance of that person's behavior. It is not the same thing as sympathy or feeling sorry for the patient. It is an objective response that allows the imaging professional to provide high-quality patient care.

• Communication is a symbolic interaction. It is not static, and it involves human feelings and attitudes as well as information. Health communication is a subset of human communication that is concerned with how individuals in a society seek to maintain health and deal with health-related issues.

• Education to enhance caring and communication may be incorporated into the imaging curriculum through a variety of methods. By developing a more caring and communicative demeanor, imaging professionals become better able to provide patients with compassionate treatment and high-quality imaging services. Caring and communication are therefore ethical imperatives in the imaging sciences.

• Caring and communication are cornerstones of medicine, since mutual trust and open communication are major factors in patient satisfaction.

• Health literacy is the ability to read, understand, and act on health care information to make effective health care decisions and follow instructions for treatment.

• Low health literacy is a barrier to open communication. Unfortunately, almost half of the adult population suffers from low health literacy. Imaging professionals see patients every day who have trouble understanding and applying health care information.

• Health care professionals can make simple changes in the way they communicate to help their patients understand. These include slowing down, choosing less technical terms, having eye contact with patients, and using the teach back technique to ensure patient understanding.

• Better communication can decrease litigation risks. Attorneys estimate that the clinician's style and attitude are major factors in 75% of malpractice suits.

• Imaging professionals also decrease litigation risks through caring. Patient dissatisfaction is linked to the filing of medical malpractice claims. Caring may be the single most important thing an imaging professional can do to minimize risk.

• Legislation in place in 16 states allows physicians to apologize when an error or adverse outcome has occurred without the apology being taken as an admission of guilt. When errors occur, it is not necessarily the medical error that causes families and patients to file suit, but rather the response to it and the failure to provide communication and emotional support. Not all states have apology statutes, so imaging professions should consult their risk management team to learn how error communication is handled in their state and facility.