The growth in demand for imaging services continues to outstrip our efforts to train more radiologists. Providers of remote reporting services help to cover that capacity shortfall and deliver an essential component of a modern radiology service without which, in the U.K. at least, our public-sector radiology departments would collapse.
As a long-time advocate for local radiology services, I may be uneasy about this situation, but there is no doubt that the patient is usually better served by a remote report than the alternative of no report at all. So is remote reporting -- as some would contend -- just the same as local reporting but with better quality assurance? I don’t think so. The paradigm of remote reporting still puts the radiologist -- however skilled and experienced -- at a significant disadvantage compared with the local reporter. That disadvantage extends to the clinician reading the report from an unknown radiologist, and by extension to the patient.
Dr. Giles Maskell.
What are the disadvantages of teleradiology?
The first problem relates to the availability of information about the patient. The limited time available to hard-pressed clinical staff (let’s be generous here!) frequently results in a referral for imaging that lacks crucial details.
The local radiologist is likely to have access to the patient’s medical record, allowing them to fill in the gaps. The remote radiologist will not. Knowledge of the results of relevant biochemical tests, endoscopies, and biopsies can all contribute to a radiology report that carries greater meaning and relevance for the individual patient. In other words, a better report.
Most importantly, the remote radiologist will not always have access to the full extent of the patient’s previous imaging record. This can result, for example, in recommendations for unnecessary further tests to evaluate abnormalities that have previously been characterized as benign and dismissed.
The second disadvantage is the lack of a relationship of any sort between the referrer and the remote reporter. Not only does this preclude the sort of discussion known to produce better outcomes in circumstances such as the evaluation of patients with acute abdominal complaints, but it also means that the radiologist has no knowledge of the interests or expertise of the referring clinician (and vice versa), which again can lead to inappropriate or poorly directed recommendations. Advice from a radiologist to conduct a rectal examination may be entirely appropriate when directed to a primary care physician, but it tends to be very badly received by a colorectal surgeon. I’ve seen it happen.
A lack of familiarity with local facilities, expertise, and circumstances can also create problems. The onsite radiologist will understand local pathways and how best to support the onward management of patients with certain conditions. The remote radiologist does not.
A clinician and radiologist who work together and meet regularly to discuss cases will also be aware of each other’s attitude to risk. Much of the skill involved in radiology is about conveying degrees of certainty or uncertainty. The clinician who reads your reports all the time and gets to discuss them with you will be aware of the language you use in your reports and what it might mean in an individual case. Others will not.
Much is sometimes made of the fact that teleradiology companies habitually undertake “quality assurance” or “audit” of their reporters, meaning in essence that a proportion of each radiologist’s work is reviewed by another radiologist. This, of course, is not a failsafe against errors occurring, but it seems a reasonable step to take when the usual safeguards of feedback from clinicians and departmental colleagues are not readily available.
One possible downside of this approach is to encourage defensive practice -- a radiologist who would normally dismiss a certain finding that they consider to be insignificant may feel obliged not only to mention it but also to make a recommendation for its further evaluation because they know that to be the preferred response of the auditor.
Having pointed out the disadvantages of reporting remotely, it is not hard to see the advantages for the radiologist resulting from this form of work. Control of workload, greater flexibility, and reliable administrative and technical support are all factors that radiologists cite when expressing a preference for undertaking remote reporting.
I can’t speak for anyone else, but I know that I prefer to work in a team with colleagues who can support me in different ways in our joint objective of providing a radiology service, and I believe that our patients benefit from that approach. Serving a local community lends added meaning to our work and brings additional reward. Regular interactions with clinicians provide us with the vital clinical context for our work, keeping us up to date with developments in clinical practice and ensuring that our reports remain relevant and useful to support patient care.
None of this is to suggest that radiologists undertaking remote reporting are any less skilled than others, but whenever I do it myself, I am reminded that reporting in that environment is not the same as what I do for most of the week. We now have considerable experience working with teleradiology and have learned to respect the value as well as the extra capacity that it brings, but I remain personally convinced that for most radiological purposes, local is best.
Dr. Giles Maskell is a consultant radiologist at Royal Cornwall Hospitals National Health Service (NHS) Trust, Truro, U.K. He is a former president of the U.K. Royal College of Radiologists, and he undertakes cross-site reporting as part of the shared insourced reporting programme (SIRP) of PenRAD, a collaboration of providers of NHS imaging services covering the Devon, Cornwall, and the Isles of Scilly peninsula.
Competing interests: None declared.
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