I'm excited to be here to talk about a subject that I am very passionate about, which is organizational culture, so we'll be talking about creating an organizational culture that fosters communication in our larger discussion about the importance of effective communication. So why do or should we care about organizational culture and its relationship to communication? I know some of you out there may say, well, can't I just go to work and read my studies and effectively communicate myself, but not necessarily worry about my organization? Well, let me give you an example of organizational culture and communication gone wrong. So this man right here is named Bob Eberling, and he was an engineer for a company Morton Thiokol in the 1980s, and this company was contracted with NASA to supply some parts for their space shuttle program. You'll recognize the space shuttle Challenger on the right here, because as you probably all know, in January of 1986, shortly after its takeoff, it had a mechanical malfunction, which led to its demise, as well as the demise of its seven crew members. So terrible tragedy, and as people are investigating this, they say, why did this happen and how can we prevent it in the future? And what they found during their investigations was that Mr. Eberling, as well as one of his colleagues, had repeatedly brought concerns to their organization, which then went up to NASA and said, we don't think that our part is safe for takeoff, we think it should be delayed. But unfortunately, there was a culture in NASA, which was so focused on getting the air, the spacecraft in the air, that eventually Mr. Eberling and his colleague were essentially shut out from communication to express their concerns, and as we know, and we all know what terrible tragedy happened. Let's talk about the cost of poor communications in organizations. This is a study out of Ohio State and Northwestern, in which about 90 executives were asked, where do you see, where are you losing money in your organization related to people problems? So some of these things are related to communication as well. Some examples, leaders who do not inspire employees, conflict avoidance, silos, unproductive conflict, and what they estimated is that organizations were losing $52 million per organization per year related to people problems. Another study asked 400 corporate executives, where are you losing money in your organization related to poor communication specifically? Their estimation was $62 million per organization per year. Now these are large organizations, but many of us are coming from large healthcare organizations as well. So I would question you, how much is your organization losing due to poor communication? These two studies, which suggest it's along the lines of tens of millions of dollars per year. But in healthcare, we are not just concerned with the, you know, what money we may lose because of poor communication, we're also concerned about our patients and our patients' lives. This is a study out of CRICO, a risk management organization associated with Harvard. And in 2015, 2016, they reviewed 23,000 medical malpractice lawsuits and claims and found that just over 7,000 of them, they could directly relate to miscommunication. These weren't including the cases in which communication may have been a problem. These are a direct result of miscommunication. And these just over 7,000 cases, $1.7 billion. Huge cost. But when they looked at the severity of patient injuries, they found that these 7,000 cases, 44% of them resulted in high severity injury or death for their patients. And when they looked at the 23,000 cases overall, a disproportionate number of them resulted in high severity injuries or death. These involved a communication failure. So I would suggest to you that the costs of poor communication are too high, not just financially, but they're also too high for the patients that we're serving. On the flip side, we can look at the benefits of good communication. And I would kind of whittle this down to one word, and that word is engagement. Engagement is when employees, they want to come to work, understand their jobs, and know how their work contributes to the success of the organization. And one way that you get employees engaged is by having good communication within your organization. Gallup did a study in 2016 in which they investigated engagement and the outcomes of the organization. When they compared the top quartile of highly engaged organizations to the bottom quartile, they found an increase in 20% productivity, a decrease 37% in absenteeism and turnover, and when they looked at their quality of work that they produced, a decrease in 48% safety incidents. For the healthcare organization specifically, 41% decrease in patient safety incidents and 41% decrease also in quality defects. And in the last decade, there's been emerging literature about the link between engagement and employee well-being, which is also something that we in medicine are more recently concerned about. And in fact, some people, when they describe engagement in the literature, they talk about it as the opposite of burnout. So again, to summarize, the costs of poor communication are too high for us not to be doing it well, and the benefits are too great for us to not care about it. So how is communication related to organizational culture? Well, I like to think about it in three ways. The first is that communication, both formal and informal, is a manifestation of organizational culture. So your culture will show itself in how you communicate. So if you have a bad organizational culture, then you will probably have bad communication happening. The second is that you need to understand the culture of an organization to make sense of the way that that organization communicates. So if I go to Stanford with Dr. Larson with my Michigan medicine culture, I probably, and I don't have a good understanding of the culture, then I probably will communicate in ways that will be ineffective because they don't fit within that cultural context. The third way that communication is tied to organizational culture is that it helps you disseminate, it helps you disseminate your culture. So what does a culture that fosters communication look like? Well, I would propose it looks something like this. An organizational culture in which people are free to give their input and ideas, information is shared freely, conflicts are discussed and worked through openly, and people are willing to express innovative ideas and take risks. And I would almost guarantee that any of us in this room, as we think about the organizations that we come from, that probably none of those organizations do this perfectly or very well. We may do well at some things, maybe our organization does very well at conflict management, maybe we are a highly innovative organization, but do we do all of these things well? Somebody may say to me, Amber, do all organizations need to look the same as far as their culture goes? And I would say no, but when it does come to communication, I think this would be ideal. So an example of an organization that has a very clear culture that has resulted in very good outcomes, Google. Fortune's 2017 number one best company to work for. Part of the reason for this is that they have a very clear culture. They value flexibility, creativity, trust, among other things, and they have a huge focus on employee needs. So they ask their employees regularly, what do you need to be productive and happy within this organization? And whether it's on-site child care or flexibility to go see a doctor when they need, the employee's needs are met, which has made Google an extremely successful company. That said, earlier this month there was an article in the New York Times which talked about an employee walkout related to sexual misconduct, so obviously they still have issues as well. Take that for what it's worth. So this culture that fosters communication that I talked about where people, ideas are expressed openly, people can express themselves without fear of retaliation. There are many challenges to this kind of culture. I've listed just a fraction that I've come up with here, and I would ask you to consider what specific challenges are you individually or your organization facing, and what are you doing about them? Are you ignoring them or are you actively trying to manage them? We'll talk about a few specifically. Bureaucracy is something that we deal with daily in medicine. We have many rules, regulations, overseeing organizations. We'll go back in time a little bit. This is Max Weber. He was a German sociologist. He described bureaucracy actually as being one of the most efficient ways to be an organization, but this was back in the 1800s. His five or six characteristics, based on what you read, I've listed here. Two that I think are important to discuss. Hierarchical authority can be a barrier to communication, and Dr. Seward will talk a little bit more about that. What I really want to focus on is impersonality. This is the idea that they treat you like a number, not a person. It's not about the person doing the work. It's that the work gets done. Impersonality can be a barrier to communication because you're not seeing the person who's doing the work as a person. You're not making sure that they're engaged, making sure that they know what value they bring to the organization. It really can affect that engagement component. I would urge you to, if you see impersonality happening in your organization, to avoid it. Conflict is another huge challenge. There are literally courses or texts that you can read about how to manage conflict. Two things about it because it's such a broad topic. One is that it can be a driver of innovation if managed appropriately. If you aren't managing conflict in your organization, then you need to figure out how. Whether that means individually doing some reading or going to your superior, going to HR, having outside consultants come in. You have to manage conflict. The second thing about conflict is going back to what I told you about absenteeism. Highly engaged organizations have less absenteeism. This study by Hays that I've listed at the bottom, when they looked at organizational conflict, they found that up to 25% of absenteeism was related to conflict. People having conflict with their boss or their peer and just not showing up to work. Two good reasons to manage conflict in your organization. We'll talk just a minute about media. L'Engle and Daft started talking about this in the 1980s as technology was advancing. They described the richest form of communication media being a face-to-face conversation. The farther you get away from that, it's considered more poor. They were quick to note that just because something is the richest doesn't always mean it's the best. You have to be very intentional about your media choice as you're communicating in your organizations. I would say, though, that if you have high stakes conversations happening, big changes coming to your organization, then the richer the media that you use, probably the better. Then lastly, a hodgepodge of things that fall under this Moravian theory of communication. This is the 73855 rule. I don't know if any of you have heard of this. Moravian did some studies on how do people perceive messages. Specifically, when it comes to face-to-face conversation. He described the importance of tone and body language and how people perceive messages. If your words don't jive with your tone and body language, then your body language and tone are going to have a much greater influence on what message they receive. This is important, especially if you're a person that maybe you don't have an open body language or maybe you have a sharp tone, even when you're trying to be friendly. This is something that you are going to want to keep in mind in how people perceive what you say. Just a summary of the challenges that we've talked about. Bureaucracy, avoid impersonality, make sure that your people know that you know who they are and you care about them. This will help them to be engaged. Conflict, manage this in order to promote innovation and decrease absenteeism. As far as media goes, consider the context of your media choice. Then lastly, practice your tone and body language. Just in the last few minutes, I'm going to talk a little bit about leadership. Probably number one thing you can do as a leader as far as your organizational culture goes is make sure that you clearly define your culture. What do you value? What are the beliefs and assumptions of your organization? If you can't tell someone what your culture is in a couple of sentences, then you probably need to go and assess it. See if it's where you want it to be. See where you want it to go. There are many resources out there about figuring out what your culture is. This is just an example. It's called the competing values framework. I'm not going to get into it, but just so you know that it exists, it's probably one of the most common ways. Another thing you can do as a leader is within that cultural framework that you define, lead with transparency and authenticity. Be open. Make sure that your people know that you hear them, you respond to them, you show appreciation to them. Select and develop leaders who align with the target culture. This is very, very important to create the organizational culture that you want. These are just some books and resources that if you don't know about them or haven't read them, I would encourage you to take a look at them because they're very good. Conclusions. The costs of poor communication are too high for us to not care about it. I told you tens of millions of dollars. How many patient lives have we... How many patients have we harmed or lost because of our communication problems? Know your culture. When you know your culture, then you can communicate it. You can have engaged employees which will lead to better outcomes for your organization. Know your communication challenges. If you don't know them and manage them and address them, then they're going to cause poor outcomes for you. And then lastly, lead with transparency and authenticity. I'll leave you with this quote. Take advantage of every opportunity to practice your communication skills so that when important occasions arise, you will have the gift, the style, the sharpness, the clarity, and the emotions to affect other people. That's it. I would like to ask you for a quick show of hands of how many of you are radiologists. This may seem like an unusual question and I see about, I would say, 80, 90 percent of people raising their hands. And now, how about if you are serving in a leadership role? That's maybe about 40 to 50 percent. Thank you very much for that. Authority gradients are defined as the established or perceived command and decision-making power hierarchy in a team or group situation and they are also known as cockpit gradients. When they are at their optimum, they help to structure teams and in training, they enable us to have that occur in a safe setting. If they are too flat, they lead to ineffective decision-making and even to the wrong decisions being made. And if they are too steep, they can actually be a barrier to communication. So let's look how often that is actually the case. So there have been many surveys in all industries and a 2005 survey in healthcare showed that 90 percent of respondents were afraid to speak up. And this included administrative assistants, nursing staff, and physician staff. And you can see that in all industries, it's at about 70 percent and even in the aviation industry, it's about 40 percent. And the aviation industry took that very seriously and they found that there is a 21 percent increase in adverse events when pilots of different rank are working together in the cockpit. And you may all remember this accident that occurred in 2013 when an Asiana flight was approaching San Francisco airport and the co-pilot noted that the pilot had made an error but did not speak up and then there was an accident with several casualties. And in healthcare, the same is true. There's an under-reporting of adverse events in about 50 to 96 percent. And the Joint Commission is very aware of that and last year issued a sentinel event alert that puts the culture of safety very much into the forefront. And it tells us that we have to assure that all team members are able to report adverse events that they see or any observations that they make and that we recognize them for doing so. So if we now all agree that patient safety is a responsibility that is shared by everyone, do our staff members actually know this? Well, we asked ours and it turned out that about a third did not consider safety part of their job description. In fact, they relied on the attending staff to take care of safety all by themselves. Now, if we want our staff to do this, we have to let them know about this. We have to set very clear expectations and then follow that up with positive reinforcement. There are many ways in which we can do this. We can talk about it at employee orientation. It should be included in our code of conduct and if you have room in your mission statement, that's a great place as well. But then we also have to evaluate staff on how often they speak up for our frontline staff and for our team leaders, whether they are actually facilitating speaking up in their environment. Now, for positive reinforcement, that could be very simple. A thank you goes a really long way and I will show data about that later. Of course, there are other ways in which we can do this and all of this information is included in your handouts. Now, here's the next question to consider. How important are actual language skills? Well, I would say this is a very difficult communication to have because the goals of the communication are inherently contradictory. So we would like to, on the one hand, alert our team members without unduly alarming the patient and by also avoiding the perception of a challenge on the receiver's end. And it's controversial in the literature how important that actually is. Our study showed, again, a third of our staff were not comfortable with how to do that language-wise. But there's another study that said it's actually only an issue in 2%. Well, let's look at the data from that study. So this was a simulation study done in an anesthesia department. And an attending anesthesiologist performed anesthesia on a VIP. And he was assisted by a nurse and by a resident. And he made seven different errors during the case. And here are the seven different scenarios. They range from something very simple, such as not testing the suctioning equipment before the anesthesia got started, to, on the end of the spectrum, injecting a potentially lethal dose of a medication. Now interesting to notice that in these brown bars, these were errors that could be reversed by a simple action. So the resident would just step up to the plate and test the suctioning equipment on his own. So when there was an option, people would choose that option over actually saying something. But if an error could only be solved by a verbal interaction, you can see that these green bars are really very small. So successfully solving a problem like that is very difficult. But also, notice here the large gray bars. And these are actually the number of times in which an error was not noted. Up to 70% in some errors. So you can see we really need everybody on board to make all of the observations regarding to safety. Now we need to give our staff some tools. So here is a language script that is a very nice script because it keeps the whole interaction in a neutral fashion. We state an observation as an I-message. We then state our concern. That's very important because we cannot just assume that the receiver will come to the same concern with our observation. And then we offer an alternate solution and obtain an agreement. You can also define your locally specific language that's just your own where your group knows if I say I'm going to call Dr. Potts, that means everybody stops, we're running into a problem. But now about how to respond. And I cannot emphasize enough how critically important that is. Remember how I asked you at the beginning about how many of you are in a leadership role? For the purpose of the communication to staff, every one of you as a physician is in a leadership role at all times. So if the technologist calls you about a protocol in the reading room, the way you answer that phone call will have a lot of impact. Why is that so? So all the human factor barriers that we will be talking about later are tied to the response to the recipient. And here are some of them. Fear of disrespect, fear of retaliation, or fear of being wrong. So what is then the first thing that you are going to say? Look at this friendly radiologist here. She's already doing everything right. We learned from Dr. Lyles, body language 55%. She is smiling, so she wants to hear from us. That is great. Now what are you going to say after you smile? Thank you for bringing this to my attention. And if there's one thing that you remember from this presentation, I really would like it to be this one. Not only because it is the answer to a Sam question, but because you can immediately assuage the associated fears in the speaker, you can increase the likelihood of future speaking up, and you have the unique opportunity to promote cultural change through positive reinforcement. And this actually works. This is a study on hand hygiene compliance. How could that actually work? So see here, they started out at 83%, which is already phenomenal, but they got it up to 96%. And the only intervention they did was that they established a program where all team members were reminding each other to wash their hands, and the person who was reminded said thank you to the person who reminded them. That's how easy that was, and that's how big the power of a thank you is. So for closing the loop now, in terms of communication, what are you going to say after saying thank you? To summarize the concerns, ask more questions to clarify, basically active listening skills, and then formulate a plan of action. But now, what are we going to do when a concern is insufficiently addressed or ignored? There is a tool from AHRQ that's called the CUS tool, the only time where that's allowed. You say I am concerned, I am uncomfortable, this is a safety issue. You can repeat it two times, maybe the second time you'll follow up with a question or you offer some more data to show that your concern is valid. Also the challenge does not have to come from the same team members, somebody else can jump in here and back that person up, and then we wait for confirmation. Now how likely is it actually that somebody will use the two challenge rule? And again, that depends upon the first response that they're getting from the team leader. Here's a study of residents from the US and from Japan, and they answered a question how willing they would be to speak up a second time. And if they thought the surgeon had not heard their first remark, they were very willing to do so. But if they thought the surgeon chose not to respond or even resented their comment, they were much less willing to do so. Now what are we going to do when new agreement is reached? We need a process by which all staff members are able to stop the line right here and then, and we need a process for arbitration. And the arbitration needs to be very timely, the arbitrator needs to be available within five minutes and be able to resolve the issue within 15 minutes. And we need assigned staff. You could theoretically just have everybody pull up a colleague and say, here, what do you think about this? But that may have some difficulties in terms of people siding with their staff group. So probably easier to have a single person who is somewhat removed, maybe your QI director could take over that role. Now let's talk in my last section of human factor barriers. And I would like to speak about challenging authority, disrespect, and fear of retribution. So fear of retribution is with 70% the most common reason for not speaking up in organizations across the United States. And here are some examples what people are afraid of would happen as retaliation. Now retaliation is very complicated in the sense that there are two things we have to deal with. We have to deal with the perception of retaliation, when actually nothing is going on but the person feels retaliated against, and then the reality. So we need two things to address it. We need a culture of transparency, which is very difficult. And then we need an actual policy to deal with the reality of retaliation. So here's just an example of our policy that very clearly states that there is a prohibition against retaliation and that a person who has been proven to have shown retaliation is subject to disciplinary action. But fear of retaliation is much more complicated. What we need is a culture of transparency, and the only way we can achieve that is by consistent and very frequent messaging. So I show you examples here of things that our staff says that really helps to create a culture of transparency, and these seem like very simple things to do. But in fact, since there is still so much fear of retaliation out there, I think we are not doing a good enough job with this. So we have to work on this consistently. Open communications around assignments so that this cannot be mistaken for retaliation. If you don't explain why you made that scheduling change, the person will have their own explanation and come to their own conclusion why you did that. Follow-up communication that we're not giving is always seen as, I bothered my supervisor with this. They're really not interested in it. They don't want to hear about it. So we need to be very good about that. Let's move on to fear of disrespect. About 52% are afraid of fear of disrespect. And if you see the data here on surveys of the U.S. population who experience disrespect at work, that seems justified. From 1998, where this was only 25%, it's up to 62%, and that was the survey in our department just this year. And there are many societal reasons for why that is the case, but one certainly outlined here by Christine Porath in the New York Times is that there is simply less time. We are all under a lot of RVU pressure. We want to be as efficient as possible. So coming back to the technologist who calls the reading room for a protocol, you're on call. You have 100 things to do. You are going to cut that short. And so why? Because you want to just make the communication that's a general CT, abdomen, pelvis, with and without IV contrast. I may even hang up the phone because for me the interaction is over. That's what we were talking about, right? But the technologist will see that as that we were disrespectful to them, and they will think twice next time whether they're going to call us or not. But the impact of disrespect on medical team performance is extraordinary. There were many studies that have shown that the diagnostic and the procedural performance of individuals gets impacted a lot, and not only of the individual. Because that individual shuts down their communication skills, they are no longer using information sharing or help seeking as tools, the team performance overall is also negatively affected. And in surveys, it has been tied to 71% of medical errors and 21% of patients' death. So we need to work on this. We need to create a culture of respect. I would recommend to you a book by Paul Meshanko, The Respect Effect, or also this great article by Christine Porath in the Harvard Business Review. There are a lot of recommendations on how to do that. This is the result from our survey. What our staff felt would make them feel most respected. Very interesting here, that working together as a team. That is something that came up a lot. And specifically, if we were seeking somebody's expertise, specifically if a physician seeks somebody's expertise, that is a great expression of respect. Now fear of disrespect can also come from an individual. Unfortunately, that's not the case very often. But if we have that in our department, we need to address it. Now the good news is, and Gerald Hickson from Vanderbilt has done a lot of work on this, that disruptive behavior can be managed very successfully. And it does really not take all that much. 70% of staff can be remediated, in fact, their disruptive behavior completely resolves with as little as one to three conversations. Just sitting down, having a cup of coffee, and talking about what happened and what didn't go so well. But what it requires is a commitment to establishing a process and dedicated personnel to do that. And now our last topic, challenging authority. And this is very complicated. We've already talked about some of these issues, so we've talked about the challenge could potentially come from the message, but I think we all agree the message is really information that as physicians and team leaders we want, so that is really not a challenge. We've talked about how the delivery could be challenging, but we now have our communication tools, and again, we have removed that challenge. How about the perception of challenging somebody on the employee's part? Well, hopefully we've convinced them by now, we really want them to do that, so that's no longer a problem either. Which leaves us with our own perception as physicians, that we feel challenged when somebody brings up a safety concern. And here's the question then, do we as physicians want to hear from our team members? And this survey in 2000 asked the question, unexperienced team members should not question the decisions of experienced staff. And 40% of surgeons in that survey, and 16% of anesthesiologists answered yes to that question, in contrast to 2% of pilots. In the same study then, there was a common belief among physicians that staff who bring up safety concerns question my competency. But let's think about this for a minute, that's not really possible, right? Competency is something that is acquired over many, many years of training, there cannot really be questions in a single interaction over one patient's safety issue. But it's understandable that we would look at it that way, because the traditional medical training puts a high value on autonomy, on independence, and self-reliance. But what we really want to get to is a point of view where staff who bring up safety concern support me and the team and protect the patient. But how are we going to get there? Many prominent voices in healthcare, among them Atul Gawande, have voiced the concern that medicine's complexity has exceeded our individual capabilities as doctors. And the policy summary from Belgium on Europe's health workforce in tomorrow's world says that it's now inconceivable that an individual health professional could keep abreast of this growth in knowledge. So we need to redesign healthcare, and this is all about the team. There are studies out there that support that teams that are built on crew resource management improve patient safety and decrease error rates. It's very much tied to the belief of the team leader that every team member has a critical role, a critical role for the success of the team performance. So we need to build high-functioning teams. We need to create the right conditions for a successful team, and then our team leaders will have a new role, which is to support the team. Here are some ways in which we can create the right conditions. We define the tasks very specifically of the individual roles and our team members. We create stability and promote communication among team members. And our new roles will be to engage with the team, to role model and ensure resources. So in summary, to facilitate communication across authority gradients, we need tools, we need policies, processes, and guidelines, and we need changes in culture. So in conclusion, authority gradients can interfere with patient safety and outcomes, but they can be overcome with a commitment to cultural change and dedication to teamwork. And I have a quote for you at the end here by Winston Churchill, courage is what it takes to stand up and speak. Courage is also what it takes to sit down and listen. So thank you for listening, please write, and don't forget to smile. So it's my privilege to talk to you today about communication with the referring clinicians. And this is something that I think we do a lot, and so we probably feel like we know a lot about it. So I'm going to hit on kind of two main aspects of it. Part of it is the things we probably should know and should be doing, just to remind us, but then the other part is things we may not have thought about, especially kind of from a fundamental and theoretical perspective about communication. And then here's a little marker to let you know that you will be seeing this again in the SAM module. I'm going to start with this. If you don't know this yet, you need to know this. We are in the business of information. That's our business. If you think about everything we do, we receive a request that's information. We acquire information from the bodies of our patients, we process that information into an interpretation, we transfer that information. It's all about information. So we're in the information business, and the information business is different from other businesses. It has to do with things like trust, reliability, speed, information, the value of information decreases over time. So some of these things that we may not think about, we're in a different business than most people in diagnostic radiology. So when recently the Institute of Medicine came out with a report called Improving Diagnosis in Healthcare, highlighted a lot of errors that happened in diagnosis and causes behind them, and a lot of it focused on radiology because we're a major specialty, a diagnostic specialty. So my colleague, Kurt Langlotz, and I really, we enjoyed this book that came out, this piece and we wanted to think about it in more depth and think about, okay, specifically how does that apply to radiology and how can we use what's in this and build on those concepts to really improve our coordination and communication. So this is what was laid out in the IOM report. They talk about the diagnostic process. The diagnostic process fits within the larger clinical care process. And so the clinical care process is where a patient shows up with a health problem, they engage with the healthcare system, and then it engages this diagnostic process that starts with information gathering, and then it goes to information integration and interpretation, and into a working diagnosis. And this is cyclical, and so it keeps going around that working diagnosis is refined through activities like a clinical history, an interview, physical exam, diagnostic testing, referral and consultation, until there's adequate information. And then that moves along to a communication of the diagnosis, treatment, and outcomes. So that was the model that they put forward. So in thinking about how does radiology fit in this, we wanted to break this down a little further. And so the way we look at it is from our perspective, the patient presents with a clinical scenario, clinical condition, and they move into a diagnostic phase, into a treatment phase, then there's some outcomes, and those outcomes will depend and put the patient often back into another clinical scenario, often in the follow-up scenario, and they'll reengage, and this continues. And we see it more that there should be frequent communication with the patient, not so much a one-time event. So some of the activities that happen in the process, then there's an initial assessment as the clinical scenario unfolds and the physician engages. Then there's the diagnosis and the treatment determination, which is based on the patient's goals and what is the clinician's assessment of the likelihood of attaining that goal with different strategies. So the diagnostic process, though, it's a process. So it starts with an initial working diagnosis, but that is a hypothesis, and that is refined as additional information is gathered. So information-gathering activities include imaging, labs and pathology, consults, and so forth. If you break that down for imaging, really what we're talking about is image acquisition and a radiology report, the two basic building blocks of imaging in diagnostic imaging. And so the activity that we perform is image interpretation. So let's talk about that result of image interpretation primarily as a radiology report that's communicated back to the referring provider, the clinical team. So let's talk about that for just a minute. This is the ACR practice parameter for communication of diagnostic imaging findings. If you haven't read this or aren't familiar with this, you really should be, especially if you plan on taking the boards anytime soon. But every radiologist should really understand this. And it's pretty straightforward. It's actually just a few-page document and outlines what should be in the radiology report. It should have things like demographics, relevant clinical information. It should have a body with procedures, materials, findings, potential limitations, clinical issues, comparisons, and then an impression containing a conclusion or diagnosis. Some of the principles that come out in this practice parameter. The first one, perhaps the most important one, the final report is the definitive documentation of results of an imaging examination or procedure. That's the thing that everything else is built around. It's the thing that we can go back and look at. It may change with addenda, but it's kind of the rock of this whole communication event. It must be created for every interpretation. The report should be clear. It should be proofread for errors. The report should be reviewed if not produced by the person who signs it. The report should be transmitted to the referring provider. It should accompany images that are transferred to an outside hospital where feasible. And a copy of the report must be maintained in the medical record. So again, these are things that we should already know. But there are other communications that we engage in. One is a preliminary report. So this may be appropriate for directing immediate patient management or meeting the needs of a particular practice environment like trainees in an academic practice. So when this happens, it may be communicated in multiple ways, but this document says should be, but these really are must-dos. It must be permanently documented and then should be converted to a final report as soon as possible. And then if any discrepancies arise between the preliminary and final interpretation, these need to be reported and dealt with and documented in that final report. Non-routine communications. These include things like phone calls, instant messages, EMR messages. These are where there's situations that warrant communications like emergent findings. If there was a discrepancy with a prior report or important but non-urgent findings like a new malignancy or unexpected finding that would be detrimental to the patient if not followed up. So these should be documented in every case, including the time, method of communication, and the name of the recipient. So informal communications. These are things like curbside consults or so-called wet readings or informal opinions provided during a clinical conference. So this is not when somebody calls you on the phone and says, hey, I have a question about this report. Can you walk me through it? That's not what we're talking about. We're talking about some type of informal communication given in place of a final report. And these situations carry risk to the patients, to the providers, to us, and so they're strongly discouraged. They should complement and not replace the final report. So one way of making sure that happens is have good processes in place that allow you to do that, like documenting all interpretations that may affect patient care and especially having a formal process for interpreting outside studies rather than just that dreaded curbside consult. Okay, so let's come back to the role of radiology in the diagnostic process. So if we look at the activities in blue down here, these are performed by the clinical team, and we look at this activity here in red, that's performed by the radiology team. Well, what about all the activities that happen in the middle? And there are lots of them, right? I call this the zone of cooperation, or you could call it the danger zone, right? So this is where we've got to work together. So this is where we've got to have a joint effort. So these are things like determining imaging appropriateness, right? How do we decide? Well, it depends on the clinical context. That's the best imaging strategy. Selecting the modality and the protocol that should be used in that situation, and then after the report is provided, integrating that back into the working diagnosis effectively. This is a joint effort. It absolutely should be a joint effort, and when it's not, that's where we run into problems. So this is a great article by Bettina and Olga and others at Beth Israel looking at the impact of communication errors in radiology, and the impact is significant. They looked at different elements, and the most common area that is impacted is in results communication. And even though they found that the majority of these errors, I mean, they're happening all the time. Most of them don't have really much impact. Some have minor, moderate, or even major impact. They didn't find any catastrophic impact in their assessment, although I will tell you, at least at our institution, the most catastrophic errors that happen in radiology generally happen around communication, especially communication of critical results. And I bet if you look closely into your organization, it doesn't happen very often, but when it does, they can be catastrophic. So let's talk about this concept of miscommunication and why they occur. Well, for one thing, I would say there's a problem that we often think of communication as just throwing information over the wall. That is not communication. So let's go through a few examples of what is communication. So let me just throw this out at you and tell me what you think. So if you just found out that your son was in an accident but not hurt, would you tell your spouse by email? So here's how that email might read. Hi, sweetie. FYI, Johnny was in an accident this morning. He's OK, but I thought you would want to know. Have a nice day. That would not go over well at my house. Why not? Well, if you think about it, what is the need in this communication? Well, there's the need to set the appropriate tone, to express urgency, to clarify details, to confirm receipt, and probably most importantly, to show respect. It would be disrespectful, profoundly disrespectful, to send this by email. What about if your spouse needed to pick up your children from school in 20 minutes? Would you tweet it? I'm thinking it would go something like this. Hey, the freeway is closed, so traffic is terrible. Can you please pick up the kids in 20 minutes on Twitter? Well, this will not work very well. Why not? Well, speed and privacy, and probably most importantly, confirming receipt and understanding of the message and reaching agreement on next steps. So this requires conversation. Let me ask you this. How would you like to be given a job interview by mail? I mean, snail mail, right? Post office. So that would go something like this. Dear Jane, please tell me about a time you had to solve a personnel challenge. Sincerely, your future boss. How would that go? It would not go well, I think. If you think about it, we need to make a complex assessment. There needs to be flexible communication and opportunity for dialogue. That could go in many potentially different ways. And let me ask you this. When was the last time you had an entire book read to you by a live person? See, I mean, if you're a little uncomfortable, that's okay. So when you're a child, this is really important, right? Well, what are the needs that children have? Well, there's the help reading, of course, but there's interaction with the parent. There's the tone, the closeness, the developing that relationship, right? That's what this is about. For adults, it's pretty much about information, right, when we're reading a book. We have other methods for reaching, you know, achieving those goals. So the method of communication is really critical. So this is an article that we looked at. Actually, many of the things that Amber talked about earlier in terms of communication in the radiology environment. So first of all, how do you define communication? Communication is the exchange of information between individuals or groups of individuals to reach shared understanding of meaning. So that's when it's successful, is when you reach shared understanding of meaning. And if you haven't reached shared understanding of meaning, then you have not successfully communicated. If you just throw it over the wall, that is not necessarily successful communication unless it results in shared understanding of meaning. So when we think about the many elements of communication, including in our environment, communication, again, it goes from one individual to another. The main element is conveyance, where we provide information from one party to another. And that's the bulk of our workflow, how we convey information. That includes both the primary stream of information, but also secondary streams like metadata that go along, or contingency streams like when your voice recognition system is down, how else are you going to communicate? There's also then a method of convergence. So yes, you've conveyed this information, but how do you make sure that you're on the same page? An opportunity for clarification or discussion. These are the primary two elements of communication. Then there are also aspects of reverse flow of information. So feedback. So recognizing whether or not that has been received, or getting any type of criticism or understanding of how this communication process is going so that we can improve it. There are tools that help us in this. There is reference information, decision support. There's communication outside this primary chain, and there's standards, policies, and procedures that support all this communication. So there's a lot to it. And so we need to be careful about how we design our systems, because if we design them well, they can dramatically facilitate this communication. And if we design them poorly, then they can actually damage this communication. Amber talked about this concept of media richness theory. So this is basically the ability to change understanding over time. And so she talked about rich versus poor. Further authors in media synchronicity theory actually talk about the spectrum is more from rich to lean. Rich versus lean communication. So a rich communication has many channels of synchronous communication. So things like verbal language, body language, maybe documents, or a presentation, for example. And there's also the opportunity for a two-way exchange. There's confirmation. There's clarification. There's discussion. So this type of communication tends to be very thorough, but it's inefficient. So we can't have all of our communication be rich communication, because we wouldn't get anything done, right? Then the opposite is lean communication. So here you have generally few channels of communication. It's asynchronous. You don't have much back and forth, but you can transfer a lot of information. It's a great big email file with that 30 megabyte PDF document that comes to you, right? Or a big stack of information. Lots of information was transferred. Not much meaning was changed until you really sift through that information. So what are the take-home points of rich versus lean communication? Well, most organizations are designed for lean communication, because it allows the organization to be efficient. Rich communications take more time and effort. But rich communications build relationships, and the lack of rich communications reinforce silos. So for example, how well do you know your radiography technologists compared to how you knew them 15 or 20 years ago when they had to come and bring the films to you? Or the ultrasound technologists? Or the referring clinicians for that matter? Where we have these rich communications, you get to know them, you get to develop relationships. And often we don't recognize that the lack of these types of interactions compromise these relationships. Lean communications can be brittle. In other words, they can foster miscommunication without realizing that it's happening. You can be going down a very bad path and not even know that you don't know, the right hand doesn't know what the left hand is doing. So the strategy is, then can you recognize when you're in a situation where you need to convert nimbly from lean communication to rich communication? And do you have the systems and processes to support that? And a general rule of thumb is if miscommunication could potentially result in a catastrophe, then it's much better to err on the side of rich communication. If you're going through, you're sending reports, but this one just doesn't feel right, it's time to get on the phone. And leadership, from a leadership perspective, insightful leaders will invest in systems that support rich communication, even though they're inefficient. They'll pay the extra money because they recognize the risk that it mitigates. But it looks like waste on a balance sheet, and that's the problem. Because you usually don't use it, except when you do, it can save lives. So again, we come back to this concept of the radiology team, the clinical team, and the joint effort. And again, we're hoping that this is the zone of cooperation, but it often, again, is the danger zone. Well, why is that? Well, again, we're throwing information over the wall, but the question I would ask is, why do these walls exist in the first place? And so this brings us to social identity theory. And this is something that we all actually probably know pretty well, we just don't ever think about, and probably have not heard of it. Social identity theory just goes to this concept that people tend to naturally form in groups. And then they tend to feel strong affinity to their group, and their individual self-worth and identity is tied up to the group that they're identified with. And so what tends to happen is you see, as individuals, we see other people as either in-group or out-group, right? They're in this group or they're out of this group. So with the in-group people, people who we see are in are their peeps, right? They're our people. We see them as more nuanced and complex. We're willing to give these individuals the benefit of the doubt, to try to understand their needs, and to help them when they need our help. And we're often willing to go even to great sacrifice for the benefit of the group, this concept of band of brothers or forgotten country, right? It's this thing that we identify with, it's very powerful. Whereas those who are in our out-group, we see them as the others. We tend to see them as homogeneous and stereotyped. We use phrases like the ED always does something, the nurses think something, the residents never think something. These gross generalizations which we ascribe to them as blocks of people. And often we don't appreciate them, quite frankly, don't even care about their subtle needs. So what are some examples of this? So let me offer you one, and let's deconstruct it. So let me tell you if you've ever heard this. Heard someone say, the ED doesn't care if the interpretation is accurate as long as it's fast. I've heard this many times. Everyone's a little nervous here, I know. So this is something that goes around. Well, let's deconstruct this. Well, first of all, a generalization. So we branded a group of people with a single label, the ED. Well, there is no ED, right? They're a bunch of, they're emergency physicians, and so forth. There's no single ED. The language itself signals that they're the out-group, and it signals that they're the others. They're those people, right? There's often a lack of context, and it ascribes questionable motivations to these individuals, and it omits our own questionable motivation. And these statements often are an expression of moral outrage, right? Also, who are you having this conversation with? You're having this conversation with someone that signals to them, you're part of my in-group, right? So the whole conversation sets up an adversarial construct. So here's another one. If we don't defend our turf, the cardiologists will take all of our business, right? The residents want greater autonomy, but they don't want to work any harder than they absolutely have to, right? Okay, so let's think about then, be conscious of this, and recognize what's happening when it happens. So how do we work together? What's the science of working together? We've touched on this, and I would say it depends on our group. So teamwork, we define teamwork as, this is, these are your, it's generally in medicine, it's your specialty. So it's, it's in this case, it's the radiologist in blue with, versus the emergency physicians and clinicians in red. Like, we have a physician, we may have a technologist, a nurse, administrator, so we have different functions, but we're on the, kind of on the same team, right? And so we work, we work in that way as a team. Whereas collegiality is, those are our colleagues, and our colleagues are the people who basically do the same thing that we do, have the same credentials, are in the same status that we have. And the way we relate to our colleagues is different than the way we relate to our individual team members, and it's important that we know how these function well, and how these can go wrong. Collaboration is more reaching across that divide. It may be physicians, but how does an emergency physician relate to a radiologist, for example? So we're in, we're in different, different groups. And all of this together could be summed up, and I think it's actually really nicely captured by the, this theory of relational coordination. It comes out of Brandeis University, Jody Hoffer Goodtell, really focuses on two elements, relationships and communication, and they're self-reinforcing. So relationships, the functional, highly functional relationships that produce excellence in organizations, have people who work with shared goals, shared knowledge, and mutual respect, and their communication tends to be frequent, timely, accurate, and problem-solving. And when things break down, you have the opposite, disrespect, infrequent communication, finger-pointing, and blame. So how do we overcome between group rivalry and hostility? Well, I don't know, but here are my thoughts, having thought about it for a while. For one thing, we should recognize it. We should catch ourselves the next time we find ourselves saying, or thinking even, the residents think X. Make the first move. We should not have to wait until the other party makes that first move. We can go ahead and start that. Get to know somebody from the other group, and really get to know them. Ed Schein talks about, who basically invented the term organizational culture, talks about personizing other individuals. Get to know them for their individual personalities. Ask them, how could we make their lives easier? Try to genuinely understand their perspective. Think about what they need. Give them the benefit of the doubt. Think about what pressures they may be under as they're trying to work through similar problems that you're working through. Try to then, to make their lives easier in some small way, and try to find an excuse to walk into their territory occasionally, in a friendly way. Call your clinician, for example, with a minor finding sometime, and I say, careful not to give them a heart attack, because they're, okay, really, why are you calling me, right? No, I'm just calling you to let you know. Just develop that relationship. The thing I would ask is, ask yourself, how would you want your mother's caregivers to work together? So, can we then convert this danger zone to truly this zone of cooperation? So in summary, again, we're in the business of communication, of information, and communication in radiology revolves around the final report, but it needs to be supported by other communication methods. Beware the danger zone, make it the zone of cooperation, and can we make it so that communication is not just throwing information over the wall? There's both conveyance and convergence, and safe care requires being able to rapidly switch from lean to rich communication. Miscommunication often stems from between-group rivalries and hostility. Watch for adversarial vocabulary in your own language, and effective relational coordination is based on both relationships, so shared goals, shared knowledge, and mutual respect, and communication, frequent, timely, accurate, and problem-solving communication. And finally, again, I think about my family members, or even myself, if I were to see individual caregivers fighting over petty disagreements, right, or territorialism, or any of that unprofessional behavior that puts my child at risk, I have no tolerance for that, and we should not have any tolerance for that in ourselves. We should be better than that. It's unbecoming and professional, and we should be professionals, reach across the aisle, and work well with our colleagues for the betterment of our, the best care for our patients. Thank you very much. Okay. Okay, so communication and radiology really occurs at every step of the way. However, it also breaks at every step of the way, and really, why? Because it's just so complex, and there is a lot of things that can break, and you know, whenever there is something to break, it will break. So how can we make it better? How can we make it fail-safe? We will, we can try to better, have better communications with the different physicians. We can standardize our processes as much as possible, policies and guidelines, but we can also involve our biggest partner here, which is patients. We can use patients' portals. We can text them. You know, it's a big hurdle, IT hurdle to go through, but if we can do it, that's, that works great. We can try to mail the instructions. That's usually quite difficult because of the delays. You can train your frontline staff, which is very important. They usually have the most of the communications with our patients, and important, always, always, always seek the feedback from your patients. How did we do? So patient satisfaction surveys, I'm sure most of you do that, right? Can you vote, please? How many of you do patient satisfaction surveys? I would say most of you. So it has been shown that patients who are happy with our service are more likely to return to the same place, more likely to recommend to their friends and family to come to the same place, and they're more likely to comply with your recommendations. That was one study, big study. It's not in radiology, but really it's the same thing. This is a study about patients under diabetes care, and they were also shown the same thing. Patients that trust their providers, that are satisfied with their care, they're, again, more likely to follow the preventive practices and recommendations. Even surgical outcomes can be improved. This is a huge study in surgical patients saying that there is some sort of association between patient satisfaction scores and some objective measures of surgical quality, as you can see here. Other studies shown that implementation of patient-centered care can actually shorten your length of stay, which is an important financial thing. So patient satisfaction is important. Patients are more likely to follow your instructions on the preventive care, will follow the recommendation for follow-up, and maybe even surgical outcomes will be better. So how does it apply to radiology? Well, we have the same thing, right? So if the patient is happy with your service, they're more likely to read and follow your PrEP instructions, which will, in turn, improve quality of study or procedure. If you recommend some follow-up study, they're more likely, again, to follow with this recommendation. And then, again, financially, if they're happy with your service, they're more likely to come back and recommend to the family and friends. So when we do patient satisfaction surveys, there is a lot of things that we can survey about. There is a lot of things that affect patient satisfaction. And so the question is always, what do you do? What do you ask about? Do you ask about everything? Well, that would not be really practical. And really, the recommendation is really not try to cover everything, just because you're not going to get too many responses. People just get tired. They will stop filling the survey, and that's it. You're not going to get any results. Try to be very specific. And being specific is not just short, but rather focus on things that you have some impact on, right? So if we are in Boston and we have no impact on our parking situation, there is no need to ask about parking, right? Because that's not something that we can use. However, if you have cleanliness, for example, that's something you can ask about, because you can do better with that. Always leave a lot of space for comments, because I have to say, however you design your survey, you don't really know what's going to be the most important thing. A lot of important stuff just come out in the comments, and we use that pretty frequently. One of the most important questions is, would you recommend this facility to your friends and family? And this is really the question that correlates overall with patient experience. And then on the other side, if you take your worst rating across all categories, that also correlates well with overall patient experience. So if you focus on that area, if you improve that, you'll improve overall patient experience dramatically. Patient portals, that's another way how do we communicate with patients. Just a question, how many of you in your institution have patient portals? That's about 50%, I would say. So it feels by literature that's pretty much everywhere, but I guess it's not yet. So what is this patient portal? This is basically a place for a patient to review their own information, medical information from labs, reports, doctor's notes. They also have a way basically to communicate with the physicians, and not necessarily just your primary physician, just a PCP, but any specialist as well. So in our institution, the patients can actually write emails or letters through this, and this will come to their physician. They can obviously reschedule their appointments, et cetera. So through that portal, our patients can see their reports. And in our institution, that actually been working for 18 years. So in our institution for 18 years, patients can read their notes, reports, et cetera. They can see the name of the radiologist. And in our days, it's very easy to find the email of the radiologist or any person. So our question was, we decided to ask the question of our radiologists, how much does it bother you? How frequently patients reached out to you to ask something about the study? Does it really interfere with our work? So that was one of the big concerns that a lot of people have. Oh, if we open reports, patients will just haunt us. Well, so how often does the patient contact you? So we ask all our radiologists. Never was quarter of our responders. Once a year was in 20%, and about once a month was 45%. So it's very, very infrequent, really. What is the question? What do they ask us about? Most of the time, it was about question about the report. And I think it's very appropriate if they have a question about report, we should be the ones to answer that and not the referring physician. There was quite a few mistakes in the report. And again, this is something that I am as a radiologist. If I have a mistake in the report, I would rather to correct it and talk to the patient myself. And then complaints. Yes, they are definitely there as well, but relatively rare. 67% of radiologists stated that patient interactions were minor with no impediment to the workflow. And they actually took less than 15 minutes per patient interaction. We don't know how much exactly because it was a survey, but it was relatively short. So again, not huge impediment on the workflow. Importantly, 57% of radiologists, yes, we all went to those dark rooms to not have interactions with radiologists, with patients. We do want more interactions, right? So yes, it was more frequent in IR and mammography subspecialties, but also in other subspecialties as well, and also among our trainees. And why do we want that? Because most of the radiologists find interactions with patients quite satisfying. This is also an agreement in this recent very large paper in radiology by Patient-Centered Radiology Steering Committee. Dr. Camp published that, and she surveyed RSNA members. And the question was, what prevents you from communicating this directly with your patients? And the answer was time and workload. I think we're pretty much not really set up to do that, but if we do have a setup, that might actually work pretty well. However, what would motivate you to communicate more directly with patients would be personal sense of satisfaction. So nowadays, when we're all talking about burnout, I think this is an important consideration. So how comfortable are we as radiologists to disclose imaging findings to patients directly? That was another question. So there are multiple studies about that, and I just want to kind of highlight a few of those. So this is one of the older studies, 1995. 92% of patients wanted radiologists to tell them if the findings were normal. And even if it's abnormal, 87% of patients wanted to tell them their results. Now, a study from MGH, a relatively recent study, was quite opposite. The patients wanted a referring physician to talk to them, even on the phone, 34%. And phone by radiologist was very rare. And that was for normal findings and for abnormal findings, that was even more, they wanted the referring physician to talk to them. Now, MD Anderson study was talking about that basically, again, patients prefer their referring physician to relay their results. However, still, despite that, 64% of respondents wanted to see their reports as well. And vast majority of those wanted to see their images. And then there is a question, what will they understand, A, from the reports and then from their images? But they definitely want to see those. I think just showing the report and the images is probably not enough. You need some sort of interpretation, whether it's in a clinic with radiologists, whether it's with referring physician, but you need to get more information out there. Our study from our group quite a few years ago showed that basically 98% of patients, and that was direct discussion with every patient, they would be comfortable hearing results from the person interpreting the examination. So, it's always a question, how do you word this question? A lot of patients don't know who is radiologist is still, but if you're saying that the person is interpreting your study or expert in imaging, much more patients are actually interested to hear your opinion. Here is an example that's another study saying that they definitely, patients, more than 70% of patients want to hear their results from experts interpreting the exams. However, 40% of those patients believe that radiologists were technicians or a nurse. So, we definitely still have a lot of work on this front as well. So, do the patients want to talk to radiologists? A lot of answer to this is how do you ask the question and what type of subcategories, what type of patients, where are they, how strong their relationship with referring physicians, how quickly they can obtain the results from their referring physician. But they definitely value their treating physician opinion. We'll be with them along the time. However, they also want to hear from us, from experts in imaging. And this really should be looked at as a complementary process. We are all here as a team and we should work here as a team. We should help the referring physician and not to be, it's not a contradictory process. So, then the question is whether radiologists are comfortable discussing results with the patients and we ask our radiologists. Again, we have this experience of 18 years of open reports. 92% of our attending radiologists would discuss benign findings with the patients. And even ominous findings, 61% of attending radiologists would discuss them with the patients. Is it feasible? So, here I'll tell you a little story. A couple of months ago on the Facebook, you know, one of those times when you really don't want to do any work, you go on the Facebook. There was this society, there was a community of women and suddenly they were looking for breast imaging services. I was like, why? What happened? So, apparently there was a service in the suburbs of Boston of dedicated breast imaging service. And basically after each study, this single physician, single radiologist practice, she would discuss the findings with the patient after each exam. Doesn't matter what it is. Yes, it is a four high risk patient. But, and again, after each exam, she would sit immediately and will tell what it is and what to do or not to do. Most of them were normal. Now, is it feasible? Well, most of us will say, no, absolutely not. You know, we all have this, all these RVUs on our back, but that's really the question is what is the business model behind it? And what are, can we bill for that? That's, that would be, we can actually bill for when we meet with the patient. If we discuss findings with the patients that definitely mammography practice or breast imaging practice would be a great example for that. She find it feasible. It is a private practice. And the only reason why those patients were looking for something else because her magnet was down. And basically all those patients that she was seeing for many years were now looking for some other solutions. A lot of us, all of those patients came eventually to our institution and we do not provide the service. But it also brought us to think more strongly about how we can provide this type of service of immediate results. Not to every patient, not to every exam, but this is definitely something that we should consider. So, and the last part that I want to talk about is do we need to, some training to communicate with the patients or we all set, we're all okay like that. So this was a study from Wilbert that evaluated radiology residents and breast cancer survivors were evaluating residents on their communication skills. And they really scored pretty poorly. This is a study by Steven Brown from Children's in Boston that was saying basically how comfortable the residents, radiologist trainees talking to the patient, discussing radiation risk, communicating bad news, communication about medical errors. And there's a definitely significant improvement after training. Here is just a plugin for new communication curriculum for radiology residents that was just came out at ACR. It really covers all essential elements of communications and from building doctor patient relationship, how to do it, what, how to understand patient perspective, sharing information, reaching agreement, and then providing closure. How to demonstrate empathy? We all know that we should, but the question is how physically do it, how to communicate accurate information, making sure that we do that. And then practice, practice, practice. It's not, it's not just enough to just to read it or learn it to the exam. You really have to practice. And that will change also changes your belief to how important this effective communication is. There are other techniques, and this is just a company out there that talks about comfort talk. It focuses on multiple things, how to communicate with the patient, including hypnosis, for example, but also other things, patient-centered talking styles and rapid rapport technique. And the goal for this is reducing anxiety and pain, less medications for procedures, and reduce procedure time, but also, for example, for MRI, reducing and claustrophobia, etc. So in summary, radiologists can and should, in my opinion, communicate with patients. Communications with patients will improve both patient and physician satisfaction, but however, training is definitely required to do it right. Thank you.

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