A Mammogram As A Metaphor For Patient-Centered Care

Several friends recently told me their tales of mammography angst. Not exactly the patient-friendly experience one should expect.

Mammograms are optional, and one can generally choose where to have them. So it seems to me that screening centers should do their best to make an accurate scan as simple, easy and fast as possible, with results provided on the spot. Getting it all over with in one visit might even increase the number of women who have these important tests at recommended intervals.

And it might save providers money by avoiding wasted administrative time trying to communicate with patients and their physicians.

But, that's not the way it happens for most women today, and that's too bad.

According to the U.S. Food and Drug Administration, 38 million mammograms are performed each year among the 64 million American women over age 40, making it probably the most common routine medical test, yet most women have to wait days, and some even weeks, for their results.

On top of their annual nervousness about submitting to the uncomfortable—sometimes downright painful—compression, friends describe with considerable drama the ritual they endure. It starts with making an appointment weeks to months in advance, and then there's several lead-up days of quiet terror in which we envision how we'll cope with the disruption a diagnosis will surely cause in our lives.

But even more awful is the time lapse after the scans are done. My friends say they're always told, "Go home. We'll contact you in a few days" with the results. Or, they're told, "Call us."

Someone from the imaging center will write or call if the images are blurry and must be redone, or if there is a problem and something "suspicious" is found. Then, patients have to go back to their physicians for another "order," make another appointment for another mammogram, perhaps an ultrasound, show up, get the test again, go back home, and then endure that quiet terror, again.

A few friends described days that turn into weeks of crossed voicemail messages from the family doctor or ob-gyn, missent letters and miscommunication because physician's offices can't leave phone messages due to privacy set by HIPAA, the Health Insurance Portability and Accountability Act.

In full disclosure, I have never had to wait.

For the last 15 years or so, I've had my tests done at Mammography Screening Center, a small San Diego imaging company run by a board certified diagnostic radiologist, Frank Hamlett MD, and his technologist wife, Diane. They provide results within 10 or 15 minutes. They did so again just last week, before the red one-hour parking meter flag went up.

Radiologist Hamlett is there on site when I am, with my imaging history in front of him ready to review. I leave not having to think about my mammogram for another year.

This is the way it should be for 90% of those 38 million mammograms—roughly the number of images that statistics indicate will turn out to be normal on the first pass.

"With mammography, the level of anxiety and apprehension a woman experiences is usually higher (than with other diagnostic tests)," acknowledges David Winchester MD, board chairman of the National Accreditation Program for Breast Centers. Many of the 125 or so mammography programs now being nationally accredited "will have that kind of rapid turnaround."

"It's a mark of a good center that has the capability of immediate interpretation," he says.

Winchester says that many more providers are making sure they have properly trained radiology readers to review mammography scans on the spot "because it's getting very competitive. Providers are having a wake-up call."

Thank goodness.

Holly Davis of Quakerbridge Radiology in Mercerville, NJ, agrees. "Our goal is to eliminate the anxiety that women experience as they wait for their results of screening mammo. And at the same time, while eliminating anxiety, we eliminate the need for physician's office staff to contact for additional imaging." It's same visit results.

Recently while at a health fair promoting Quakerbridge, Davis recalled talking with women about the benefits of same-visit results, and hearing them marvel at the possibility. "They said, 'Really? I can get the results before I walk out?' That's right, I said, and they said, 'Okay!'"

So why aren't more mammography centers more patient-centered, especially in this sensitive and emotionally-driven area? Why aren't same-visit results the standard? And with so many mammograms in this electronic age, why can't interpreters in distant locations instantly read the images via networks?

Turns out, the process of reading mammography is a bit more complicated for most centers. Carl D'Orsi, MD, co-chair of the American College of Radiology's Breast Imaging Commission, says centers find it more efficient to have separate teams of radiologists reading batches of screening mammograms versus diagnostic ones—those tests done when the woman detects something unusual. When the same radiologist is reading both types of mammograms, he says, "the accuracy goes down."

Most centers, he says, "don't have someone physically sitting there in a screening center."

That's certainly true in rural areas, which have to send images elsewhere in batches to be interpreted, Winchester says.

Susan Brown, director of health education for Susan G. Komen For The Cure says throughout the country "it's customary for women to leave their mammograms without having the results."

Brown says she understands how some women—women like me—might fret if they have to wait.

Brown says this worry may translate into many women not getting mammograms when they should. "It may mean next year they don't want to go through the hassle again. Maybe they've had good results for the last few years, and their concern was less, perhaps, than the degree of hassle they felt going through the process."

There may be good excuses why most centers can't give results right away, but with today's capacity for telemedicine and electronic images easily sent within moments of capture, perhaps more mammography results could be given more promptly. That would be a great way to provide patient-centered care.