Additional reporting by Jenny Bogert, Alyssa Collantes, Jessica Flynn, Eduard Marmut, Jennifer Varga
AS SONOGRAPHERS, we tend to focus our improvement efforts on image optimization, protocols, and ergonomics.
One muscle we often forget to exercise is communication, yet communication between the sonographer and the patient is equally as important as the technical aspect of our work.
Even when we perform a technically perfect study, if the patient has an unpleasant or stressful experience, we have not accomplished our job as healthcare providers. On a diagnostic level, the sonographer and physician alone cannot acquire 100% of the pertinent patient information. When investigating the patient’s case, the patient is the most significant part of the sonographer-physician-patient triangle.
Over the years, I have translated that valuable lesson into five major rules, which any sonographer can follow to ensure that the patient has an ideal experience and that crucial patient information is not overlooked.
Rule 1: Accommodation
The first rule is accommodation. Vascular, cardiac, and musculoskeletal, the entire spectrum of pathology affects nearly the entire patient population. Thus, as sonographers, we interact with patients of varying gender, race, age, body habitus, and physical condition. When dealing with diversity, having a static mindset regarding the evaluation will steer you in the wrong direction. Instead, the sonographer must learn to adapt to the patient by adjusting her protocol depending on the individual patient. A middle-aged patient will scan differently than a geriatric, a female patient will scan differently from a male patient. A morbidly obese patient will scan differently compared to someone with an average BMI.
Even if you are imaging identical twins, you have to remain vigilant. You may not realize that there is variation in their lifestyle, diet, or even their acute level of hydration. These are all factors that can influence patient presentation upon insonation. To accommodate for these factors, always select the appropriate transducer, adjust your ultrasound system settings, and perform image optimization throughout the exam.
Beyond the influence of patient demographics and body habitus, the patient’s own symptoms may prove to be a challenge. For example, consider imaging the lower extremities. Patients with advanced arterial or venous disease may present with gangrenous wounds or ulcers respectively. If the skin is not intact, this will require the use of a sterile technique. Specifically, a sterile probe cover and sterile gel should be utilized, with the gel placed both inside the cover and on the surface of the skin to create a matching layer. Patients with severe edematous tissue, post-operative wrapping, or braces present another challenge altogether: a physical barrier against insonation. These situations require careful transducer manipulation to obtain an optimal view around the obstacle.
In the same way that it is necessary to adjust your performance of the technical protocol depending on the individual patient, it is also necessary to adjust your methods of patient care. A high proportion of the elderly patient population has physical ailments that make it difficult to ambulate. Patients utilizing canes, walkers or wheelchairs cannot be treated in the same manner as an ambulatory patients. They require extra as- assistance and attention. Whether this attention entails physically wheeling the patient to the imaging lab, offering an elbow for support, or simply placing a hand on their back for guidance should be judged on a case-by-case basis.
This extra level of attention should not cease once the patient is on the bed. Patient positioning plays an essential role in patient comfort. For example, a common patient complaint is pain upon lying flat. In order to accommodate the patient, tilt the back of the bed. If your equipment does not permit this, provide an extra pillow under their upper back for cushioning. Do not hesitate to improvise in order to maximize patient comfort.
Rule 2: Investigation
The second rule is investigation. Patients will let you know, often with enthusiasm, when you are not being accommodative regarding something that pains them. However, physical pain is not the only symptom that you should devote your attention to. Latex allergies, vertigo, contagious illnesses, and mental health issues are just a few of the conditions that require different forms of accommodation, although not all are immediately evident. The sonographer can figure out exactly what to accommodate by investigating the patient.
Beyond assisting inpatient accommodation, investigation helps the sonographer gather important clues regarding what the physician is specifically looking for and to help piece together the puzzle that we call “the clinical question.” Ask the patient about their signs and symptoms to help you hone in on the source of the pathology. Ask the patient about medical, surgical, and family history relevant to the exam and ensure that the patient answers each one before proceeding to the next. If the patient is having trouble answering sufficiently, probe for details. Instead of asking binary questions, allow the patient to elaborate on the clinical question by making it open-ended.
Thoroughly review the patient chart as well. If access to the full patient chart is unavailable or outdated, the aforementioned questions become doubly important. For example, a study indication of shortness of breath won’t specifically clue you in about the patent foramen ovale closure the patient had recently. If you don’t investigate, specialized focus of the interatrial septum that the patient requires may not be performed.
Frequently, the patient may view the sonographer as someone closer to a peer and will talk more freely regarding the clinical questions than they would to a physician. It is the responsibility of the sonographer to embrace this role and encourage this behavior.
Rule 3: Interaction
The third rule is interaction. As a sonographer, you hope that the patient is active in sharing their information. However, what we often fail to realize is that the patient has similar hopes for us. Empathizing with the patient will make this immediately evident.
For the sonographer, the imaging facility is your familiar place of work. For the patient, it is a foreign environment. To alleviate the stress a new environment may induce, your job is to make the patient feel at home. Introduce yourself in a pleasant tone of voice, offering a positive smile and maintain- ing eye contact. Respect the patient’s privacy, providing them with a personal area to change into appropriate clothing for sonographic access and a basket to securely place their belongings instead of sprawling them out on a desk or chair.
Patients are not always briefed and, even when they are, may not understand the health-care lingo. Patients will often come into the imaging lab unaware of which exam is going to be performed or what it entails. Sometimes, they are under the impression that their appointment only entailed speaking with the physician. It is important to explain the modality, duration, and purpose of the exam in clear, concise terms without being patronizing.
A patient who has recently received a peripheral arterial exam and is now receiving a peripheral venous ultrasound might be perplexed as to why they are “having this exam done all over again.” I make it a point to reassure the patient that they are receiving the correct exam and to explain that while both studies might seem similar, one looks at the arteries while the other looks at the veins, so there are two different protocols that we follow.
As you are performing the examination, describe the specific steps you will take before you perform them, so that the patient feels involved in the process and knows what to expect. There may be some pressure applied during the exam. You may need to move the patient’s body into a certain position, or you may need to reapply that ice-cold gel. Advise the unsuspecting patient so that they are not startled.
Interacting with the patients will help you with achieving the first two rules: accommodating and investigating the patient. Unless the patient has specifically requested quiet, you can usually assume that silence stems from the patient’s uncertainty or anxiety. Cutting through the tension with friendly banter can lighten the mood. This will make the patient more cooperative, allowing you to obtain images of the highest diagnostic quality. You will be surprised by how much information patients will share if you put them at ease from the start. Furthermore, don’t underestimate the sense of satisfaction that you derive from these interactions. Many patients, especially of the geriatric population, have few people to talk to, and you may just be the bright spot in their day.
Rule 4: Maintain Composure
The fourth rule is to always maintain composure. The patient’s emotional state plays a significant role in the sonographer’s daily interactions. Despite your best efforts to accommodate and interact, a patient may still be defensive, anxious, argumentative or frustrated. This attitude will not only project onto you but might also impede your ability to have a clear line of communication with the patient. As professionals, we are responsible for maintaining composure and continuing to utilize positive communication skills. This is not achieved by submitting to the frustrated patient. This is achieved by speaking with confidence and conviction and by providing frequent instruction. Encountering authority gives the patient a sense that the situation is under control and can be resolved. Remember to balance your emotions with rationality.
In a worst-case scenario, communication can completely break down. When a patient is lacking relationship skills, they can often make inappropriate actions or remarks. They can cause you to feel uncomfortable, distracted, degraded, or even threatened. Patients that are harassing sonographers should be initially handled by setting boundaries. Address the patient by clearly letting them know that their comment was inappropriate and asking them to maintain a respectful demeanor during the remainder of the exam. If this does not change the patient’s behavior, do not hesitate to end the exam early and address the issue with your supervisor.
Rule 5: Prioritize
The fifth rule is prioritization. This is the most recent rule I’ve established after reflecting on why some of my and my team’s communicative experiences ended poorly. Most human interaction stems from the human needs of each party involved. Maslow’s hierarchy of needs divides these needs into five generalized tiers on a pyramid. From bottom to top these tiers are physiological needs (i.e. air, sustenance, sleep), safety (i.e. shelter and security), belongingness (i.e. intimacy and friendship), esteem (i.e. respect, status, recognition), and self-actualization (i.e. achieving one’s full potential, morally and creatively). The needs of a lower tier of the pyramid must be fulfilled before one can attend to the needs of the higher tiers. Communication that attempts to fulfill higher-tier needs while ignoring basic lower-tier needs will be ineffective. This is an intuitive concept when applied to real-world examples. For example, it would be a poor marketing strategy to advertise diamond jewelry to unemployed students.
The same concept is highly compatible with the healthcare field. In many instances of poor sonographer-patient communication, my team found that the issue was not resolved because we attempted to resolve it by placating the needs of the incorrect tier. It is difficult to investigate the patient if they are experiencing severe anxiety, irritability, or white coat syndrome. Explain the exam and make friendly banter to improve their mental state. Likewise, it is difficult to make friendly banter if they are experiencing acute or severe pain. Adjust the patient’s position and do everything you can to alleviate their physical pain. If you develop the necessary skills to prioritize and handle these needs in the proper order, you will notice a tangible, positive difference in your daily interactions.
Sonography is an art. Our goal as sonographers isn’t to autonomously follow a protocol and acquire images. Our goal is to prove our case and to create a rich story, from beginning to end. The telling of this story is achieved through both streamlining ultrasound images and streamlining communication. Your aptitude to accommodate, investigate, interact, maintain composure and prioritize are invaluable to this process. Remember that the quality of your communication skills directly affects your ability to obtain pertinent clinical information, which directly affects the physician’s ability to manage the patient, which directly affects the quality of patient care in your community.