University of Pretoria
The use of diagnostic medical imaging can be defined as “timely access to and delivery of inte¬grated and appropriate radiological studies and interventions in a safe and responsive facility and a prompt delivery of accurately interpreted reports by capable personnel in an efficient, effective, and sustainable manner”. According to Ber¬nardy et al. (2009: 844), the quality of medical care brings value to both patient and provider when medical imaging is justified and is performed correctly. These fragmented studies focus on test ordering, cost, and over-utilisation of diagnostic services. The current study was an attempt to bridge the gap of fragmentation and to embrace the shift from a technology-centred approach to an integrated patient-centred approach. The main aim of this study was to get an understanding of the various decision-making processes involved in referral for and the choice of the most appropriate diagnostic imaging investigation and how they had a bearing on the interactions between pa¬tients and health care professionals. Methodology: A social constructivist conceptual framework informed the inductive, emerging qualitative research design adopted for this study. An instrumental case study of one district hospital and its referral links was selected as methodological point of departure. The study consisted of two main phases, the one follow¬ing on the other. In the first phase, real-life, individual mini-case studies were con¬ducted by “shadowing” 24 patients, from the point of reporting to the hospital up to their discharge from hospital or admission for in-hospital treatment. Data collection methods in this phase included entry and exit interviews with patients, observations at various points of care, and interviews with different health care providers involved with the care of each patient. In the second phase, focus group interviews were conducted with the same and other health pro¬fessionals to triangulate the findings emerging from the shadowing process. Findings: Provider-patient interactions are explored in terms of patterns of interaction during the consultation and the diagnostic imaging investigation, as well as in terms of issues of communication, continuity and fragmentation. Patient expectations and experiences are explored from the viewpoint of health providers and of the patients themselves. The findings in this report are structured around the following themes: (a) services and administrative processes and referral pathways for diagnostic imaging investigations; with an overview of the health-facility complex in which the district hospital was situated and the various referral pathways for diagnostic imaging investigation that could be followed. (b) This exposition is followed by an exploration of structural and organisational interactions between health care providers from referral for diagnostic imaging, to investigation, interpretation and integration.; (c) Interprofessional interactions between and experiences of health care providers; (d) provider-patient inter¬actions with regard to diagnostic imaging investigation, with a special focus on the role of the radiographer as trainer, mediator, gate keeper and gap filler and the differences in interactions inside a radiology department and outside of it. Hierar¬chies, boundaries and task-shifting are also highlighted. Radiographers were found to occupy a tenuous space in decision-making processes and interactions, with their services needed but their profession not appreciated by all cadres of health professionals; (e) provider-patient interactions were explored in terms of patterns of interaction during the consultation and the diagnostic imaging investigation, as well as in terms of issues of communication, continuity and fragmentation and (f) patient expectations and experiences are explored from the viewpoint of health providers and of the patients themselves. Conclusion: Diagnostic decision-making processes are interwoven within the hierarchical structures of the institution across the different levels of care. Insights from various theoretical models and themes were applied eclectically to construct the “bigger” picture of decision making in a complex health system. In order to accommodate the complexities of and all role players involved in diagnostic imaging investigations it is proposed that the notions of patient-centred care and shared deci¬sion making be replaced with a patient-provider-centred approach to care and collective decision making. Collective decision making includes elements of distributed, shared, negoti¬ated and collaborative decision making.