Understanding explanations.

In Senegal, where patients have a low level of literacy, understanding the nature of prostate diseases seems to have been facilitated by the 3D digital anatomy model. In the long run, this should help patients to participate and stay engaged in their disease management. Over the past decade, several studies across Africa have revealed a low level of knowledge and awareness of prostate cancer [25–30]. A tool that facilitates the communication and understanding of prostate diseases could be beneficial in improving the quality of care and reducing healthcare costs. According to Bennett et al. [31], low literacy level can be a significant barrier to early diagnosis of prostate cancer among low-income patients in America, and it is safe to assume that this is true throughout sub-Saharan Africa. It follows that appropriate communication strategies would improve awareness of prostate disease and promote earlier diagnosis. This, in turn, would reduce costs associated with the complex treatment of advanced diseases.

Impact on treatment decisions.

The discussion with the patient for consenting to treatment is especially important when they present with high-risk disease, such as prostate cancer. The need to consider and accommodate the patient’s preferences for disease management has long been the cornerstone of communication between physician and patient [32] and the use of a 3D digital anatomy model seemed helpful in this regard.

Table 3 shows that, on the whole patients favored of the digital model regardless of the reference group. However, the differences were less significant in decision-making for first-time consultants and patients monitored by watchful waiting. At the same time, the differences were much more significant in decision-making for “high-risk” patient groups, especially the biopsy candidate group, who needed immediate management of the disease.

Ability to ask questions.

Encouraging patients to ask well-informed questions should help them understand not only the benefits, but also the risks of treatment. The quality of physician-patient communication has direct impact on managing expectations and post-treatment grievances [33]. In our study, the use of a 3D digital anatomy model allowed the patient to better understand the risks and potential consequences of procedures, whether biopsy, radical prostatectomy or TURP. With just a few simple mouse clicks on the computer, physicians were able to explain complicated concepts, like the mechanism of DRE as an important diagnostic tool, or what radical prostatectomy involves in relation to functional outcomes, or the need for regular follow-ups after a negative biopsy. Lack of understanding of basic health information has had a well-documented negative impact on health care [34] and thus, the importance of making advances in patient education cannot be underestimated. Our preliminary study suggests that a modest or low level of literacy and knowledge of prostate diseases is not an insurmountable obstacle, and that the gap can be bridged by improved communication, in which the use of a 3D digital anatomy model appeared to be decidedly helpful. In this regard, our findings are consistent with Rajbabu et al. [35], who found that low levels of income and literacy are associated with poor awareness of prostate cancer, but that this situation may be improved by effectively conveying information about the nature of the disease and its management.

The mean age of patients was 69.6 ± 6,7 years in this exploratory study. In Senegal, men younger than 55 years of age are seldom seen in urology consultation. Practically speaking, nearly all patients who participated in our study were born before the “digital age”, and they were likely to have been affected similarly by the “novelty factor” of digital anatomy technology, regardless of their exact age.

Communication skills.

Communication techniques are not taught in medical school in Senegal. The use of an interactive 3D digital anatomy model represents not only innovation but is also a tool to guide and help the physician in conveying information to the patient, thus facilitating communication. It can also be a useful tool for the physician to emphasize certain aspects of the disease and to finetune communication of the patient’s specific needs in consideration of his symptoms and prostatic pathology.

Obtaining consent to treatment.

Our findings were consistent with existing literature. Our 3D digital anatomy model can be considered conceptually similar to the cartoon illustrations proposed by Delp et al. [36], which were found to improve adherence to treatment. Haskard Zolnierek et al. [37] found that the risk of non-adherence to treatment by patients increases by 19% when the physician does not communicate well with the patient, and the chances of adherence are 1.6 times higher when the physician has undergone communication training.

Lengthening the consultation.

The increased length of the consultation, which was reported by the majority of physicians, is a significant concern. Simple didactic anatomic pictures play a similar role and they take less time. During the first part of the consultation session the physicians used some didactic anatomical pictures of their own design and drawing. Nonetheless, both physician and patients uniformly reported favorable experience from additionally using 3D digital anatomy models. Hence in this paper we argue that the use of 3D digital models may help improve upon the quality of patient-physician communication.

This could be explained by that fact that using interactive 3D anatomy model is a novelty for both parties. Over 90% of patients found that the 3D digital anatomy model improved their ability to ask questions, and more questions always lead to longer consultations. For physicians, the 3D digital anatomy model is a new technology that involves a learning curve; it is quite probable that the length of each consultation would be reduced as physicians become more proficient in using this technology on the computer. Moreover, the use of the 3D Slicer software adds complexity and can be confusing for novice users and may require extra time to use during consultations. However, one can argue that, in contrast to the current practice, the increase in the length of consultations may be well-compensated by the gain in the quality of communication, and in turn, in the quality of care.

Encouraging colleagues to adopt the technology.

The willingness, unanimously expressed by physicians in this study, to popularize the use of 3D digital anatomy models reinforces the hope that this technology will be well-appreciated by its physician users.

Study design.

In this single-arm exploratory and preliminary study, with each patient we conducted two urological consultations, back-to-back: first a conventional consultation session that was immediately followed by a session using 3D digital anatomical models, and then we gauged the perceived improvement on the quality of the physician-patient communication through simple questionnaires.

The ultimate objective of improving physician-patient communication is to improve patient willingness to pursue further care and sustained compliance with the prescribed follow-up regimen, a crucially important aspect for all patients with prostate disease. Although this could not be measured in this short preliminary study, existing literature supports our expectation that improved patient-physician communication should lead to improved patient compliance in general [37]. In follow-up work, we plan to run a randomized study with two arms of patients, one receiving conventional consultation and one receiving consultation with using 3D digital anatomical models. This future study would allow us to compare clinical outcome variables, such as willingness to pursue further care, etc.

Choice of questionnaires.

We used simple binary questions to gage various aspects in patient and physician experience with the 3D digital anatomy model, with respect to the quality of communication during consultation. We considered the use of scaled feedback, even as simple as Likert scales, and decided not to follow that approach. As our patients have a very modest level of literacy, they could have been easily overwhelmed by more complicated questions involving concepts like “scale” or “percentage”. The physicians, however, could have been asked more nuanced questions, and this will be considered in future studies.

In this exploratory study, we intended to size up the perception of participant, rather than more objectively assessing knowledge and experience gained by the participants through using of 3D digital anatomy models and whether the actual communication skills of the physician is improved, for which we will need to capture and analyze what is actually said and communicated to the patients; all this, however, we were compelled to reserve for future work. In further follow-up work, in the randomized dual-arm study mentioned earlier above, we would construct the questionnaires differently and would also break down the results by referral groups; it is suspected that patients with benign and malignant conditions may react to the outcome of urological consultation differently and thus may differ in their willingness to pursue further care.

Choice of the 3D anatomical model.

The 3D digital model was not personalized based on the individual patient case, for this is not possible in Senegal, for multiple reasons. For many patients, the consultation session studied in this paper was the first meeting between the physician and the patient upon referral, when practically no Senegalese patient has prior imaging scan of any sort. Moreover, due to general lack of imaging capacity, especially that of MRI. In future work, we consider creating several anatomical models, and based on a quick digital rectal examination, the physician could select the one that feels the most similar one to the prostate of the given patient.

Choice of digital anatomy viewing software.

During the urology consultation, the 3D digital anatomy model was viewed with the free, open-source 3D Slicer software [22, 23]. 3D Slicer is an extremely powerful and complex research platform for medical image analysis and visualization, offering over 1,000 major functions in its core, and fortified by over 100 extension packages. The use of 3D Slicer for the sole purpose of visual rendering may have been overly complex for new users, and it was probably the most important reason why over 76% of the physicians felt that using the 3D digital anatomy model lengthened the consultation exceedingly. In future work, we consider using the Open Anatomy Browser [22], another free open-source digital anatomy viewing platform that is much simpler to learn and operate, which, in turn, should help reduce the length of the consultation session without loss of effectiveness. Moreover, the Open Anatomy Browser visualizes 3D digital anatomy model created in 3D Slicer, allowing is to reuse previously created models. The Open Anatomy Browser works through a public web interface, accessible from mobile device, such as smart phone, that practically all Senegalese physicians possess. Finally, the simple user interface of the Open Anatomy Browser may allow patients to review on their own mobile device the main points of the consultation with their family and their referring physician.

Robustness of findings over time.

One significant limitation of this study was the 4-month duration, a time frame insufficient to ascertain the consistency and robustness of our findings over time, particularly of the enthusiasm of doctors to use the 3D digital anatomy model and their desire to popularize it among their colleagues. It is possible that part of their enthusiasm was generated by the appealing technological novelty and the fact this study was the first of its kind in Senegal and, according to our knowledge, in sub-Saharan Africa.

Relationship to public awareness of prostate disease.

The work presented here is not a “community intervention” on awareness, but rather can be considered as a “clinical intervention” following initial referral for consultation. Increasing the awareness of prostate disease and improving the management of the disease (including patient-physician communication, the subject of this paper) must go hand in hand. In Senegal, we promote the awareness of prostate disease to the public through the annual Prostate Disease Awareness Day (PDAD), a sweeping outreach effort in the Senegalese media and social platforms. Participating media outlets include the Senegalese National Television, 4 private television networks, 6 radio stations, and 2 major social platforms. PDAD provides not only general information to the public, but also free, walk-in urology consultation for ad-hoc patients. In Dakar alone, over 60 participating physicians (urologists and general practitioners) provide free clinical consultation during PDAD.