A few months ago, one of my readers sent me the following message, “I would like you to write about what clinicians want from a radiologist.” That comment initiated some thoughts about the topic since our primary goal, as radiologists, is to answer the clinician’s questions. But let’s take this idea from a different angle. At some point in our careers, we all have made cardinal mistakes that turn off our referring clinicians. What is more interesting than the mistakes that most of us have made in our career to teach us lessons about how we can avoid angering our referring physicians and make things right for them? So, let’s talk about what clinicians don’t want from a radiologist! (The negative tends to be more interesting than the positive!) Let’s give this a whirl…
The Forced Hand
In training and board examinations, our instructors tell us to write recommendations for further management. So, how bad could it be to recommend a biopsy for a thyroid nodule when you see a new one? An angry head and neck surgeon stomps up to the department and looks for you. He yells loudly, “Why are you telling me what to do with my patient. He should not be getting a biopsy in this condition!!!” Bzzzzzzzz… (Buzzer sound)
Pretty darn bad! When you write a recommendation, you have to remember that you often don’t have the full picture of the patient’s situation. In other words, there is an asymmetry of information between the clinician, the radiologist, and the patient. Maybe, the patient can’t lie flat. Perhaps, the patient can’t handle needles. Possibly, the clinician knows about an outside study that you don’t. Or, the clinician is privy to some other issue that you cannot imagine. By recommending a biopsy of a thyroid nodule without a caveat, for instance, you are legally forcing the clinician into having to investigate it further. In contrast, it may not be the correct management protocol for the patient. I have learned to be very gentle with my management recommendations over the years!!! Always leave the clinician a way out…
We write a list of 10 items in our differential diagnosis without additional comment- like a laundry list to give a “complete differential.” Days later, you get a phone call from the clinician- “I don’t understand what you are saying- what do you think is going on here?”
How can we avoid this scenario? If you have an extensive differential diagnosis, always state what you think is most likely and why. Avoid delving too far into the 1 in a million diagnosis unless you have a real sneaking suspicion it might be the correct one. Clinicians appreciate when you make your best guess since it often will steer the doctor down the right path. Too much information without direction can be harmful!
The Saucy Radiology Report
You are angry that the referring physician did an inappropriate workup on a patient performing iodine scan as the first test in a workup for a palpable thyroid nodule. In contrast, you know that it should be a thyroid ultrasound instead, so you put in your report the following statement, Make sure to order the ultrasound instead of a thyroid scan in patients with a palpable lump. The doctor comes storming in, “How dare you to talk to me like this in your report. It is a legal document!”
If you have an issue with a clinician, make sure to air your dirty laundry outside of the report. The clinician is correct. You are putting the physician in a potential situation with legal liability. This sort of comment does not belong anywhere inside the report.
The Discrepant Report
You dictate a case from the night before when the overnight resident was on call. In the morning, you find a pulmonary embolus, but you do not look at the additional documentation from the resident or the nighthawk. You do not call the doctors to let them know. Later in the day, the ER doctor walks up to the emergency department and says, “What the hell is going on here?” It turns out the overnight doctors did not call the study positive and sent the patient home. You didn’t notify the doctor!
Discrepant reports between you and other physicians can cause negligent patient care. Be sure to check all the information to make sure that all parties are on the same page. Discrepancies will occur. But make sure to notify all parties!!!
Is It Better, Worse, Or Unchanged?
You are following a patient with breast cancer on a CT scan, and you proudly discover and then mention a subtle liver lesion in your report. Next, you refer to the prior study, but don’t look at it. You also do not document the size of the lesions, nor compare the size of the abnormalities to the previous study. Two days later, you get a phone call from the oncologist, “What is going with my patient? I need to know if I have to change chemotherapy. Are the hepatic masses changed?”
Clinicians always want to know if their patient is improving, unchanged, or progressively worsening. These imaging issues often change clinical management and are of the utmost importance to the clinician. Always make sure to put these findings under the impression of your report!!!
You look at a pelvic MRI on a patient with fibroids. The fibroids seem to be growing over time. However, you don’t check the report and click the sign off button. Before you know it, the dictation goes out to the clinician. Three days later you get a phone call from the doctor, “It says here in the body of the report that there is interval enlargement and in the impression, there is no interval enlargement of the fibroids. Which one is correct?”
Make sure to check for grammatical and logical statements within a completed dictation before signing it off. Very few things piss off a clinician more than having them read an incomprehensible report. An unclear story leads the clinicians down this pathway. Always check your work!!!
The Wrong Diagnosis
You are looking at a hand x-ray with a type of arthritis that you have not seen before. Finally, you decide to dictate the case without confirming the diagnosis via Google or running it by another clinician. You call it osteoarthritis. The patient gets treated based on your report. One year later, the patient is still not getting better, and the doctor sends a new film to another one of your colleagues. He comes up to you later in the day and states, “you dictated a case and called it osteoarthritis. It was a definite case of gout!!!”
If you are not sure about a diagnosis, always make sure to either look it up or run it by someone else. We are in the business of healing others. You should never have too much pride to make guesses when you can get the correct answer!!!
Not Answering The Clinical Question
You dictate a plain film of the chest, and you happen to see a lytic lesion in the middle of the thoracic spine and a pulmonary nodule in the right lower lobe. So, you put in your impression- MRI of the thoracic spine recommended for further characterization. 8 mm right lower lobe pulmonary nodule. A few days later, you get a phone call from the physician- “We already know about the bony lesion, and it is a known hemangioma as seen in previous studies. The history said to compare the lung nodule with the prior study. Please take a look at that!”
It is imperative to scour the history for whatever clinical question the clinician wants you to answer. This way, you can provide a helpful answer to improve patient care. That is the main reason we are here as radiologists!
The Eight Deadly Sins- Lessons Learned
As clinicians, we always need to self-reflect to improve our practice of medicine. There is no room for too much pride. We should continuously look for ways to improve our clinical skills, reports, and communications with our colleagues. I have just given you eight different examples of issues that can arise if you want to cut corners. You can easily avoid further carnage with your reputation, your patients, and your colleagues by remembering these situations. Use these examples as a template to prevent the eight deadly sins of a radiologist!