Month: April 2022

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Most Commonly Mistaken Orders From Clinicians

mistaken orders

Teaching radiology to students is not the priority at many medical and physician assistant schools. Eventually, these students become staff, faculty, and attendings. And, knowing how to avoid mistaken orders in radiology takes a little bit of savvy and education. Therefore, many folks do not know what to request, even though they are responsible for ordering the correct studies. And I’m sure many of you have noticed this issue, whether beginning on your path through radiology or as a more seasoned veteran.

To make this point, recently, a group of referrers wanted to me give them some tips about how they should order studies. In particular, they wanted to know when to request contrast and how to make sure their patients are getting the proper test. So, as I mulled over how to present this information to them, I realized this would create an excellent blog! So, let’s go through some of the most commonly mistaken orders that clinicians make when they order studies.

Most Commonly Mistaken Orders!

Chest CT

Hilar and Mediastinal Masses

How often do you see patients receiving non-contrast chest CT studies where the primary diagnosis is a hilar or mediastinal mass? I don’t know about you, but we come across these mistaken orders frequently, especially in cases where the patient has no contraindication to intravenous contrast. Why is this a mistake? Well, you need to be able to separate the mediastinal vessels from an adjacent mass of the same density to evaluate it!

Pulmonary Nodules

Likewise, for pulmonary nodules, typically, we don’t need contrast because the contrast between a soft tissue density nodule and the adjacent pulmonary parenchyma is spectacular, to begin with! With all its complications, intravenous contrast does not play a role in the situation of following a pulmonary nodule.

Ordering Chest CTAs vs. VQ Scans

Commonly, we see the mistaken orders for this situation all the time. First of all, a chest CTA is usually the best test when you are not sure about the diagnosis. For example, one of many possible diagnoses is pulmonary embolus. A chest CTA will allow you to figure out if pulmonary emboli are causing the symptoms and if one of a million other diagnoses are causing the same (pneumonia, pneumothorax, masses, etc.)

On the other hand, a VQ scan is best when the patient is significantly less likely to have an alternative diagnosis. Of course, VQ scans should also be the first-line test when patients have c0ntraindications to contrast for any one of many reasons.

Moreover, if the patient has a history of pulmonary embolus, diagnosed on any test, and you want to check for interval change, you should order the same test next time. It adds specificity to the diagnosis, whether the prior was a chest CTA or a VQ scan.

Abdominal Imaging

Mistaken Orders For Abscesses And CT Scans

We see patients who receive mistaken abdominal and pelvic CT scans orders that do not recommend intravenous or oral contrast for a suspected abscess. Why are these specifications critical for performing a workup for abscess? Well, bowel loops and abscesses can have the same density. So, you can quickly lose the forest for the trees and miss an abdominal abscess.

Additionally, we often see a workup with an order that only includes an abdomen or pelvis for an intra-abdominal abscess. It is an incomplete study if you only order an abdomen without the pelvis and a pelvis without the abdomen. Patients refer visceral pain to many places different from the site of symptoms! So, don’t limit yourself to only one if you are unsure.

When To Order Abdominal MRI

One of the biggest confusions I see is when to order an abdominal MRI vs. CT scan. In the case of any time when non-ionizing radiation can take the place of a CT scan with similar or better specificity, MRI is the preferred exam. Therefore, ordering an MRI for a possible hepatic hemangioma would make a lot of sense. Imaging pancreatic cysts is also usually the preferred method for the same reasons!

Don’t Order Ultrasound For Pancreatic Mass/Pancreatitis Screening!

Ultrasound is an inferior test for the evaluation of the pancreas. You can miss as much pathology as you can find because it sits in a location that bowel and body habitus can easily obscure. So, consider another test instead!

Extremities CT vs. MRI

Ligamentous/Cartilaginous Pathology

MRI of the extremities is a better option for almost all soft tissue pathology. CT does not resolve the nuanced difference in soft tissue because it relies upon different densities to pick out pathology. And, pathologies of the ligaments, cartilage, and muscles usually have the same density as the adjacent normal tissue. MRI allows you to differentiate the differences between these tissues based on water and fat content!

Bone Pathology

CT works much better for evaluating primary bone abnormalities such as fractures, bone tumors, and degenerative changes to help make an initial diagnosis. CT scan allows for a better evaluation of the calcific matrix. On the other hand, MR or CT may make sense in a follow-up study of a bone issue, depending on the situation. For instance, a follow-up of the extent of a known bone tumor or metastases can be more sensitive on an MRI. I would recommend calling the reading radiologist if there is any question!

Breast Imaging

Ordering Mammograms Vs. Breast Ultrasound

In general, for patients with a breast lump, clinicians should order a breast ultrasound when the patient is under 30 and a mammogram over 30. Why do we recommend this? Under the age of thirty, breast tissue is more sensitive to radiation. Additionally, the pathologies, such as cysts and fibroadenomas, tend to be more specific. Do an ultrasound before the mammogram in the older population. You can miss the entire picture and need to bring the patient back for a wasteful second ultrasound to figure out if there is pathology!

Ultrasound Breast Screening Versus Diagnostic Breast Ultrasound

I find this issue one of the most frustrating of them all. But, it is also confusing for the ordering clinician. We will often get a prescription for a patient with breast pain for a mammogram and ultrasound. A mammogram is often all you need for this symptom because breast pain is not a risk factor for detecting breast cancer. But, sometimes, the ordering doctor may want a screening ultrasound test or a focused diagnostic ultrasound, not both. A screening ultrasound involves all of both breasts. And a focused diagnostic ultrasound is only for the area of symptoms. Based on the order, we often cannot tell which one it is. So, the ordering doctor must tell us what they want. Otherwise, the patient may not get the correct exam!

Lumbar Spine MRI

Contrast Vs. No Contrast

Get this one right because it can waste time for the radiologist and the patient! For generalized back pain, MRI without contrast is sufficient. It can detect all sorts of disc and bone pathology. Intravenous contrast is not harmless and usually does not add any particular benefit in this situation. And, if there is something that needs further workup, we will rarely recommend an additional test with intravenous contrast. On the other hand, prior surgery is a common indication for intravenous contrast because it can be difficult to distinguish between post-surgical scarring and disc pathology.

Fluoroscopy Mistaken Orders

Upper GI series vs. esophageal vs. small bowel series

Clinicians should be as specific as they can with what they want to order. If they’re going to evaluate dysphagia, request an esophagram. Or if you a patient has reflux with abdominal pain and possible ulcer, order an upper GI series. Likewise, if the patient has anemia, order a small bowel series. Fluoroscopy exams are focused, and these examinations are not precisely the same, so they need to let us know what they want!

Mistaken Orders- A Radiology Conundrum!

As radiologists, we want to ensure that the patients receive the best exam possible for their condition. Doing the proper examination can improve patient health, prevent undue complications, and decrease the length of the disease course. And, many ordering clinicians do not have the training we have had. So, make sure that the tests that clinicians order are correct and make sense. We need to continue educating the folks who order these studies to improve the health care system for all!

 

 

 

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Am I Efficient Enough?

efficient

The ACGME requires all radiology residents to fill out a log of studies that they have reviewed in all radiology residencies throughout the country. Unfortunately, though, the onus is on the resident to assess for themselves if the numbers mean that they have learned enough to build their skills to the appropriate level. And, as most residency directors are aware, that number can significantly deviate among residents. Some residents fill out numbers that may reflect a glance at a study. Others give in the number of studies that they have dictated. These numbers can be high or low. Regardless, the gross number maybe not be so critical if you still cannot get through as many cases when you start in practice. In that case, how can you tell how efficient you are right now? And, where should you be at any stage of your training? Let me start by talking about rotation goals and objectives (because you might think that would help), and then I will give you a few guideposts that you may be able to use.

Can Goals And Objectives Tell You Where You Are?

Every program has written goals and objectives for each rotation that you should aim to complete before you finish it. As you scan through this list, you will probably notice a list of bullet points that you are supposed to do and know during any year. You can use it to figure out what information you have learned and where you need to focus. Nevertheless, I am the first to admit that it may not be all that helpful to determine efficiency. Additionally, the goals and objectives are often outdated. Or even worse, the residency program has copied it from other residency programs! So, the utility is equivocal for determining your efficiency.

Fundamental Ways To Tell You How Efficient You Are At Any Level During Residency

Clocking Speed To Become More Efficient

Clocking your reading speed can be an effective tool to determine how fast you are. But I bet many of you have never tried it. Take ten cases in any modality and read them like you usually would. And measure how fast you read them all. Then, compare with your peers. This technique can be a starting point to determine your actual speed. You may be surprised to learn that you are faster or slower than you initially thought!

Do You Have A Search Pattern That Is Second Nature?

If you are a long-time reader of my blogs, you have probably seen a pattern where I mention search patterns a lot. But, there is a reason for it. A search pattern is a primary tool that radiologists do to make the findings. So, think about your search patterns. Do you know them cold? Or, are always forgetting one or two parts of a film or CT scan each time you read. By the second year of your residency, the search pattern should become ingrained in your psyche. If not, think about reviewing them repeatedly until they become second nature.

Comfort Level Is Critical

If you dread reading certain studies or doing particular procedures, there is probably a good reason. Either you haven’t done the background reading for them. Or you have not participated in reading or doing them. So, assessing your comfort level in any rotation is an excellent way to determine if you are efficient at this point.

Can You Dictate Rapidly?

At this point in my career, when I have a dictaphone in hand, I will often go into a “holy chant.” It is a snappy banter that gets my point across in a relatively short amount of time. Most of you are probably not at this level because you have not read as many images. But, if you struggle to dictate a case at the end of your second year, there is a pretty good chance you are not all that efficient yet!

Am I Efficient Enough?

Anyone who poo-poos or ignores efficiency will have a problem when they get into practice. You will not be able to meet the hospital or imaging centers benchmarks. So, there is no better time than the present to measure how efficient you are.

Remember, you typically will want to avoid using goals and objectives as a primary resource. On the other hand, consider clocking speed, determining if your search patterns are second nature, and assessing your comfort levels and dictation speeds. Think about using these recommendations because efficiency is essential. Efficiency becomes more and more critical as you continue through residency and eventually on to your first job!

 

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The Art Of Benign Neglect In Radiology

benign neglect

One of the most formidable skills in radiology is the art of benign neglect. Knowing when not to complete a request can be as important as finishing a test rapidly. It is a critical skill to learn in radiology when on call, running a department, or covering a rotation. With benign neglect, what you don’t do right away often resolves itself. It is a powerful tool. Although we usually like to be direct, sometimes, it can improve patient care by decreasing hospital stays and ensuring the patient gets the correct diagnosis and treatment. So, when does it make sense to practice this technique? And, how can you make sure that these requests are changed, tabled, or canceled?

Orders/Requests That Benefit From Benign Neglect

Redundant Orders

Technologists will often come up to you and ask you if an order makes sense at nighttime. For instance, a patient will get an order for a VQ scan with a normal CTA for pulmonary embolus. And, you have to decide whether to call the technologist to perform the study. Yes, there is a remote possibility that the new VQ scan would be positive, but highly unlikely. And the patient will receive more radiation when another test has made the diagnosis. 

Orders With Marginal Utility

Frequently, in fluoroscopy, you will receive an excessive order. For instance, a physician orders an upper GI series for a patient with a history of upper esophageal dysphagia. Usually, performing the upper GI series, which includes the stomach and duodenum, does not make sense when you only need to analyze the swallowing mechanism based on the history. Looking at the duodenum will not add much to the patient’s workup!

Orders That Clinicians Don’t Want But Ask For

In this category, let me give you the example of a patient with a right-sided breast lump but an order for a bilateral mammogram/ultrasound. Reflexively, many clinicians will send a patient in for a workup of a lump with a script for a bilateral mammogram and ultrasound when they only need a workup on one site based on having additional recent studies. Most clinicians don’t necessarily want the workup of the other side, especially when the patient recently had another negative test.

Requests To Look At Ancient Films Without Current Benefit

Especially on call, every once in a while, you will get a request to look at films from 2 weeks earlier because a resident has a research project or presentation. It is very appropriate to ignore these requests when you have a gazillion other tasks to complete that have a meaningful impact on patient care. In fact, by attending to these requests, you would be delaying urgently needed care!

Orders That Will Open A Can Of Worms For The Clinician

Referrers will sometimes order studies that can open up a whole new set of problems for their patient without solving the initial reasons for the order. Let me direct your attention to ordering an MRCP in the case of a patient that has an indeterminate test for cholecystitis on an ultrasound. Instead, the patient needs a hepatobiliary scan to make the diagnosis. First of all, by complying with the order, you may find additional irrelevant findings such as hepatic or adrenal lesions. And, of course, it will not be as specific for diagnosing cholecystitis as a hepatobiliary scan.

Techniques To Be Successful At Benign Neglect

What are some basic techniques to ensure that you are performing benign neglect for good patient care? First, you can table those orders with less significant clinical impact to the end of the shift. This technique works particularly well on a busy night when you have loads of orders and not much time to get them all done. Additionally, delaying a return phone call in the situation of an unreasonable attending can help ensure that the doctor does not place the order in the system. And finally, make sure to limit a study for the right reasons to limit additional exposure to yourself and the patient. 

“Benign Neglect” As A Tool To Achieving Good Radiology Patient Care

With all the redundant orders, requests that don’t make sense, unruly referrers, and time sinks for completing critical patient care; benign neglect is sometimes the best option to ensure a patient gets the best care possible. Sure, it is not optimal. But, it can work to make sure patients receive the proper test at the right time. It’s a tool to consider when others do not work!

 

 

 

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Residency Is Not The Time To Live Far Away!

live far away

It’s about that time of the year. You have recently matched into your internship or are about to move on to your radiology residency. And, it’s time to choose a place to live. You are probably not sure about the areas; many choices await you or your loved ones. Do you move close to your residency where not much happens? Or, do you live in a more cultural part of town? How about living closer to where you and your spouse want to be? How much should you spend? Is the area safe around the hospital where you are going to work? Many of you will face these questions over the next several months as you start your search for a place.

Out of all those questions, what is the most critical decision? Of course, you can stare at the title and probably come up with the conclusion! But, it is true. Make sure to prioritize living reasonably close to your residency site. Let me give you some good reasons for making this a significant priority during residency.

Every Minute On The Road Reduces Your Time To Study And Family Time

Time is one of your most valuable commodities as a radiology resident. You need it to study, spend time with family, and accomplish all the goals you set out to do. However, the farther you decide to live, the less time you will have for fitting all these critical activities into your schedule. Especially when you have very little, to begin with. Does it matter if there are tons of theaters nearby if you can rarely get to them because you need to study for your boards? Probably not!

Paying Up Now To Be Closer May Make The Difference Between Owing More Later!

If living close to the hospital costs more, it may pay for itself eventually. Let me explain. Living far away has many additional costs. Remember you have to factor in other expenses as well. There is the gas price (now at a record high!). And, of course, there is also the price of not passing the boards because you do not have the time to study. So, consider keeping close to the residency program site if you can!

If You Live Far Away, The More Exhausted You Will Be

Trust me. This factor is critical. I used to drive an hour or hour and a half to get back and forth to work. And, you don’t realize the tax that your will body will encounter with all that driving time. Traffic can become very frustrating. And, there is always a risk of getting into an accident late at night when on call.

Moreover, sitting for so long is not so great for you either. It’s a recipe for bad health and exhaustion. You can avoid all this by renting nearby!

More Things To Do, More Distractions!

Perhaps, you will have lots to do when you live in the city’s heart, possibly far from your residency program. But, that may come at the expense of the time you will need to study and participate in the residency program. Distractions can take a toll on the constant need that you will have to learn radiology. So, consider this when you make your final decision about where to live.

Emergencies Happen 

And, finally, of course, invariably, you will have emergencies at work that will happen. Maybe you forget your bag at work. Or, you need to help to cover a colleague. Whatever the case may be, it can be very challenging to take care of these events when you live far from the hospital!

Don’t Live Far Away During Residency!

Residency is a time to hunker down and complete all the requirements you need to succeed in your prospective field. Why jeopardize your future by making it more difficult for yourself now? Living far away can reduce the time for work and life, increase expenses, augment exhaustion and distractions, and make it much more difficult in an emergency. So, if you have to pick the most critical issue about selecting a place to live, it is to live closer to your new job. It will make a world of difference!