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!
