Tag: patient care

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Why Radiologists Need To Protocol Cases

protocol

Like many institutions, we perform cardiac CTA studies at the behest of our emergency medicine, internal medicine, and cardiology colleagues. They say do the study, with or without a protocol, and the technologists jump without a reflexive thought. For example, one patient had a chest CT scan a few days earlier for shortness of breath. It turned out that the patient had enough calcium in their coronary arteries to make their vessels look like lead pipes. For those who know anything about cardiac imaging and CTAs, tons of calcium within the coronary arteries make it nearly impossible to interpret them for stenosis because of significant beam hardening artifact, limiting evaluation of the lumen.

Nevertheless, without batting an eyelash, the technologists completed the coronary CTA, which was uninterpretable for detecting coronary stenosis. It had a calcium score of over 4400! Now, if only someone had looked at the CT chest, we could have avoided the CTA chest at the cost of unnecessary contrast, additional radiation, and of course, the financial cost to the patient.

This case is a microcosm of what is happening to radiology. Scans come through fast and furious, making it difficult to vet the protocol and the priors on everyone. But, by letting cases get through the system without forethought and protocols, we expose our patients to subpar medicine. In light of these facts, here are some of the critical reasons why radiologists need to protocol cases.

Avoid Unnecessary Studies

How often do we get the wrong orders for the indication? Very frequently! Daily we get orders for CT scans that ask for contrast when none is needed and vice-versa. Of course, a patient with flank pain should not generally get contrast on the first scan if they are looking for stones. But, wrong orders for studies with contrast happen all the time, causing unnecessary exposure to radiation and contrast that is not needed. Protocoling can prevent most of that.!

A Protocol Can Make Sure Studies Are Done For The Right Reason

When technologists and nurses come up to me and ask if they are performing the correct study, the first question I always ask is, “why are we doing the study?” There is a reason for that. We get orders that are not necessarily for the indication that clinicians want. It could be a white blood cell scan for when a simple gallium scan is warranted. Nevertheless, we can correct most of these potential errors before they get to the table!

Protocols Can Add Information To The Case

Protocoling can add critical information to the case. It may help find a relevant prior like the cardiac CTA above. Or you might find a valid reason for a study that might not be evident initially. Perhaps, the doctor is looking for a fistula and needs rectal contrast. Sometimes, you can only figure that out by digging deeper. You know what they say… Garbage in. Garbage out!

Prevent Patient Discomfort

Many radiology studies are uncomfortable and difficult. A CT scan on a patient with severe back pain can be a nightmare. Imagine going through a CT scan in this situation when you could have avoided the test if the radiologist had protocoled it beforehand. Well, this issue happens all the time. We owe it to the patients to prevent additional harm!

Prevent Angry Clinicians

When we do not protocol cases before imaging, we do not get the answers that the doctors are looking for. This cycle leads to unhappy referrers that do not receive the intended study. And, we get these irate phone calls afterward. Do you want your clinician to send patients back to your department again? Well, if you consistently deliver the wrong studies for the patients, that will not happen!

A Protocol Can Decreases Costs

The costs to image patients are immense. And simply one incorrect study can cost the patient and the institution thousands of dollars. Protocoling is a tremendous backstop to ensure that health care costs are more reasonable. Sure, we may not have much time in our busy schedules. But, protocoling can certainly decrease costs to the system!

Protocol: An Easy Way To Prevent Bad Medicine

If your attending asks you to take a stack of patients and ensure the protocols are correct, it is not a waste of time. With all the benefits of eliminating waste and practicing good medicine, it is something that we should all do regularly. So, look at those orders before the hospital performs the studies. Protocoling can make a huge difference in patient care!

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The Magic Of Priors

magic

As I was scrolling through the worklist, I came across a case with priors that significantly changed the disposition of a patient, emphasizing the magic of priors. A chest CTA showed numerous pulmonary emboli sitting in multiple branches of the pulmonary arteries. At first glance, any radiologist would be ready to pick up the phone and call the ER to let them know about the pulmonary emboli. Of course, this patient would most likely need anti-coagulation and possibly thrombolysis. But then, at the very end of the list of prior studies, I noticed a previous chest CTA from 2017. To my surprise, the images looked the same. Those bilateral pulmonary emboli were most likely chronic! No new treatment would likely be necessary. If you want to talk about why priors are so important, this is an excellent example of why. It entirely changed the management of this patient. And it is the proverbial tip of the iceberg. So, if you ever get that feeling of laziness, here are some reasons it pays to take the time to press on and look at the patient’s prior studies.

Increases Sensitivity

No, it is not cheating to look at the prior report. Instead, it is excellent patient care. Some lesions, for instance, pancreatic lesions, can be very subtle. And, if you don’t look back at the prior report and the prior study, you are much more likely to miss it. You may neglect to recommend follow-up on this sort of lesion. And, in this case, you never know what can happen next. It can grow and need further treatment or not. Regardless, why not increase your chances of picking up significant findings?

Increases Specificity

Let’s give the example of that lowly nonspecific liver lesion that we always seem to find. The second time around, the diagnosis can become a lot more specific. If the lesion has been stable for the past ten years, it is highly likely to not be malignant. And, you have made of critical management decision of leaving the lesion alone. Otherwise, a whole workup can ensue, wasting health care dollars and causing potential psychological discomfort to the patient. These issues happen all the time, so don’t forget to compare to the priors.

The Magic Of Priors Changes Patient Treatment

I can’t tell you how often I get calls from oncologists that fail to give us the most recent priors, subsequently add them to our system, and then request an addendum. Why is that, you might ask? Well, most oncologists know the value of comparing to priors. How would you know whether to continue on a chemotherapeutic regimen or not? In an imaging study, learning if there is improvement, stability, or progression takes the guesswork of how to treat the patient next. And this is not to mention the potential life-saving acute issues I mentioned with the chronic PE case at the beginning!

Increases Referring Physician Confidence

Knowing that you have an eye on the previous study on all your reports allows your referrers to feel comfortable that you are safely and methodically correctly interpreting images. Of course, this step can lead to a virtuous circle. You get more patients referred because you increase clinician confidence and patient well-being. And, you earn a better living. It’s all good!

The Magic Of Priors

One of the big life lessons of practicing radiology for so many years is to avoid neglecting prior studies. I have seen one too many cases slip through the cracks, and I certainly don’t want the same to happen on my watch. And, I am sure that you probably don’t want that on yours. So remember why the magic of priors is so essential- increasing sensitivity and specificity, changing patient management, and increasing clinician confidence. And, you should make it part of your standard protocol never to forget to look at them too!

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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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Check With Your Faculty Before Letting A Barium Patient Go!

barium patient

Barium slinging is harmless, right? I mean, what’s the big deal about letting a patient go after you complete a standard esophagram or barium enema? How often have you, as a resident, completed one of these studies without checking the results with your attending, only to let the patient go home right afterward? I bet most of you have done so at one point or another. If there is any complexity in the case whatsoever, I would think twice before letting the barium patient leave before checking it. Why? Well, for lots of reasons. And I will divide them into the following broad categories, legal, lack of experience, extra scrutiny, patient-related issues, and lack of insight into history. Let’s go through them one by one.

Legal Issues

Residents are not the final interpreters of any study, whether it be a plain film, CT scan, or ultrasound. Additionally, distinct from most other imaging modalities (except for ultrasound), the resident is responsible for showing and carefully examining the findings. If she does not technically demonstrate the findings based on history, the study becomes useless to the ordering physician. Consider the resident not spotting the terminal ileum in a small bowel series for inflammatory bowel disease. Or, maybe he doesn’t complete a cine of the upper esophagus in a patient with dysphagia. Who is responsible for the lack of information targeted to patient history? The attending, of course! Just read this AJR article about barium enemas and malpractice, and you will think again. Radiologists are liable for the missed interpretation based on resident imaging!

Relative Lack Of Training

When barium slinging was more common years ago, it used to be one of the more litigious radiology areas. Just like mammography, you could easily miss all sorts of colon cancers, ulcers, and more. Typically, it would take years of experience to develop the trained eye to find these abnormalities. Don’t think that barium work is easy, so much so that you can blow it off as a low tech waste of time. On the contrary, one inexperienced resident may not be enough to catch the pathology that you will need to find. There is hubris in thinking you know more than you do! Moreover, think of this opportunity to go over the case as an additional learning opportunity to become better.

Second Set Of Eyes

On that same notion, having a second set of eyes can be a critical adjunct to making the finding. It’s like breast imaging. Often, the ultrasound technologist cannot find a blessed thing corresponding to the patient’s lump. But, as soon as you, the physician, walk into the room, WHAM! It’s right in front of your face as clear as day. Sometimes, you need that second set of eyes to get you out a particular mindset. It’s worth it.

It’s A Big Deal To Bring The Patient Back

Finally, if you miss looking for a finding on the study, the patient may not return so quickly, especially as an outpatient. For instance, in the patient population with dysphagia, many of these patients may come from rehabilitation facilities or nursing homes. Did you ever think about how hard it was to get the patient to the study in the first place? Or, maybe the person has a hectic job and made special arrangements to complete the procedure. Now, you need to bring the patient back. You may not think so, but it can become a huge issue!

Check With Your Faculty Before Letting The Barium Patient Go!

Don’t take these studies for granted. Allowing for these studies to go unchecked can cause all sorts of trouble, including legal dilemmas, missing findings, and having to bring unavailable patients back for more imaging. So, please, if you are on the fence, think twice before sending that patient home without having your attending check it. It could be lousy patient care!

 

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How To Decrease Radiologist Hospital Presence Without Jeopardizing Care

jeopardizing care

For years, the mantra of quality radiology groups was to provide excellent service. And that would involve establishing a presence at all times. But, like many other former tenets of radiology practices, Covid has been turning over many assumptions about our work. Now that we have a situation where physical presence in the hospital can jeopardize radiologist safety, radiology groups have been decreasing their in-hospital staffing. However, potentially reducing staffing can increase patient barriers to quality care. So this begs the question, how are radiologists replacing physical presence in the radiology department without jeopardizing care? I am going to talk about how many groups are going about this process. Then, let’s discuss the reasons why some radiologists will always still need to remain on-site. Finally, we will use a crystal ball and decide where this is all heading.

Ways Radiologists Are Decreasing Physical Presence Without Jeopardizing Care

Less Physical Patient Facetime And More Apple Facetime!

Interventionalists and mammographers, if they haven’t already, will followup patients without an on-site visit. We see even more utilization of online communications via Zoom, Google Meet, Facetime, and whatever other technology rears its head. It also enables radiologists to maintain efficiency and have office hours between reading films at home.

Increased Ordering Of Hands-off Testing

We are noticing an increase in those tests that do not involve a radiologist presence. For instance, if a mammographer cannot be on the site to see patients, instead of a hands-on ultrasound for a positive mammographic finding, he may recommend a breast MRI. Or, radiologists will be more apt to followup findings when they may have suggested a physical procedure such as a biopsy in the past. All these changes are presently occurring below the surface, but they are happening.

Replacing In-Person Interaction With Referring Clinicians

Since the advent of PACS, most radiologists have already noticed a steady decline in direct physical interactions with their clinicians. Surgeons and internal medicine physicians come down much less frequently to review films than ever. And, today’s pandemic is further catalyzing this change. We are seeing even fewer of our colleagues and having more phone interactions than ever before. Even extracurricular activities with our fellow physicians are decreasing. Hospital meetings are becoming online.

More Tech Issues Resolved Remotely

Many radiologists are increasing the physical barriers between the technologist and the radiologist. In the past, radiologists would often ask a question from their technologist, and she would stop by. No longer. Radiologists are tackling these same issues with a phone call or a text. It has become less feasible to have that direct physical technologist interaction.

More Remote Teaching For Residents

And, finally, training is not immune to the Covid world. Already, online seminars have replaced in-house lectures at most training programs throughout the country.  And, I would not expect that to go back to the traditional in-person norm entirely. It becomes more accessible than ever before to teach from a remote site.

So, What’s Left For The Radiologist To Do At The Hospital?

Alright, even with all these factors allowing radiologists to practice off-site, some radiologists must remain as a physical presence in the hospital. Of course, some procedures will always involve a human being. Administration of radioactive treatments, interventional procedures, and emergency coverage for contrast injections will continue to require a radiologist on-site. But, compared to all the roles a radiologist can perform off-site, it is indeed limited. Don’t expect to see as many radiologists sticking around the treatment facilities as they did before. Many practices have reduced their on-site staffing by as much as 30-70% during this crisis.

How Will Radiologist’s Presence At The Hospital Ultimately Evolve?

Many changes are currently in motion, making it even easier to perform more activities outside the confines of a typical hospital or imaging center without jeopardizing care. And, facetime, ordering preference changes, and other remote capabilities are some ways that radiologists have been decreasing physical presence at primary sites. In time, we may begin to see some return of radiologists back to the hospital as the risks to radiologists dwindle. Nevertheless, don’t expect radiologists to return to the same complement on-site after the dust settles as the tools for remote patient care have developed. When culture changes, even temporarily, some of it always sticks. Radiologists are by no means immune!

 

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Is The Adult Abdominal Series Like Reading Tea Leaves?

abdominal series

At some point, most of you have probably come across the adult abdominal series, most often used for abdominal pain. You will see these exams performed in most Emergency Departments throughout the country. Typically, it includes a supine and upright or decubitus view of the abdomen.  At some institutions (like ours), it also consists of an upright chest x-ray. So, why do I want to bother discussing this imaging examination? It must have some issues, right? Well, of course!

So, what’s my beef with this exam? Well, I will go through all my issues with the study one by one. First of all, we will mull over the purpose of the imaging examination and its redundancies within the system.  Then, we will discuss precisely who may be ordering the study and why that has repercussions for the expense and overutilization of patient care. And finally, I will go into detail on how the ordering clinician uses the information (if they do at all!). All these points will show why I have negative feelings about the abdominal x-ray series. And, by the time you are done reading this, I believe you will too (assuming you don’t already!)

The Lowly Abdominal Series: Is It Being Used As It Should?

It may seem that every time a patient walks through the door with the complaint of abdominal pain, he gets an abdominal/pelvic CT scan and an abdominal series.  But, what is the point of getting an abdominal series if you already know that the patient is going to receive an abdominal CT scan for the same complaint? Can’t you get more information from a CT scan than an abdominal series? Well, the answer to that is clearly yes. That abdominal series becomes nothing more than redundant when you have already have a CT scan on the same patient.

Moreover, some clinicians say that they need it for triage. Well, in my experience, that is debatable as well. I can’t tell you how many times clinicians report that they will utilize the test to help them to determine if the patient needs a CT scan. But, if you think about that usage, it does not make sense as well. Why? Because the abdominal series is a notoriously insensitive and nonspecific test. I can think of gazillion times that I have seen a negative abdominal series in the setting of a rip-roaring positive abdominal/pelvic CT scan. Likewise, I see lots of positive tests that turned out to be nothing on the CT scan.

And, I have the data to back me up. Check this out. Here is a paper from the Radiology journal that gives the sensitivity of an abdominal series compared to a CT scan of 30%. Now, that statistic alone is pretty horrible. Translating that number into everyday English, it means that you will miss a positive abdominal diagnosis of about 70% of the time. Moreover, the specificity of a plain is around 56.5 percent. Or, that means that only just over about half the amount of time will the study give you the correct diagnosis. Not much of an improvement, huh? All this information begs the question, should we use this examination at all for triage for the complaint of general abdominal pain? Probably not!

Who Is Ordering This Study And Why It May Be A Problem

I don’t know about your ED, but at ours, ordering this study has almost become reflexive.  As soon as the patient walks through the door, a “midlevel” orders the study. Very rarely is the abdominal series used as initially intended, as a triage tool. And, using the abdominal films for triage is also likely not of much value, with such low sensitivity and specificity. It will misguide as often as it will send you in the correct direction.

So, why do clinicians utilize the study? I have a theory that it is no more than a crutch of tradition. It’s something that some clinicians hang onto because it was the test of choice in the past. And, the less you know, the more you cling onto things. Unfortunately, that leaves the less informed and educated staff to continue ordering the study.

And it is not a “benign test.” There is a significant radiation dose that accompanies it. Check out the list of radiation doses on this RSNA sponsored informational site. Each clinician needs to think about every test they order before they do so.  I have a feeling that is not happening!

Does It Help Managing Patient Care?

And, then finally, what happens when the clinicians receive the report from the lowly abdominal series? Is that information used? Well, I hope not! If you buy the previous studies, you will miss most diagnoses if you use it without a CT scan. Given the sensitivity and specificity, I believe the exam more likely increases the expense of healthcare because of false negatives and positives. The abdominal series is a prime example of a test that may cause the caring physician to order more tests than otherwise needed.

Abdominal Series For Abdominal Pain: Is It Like Reading Tea Leaves?

Based on the preponderance of evidence here, I believe it is probably not the best usage of our health care dollars. Sure, it is a quick and easy test.  But, quick and easy does not imply cost-effective and useful for patient care. We need to reconsider the use of this unhelpful exam, especially for the general complaint of abdominal pain. It does no more than lead our clinicians astray and increase the costs of health care for you and me.