Tag: radiologist

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Clinician Interruptions In The Reading Room: A Necessary Evil Or An Avoidable Interaction?

clinician interruptions

For those of you that practice radiology, how often do clinicians interrupt you on a busy rotation? And, what percentage of the time does the clinician provide helpful information without interrupting your train of thought? I know I can only speak for myself, but many clinical interactions prevent me from completing my work, increase my inattention, and should probably occur at another time. How often does a clinician stop by to ask you when you will finish his patient’s report only to lengthen the time to complete the dictation? Assuming my experience is similar to others, I believe those clinician interruptions can overwhelm many positive daily interactions.

 Plus, based on the evidence (check out Should Radiologists Ignore The Phone?), we know that interruptions cause an increase in error rate with our reads. So, therefore, clinician interruptions become much more than an issue of mere convenience. Instead, we need to take clinician interruptions very seriously. To cover this longstanding theme, we will discuss whether clinicians and providers should be allowed to enter the radiology reading room. Then, we will talk about potential solutions to these problems. So, let’s begin!

Reasons To Allow Clinicians To Enter The Reading Room

Knowing that interruptions prevent us from reading cases to the best of our ability, one could make a case that we should nail our reading room doors shut. But fortunately (or unfortunately!), this cannot happen in reality. Moreover, it probably is not such a good idea.

So, what are some legitimate situations when a clinician in the room may enhance the reading of our cases? Well, first of all, we must welcome all good histories that help us to make a diagnosis. A clinician coming into the room with this message can become a lifesaver, literally. The clinician can change the diagnosis and management.

Second, a clinician in the room can help when we need to relay an urgent message. For instance, perhaps you find an impending aortic rupture and need to get in touch with the vascular surgeon. Wouldn’t it be nice if the physician just happened to be standing next to you instead of calling all over the hospital to find him?

And then, sometimes, a clinician can enhance our reads when we are unsure of the best way to manage the patient. For instance, maybe, you recommend an MRI, but unknowingly the patient already has a pacemaker. Yet, if a knowledgeable clinician stood next to you, you would ensure that the patient had received some other test, such as a gallium scan.

Clinician Interactions That You Should Prevent

As I discussed above, clinicians should not ask the radiologist when he will complete the study. An assistant or secretary should handle these requests. Furthermore, the technologist or clinician should mark a study as STAT, priority, or routine. And the radiologists should dictate these cases in an appropriate order from most emergent to least. For this reason, a clinician stopping by the reading room interrupts the workflow and is redundant.

In addition, as much as I like medicine rounds from an educational point of view, having a team of medical physicians interrupting the radiology workflow on initial patient reads does not contribute to good patient care. Educational rounds during live readouts can disrupt search patterns and often warrant inefficient rereads of the same films. Furthermore, these types of interactions can cause other errors. On the other hand, educational rounds at a specified time after the radiologist made the reading would not detract from patient care.

Finally, as much as I like a suitable, quality, friendly conversation, clinicians should not use the reading room as a place for small talk. These sorts of conversations can also act as a nidus for errors!

What Are Some Potential Solutions To Allow Useful Clinical Interactions While Mitigating Interruptions?

Unfortunately, the task is not easy. But here are some logical recommendations:

First of all, having a “1st line triage” can help the process of selecting who can enter the reading room. Like other professionals with secretaries and assistants, radiologists should also have clinical assistants who can manage interactions with our colleagues. Radiology assistants can serve this function. (a more expensive option) Alternatively, junior residents may also help to prevent unwarranted interaction. Rather than interrupting the clinician workflow, the junior resident can field the questions and may interact appropriately with the physician. The junior resident can also learn about clinical medicine from the interaction.

Second, make sure to make it understood that the reading room should exist as a place for reading films and not unwarranted conversations. The placement of signs and a general culture of using the reading room as a workplace can prevent some of these disruptions.

Finally, we should proactively inform and train our clinical colleagues regarding the appropriate questions and times to enter a reading room. Continuing education via interdisciplinary conferences and general interactions can undoubtedly help.

Final Thoughts About Clinician Interruptions In The Reading Room

Clinical interruptions are more than just a nuisance. Instead, they directly impact workflow and increase the error rates of the interpreting radiologist. Therefore, hospitals and imaging centers should create appropriate reading environments for beneficial clinical interactions with radiologists. At the same time, they should create an environment that avoids significant clinician interruptions. Hiring more staff, using residents appropriately to triage, and creating quiet reading rooms can allow uninterrupted workflow. So, next time you are interrupted, be proactive and do not allow these interactions to continue. Politely ask the offending clinician to wait until you complete the reading. And then consider discussing the issue with your residency or hospital. Working to improve the efficiency and quality of clinical interactions can save lives!

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What Really Goes On At A Radiology Practice Partners’ Meeting?

partners' meeting

I can remember back during my radiology residency many years ago. Every so often, the radiologists at my hospital would meet secretly outside the hospital for their partners’ meetings. As the radiology attendings rapidly left to abandon their shifts to get to this meeting, I thought perhaps the partnership was just like the secret societies such as the Freemasons or the Illuminati. Maybe, they had a secret handshake? Or could they be plotting the overthrow of the hospital or government? What was going on at the partners’ meeting?

Most likely, you also wonder what happens during the partners’ meeting since you have never experienced anything like it. Moreover, you are an outsider, not privy to private practice business. Yet, one day many of you will also become a partner in a radiology practice. So, today I will reveal the secrets behind what partners discuss at their business meetings. Therefore, pull up a chair, read this post, sit back, drink, relax, and enjoy. Now, you will learn the truth behind what the partners discuss at a partners’ meeting!

Finances

As you might expect, at most meetings, a business manager often discusses the current state of a practice’s finances. Are reimbursements declining? Do new potential sources of revenue exist? What imaging modalities are trending higher? Should the business renegotiate insurance contracts? For some of you, your eyes may glaze over when you hear about a practice’s finances. However, these discussions are essential for continuing business as usual. And, yes, radiology is not just about health care. It also needs to run positive income to pay the employees, the fixed costs, the partners’ salaries, that end-of-the-year Christmas party, and more. Most meetings involve financial discussions.

Long-Term Strategies- Mergers, Acquisitions, And Partnerships

Nowadays, practice size has trended upward. Many practices must evolve to create larger entities so that they can use economies of scale to reduce costs and maximize profits. What do I mean by that? Essentially, practices can distribute fixed costs among a larger group of employees, thus saving money for the business. Therefore, you probably hear a lot about practices merging or private equity firms buying out imaging companies to save on costs. Well, partner meetings are common private forums for discussing these issues. In addition, you can expect practices to talk about ways to maintain good relationships with the hospitals and clinical colleagues as a long-term strategy. This long-term strategizing all happens at some partners’ meetings.

Manpower Issues/ Human Resources

Almost every practice has its fair share of issues with employees. Perhaps, some physicians do not meet the requirements of the hospital. Or maybe, clinicians have been complaining about certain practice members. Partners meetings are the appropriate forums to discuss these practice problems. In addition, partners discuss hiring new employees to meet the demands of the practice. Partners will discuss these problems and attempt to devise solutions to match the workforce to the practice’s needs.

Scheduling

One thing that is constant in any practice is change! Whether it be new imaging modalities, increasing requirements of films to be read, or losing business to other clinicians, the scheduling demands must meet the appropriate workloads. Partnerships will broach better ways to schedule partners and employees to maintain maximal efficiency. In this same vein, practices will also debate vacation policy schedules and the appropriate workloads for daily and weekly rotations whose needs may differ over time. These items commonly enter into the typical partners’ meeting.

Beauracracy and Compliance Issues

Every year, governments develop new rules and regulations for practices to follow. A few years ago, it was ICD-10 codes. Now we have new quality improvement mandates set by Medicare. Whether for certification maintenance or hospital credentialing bylaws, these items constantly change and can be crucial for maintaining the practice and complying with the law. All partners need to keep aware of the newest compliance issues to run an imaging business successfully. What better forum than a partner’s meeting to discuss this?

Insurance And Benefits

In this category, I will include malpractice, health, life, and disability insurance, pension plans, and yearly bonuses. Partners must approve the renewal and disbandment of these annual benefits. These changes depend on the costs and overall contribution to the practice and partners. You wonder how they come up with these policies. Well, usually, this occurs at the partnership meeting!

Residency Issues

Lastly, although residency issues crop up, that can affect the practice. If you have an imaging company with a residency, the partners may or may not discuss it in a partnership meeting. But, they occasionally make it to the partners’ meeting agenda. The discussion could be about new residency requirements, a site visit from the ACGME that all partners need to plan for, a specific resident issue, a problem resident, and more.

The Secret Partners’ Meeting- Final Thoughts

A partners’ meeting is a necessary evil to maintain a practice. And, as you can see, a partners’ meeting agenda can fill up quickly. Depending on the time of year and the number of issues, meetings can take hours and hours. Yet, the partners’ meeting is an essential aspect of a quality partnership and business. So, the next time you see the partners disappearing to attend the partners’ meeting, you now have some faint idea of what happens. Although you may never learn the secret handshake (or the nitty-gritty financial details), you now know what to expect from that occult partners’ meeting. And no, it’s most likely not just about discussing you!

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Urgent Case And I Can’t Get In Touch With The Doctor: What Do I Do?

urgent case

Covering physicians should always be available, especially in an urgent case. However, when you begin radiology practice, you will find that 24-hour physician availability is a pipe dream. Once in a while, I encounter situations when I cannot reach a physician, let alone a nurse. Fortunately, most of the time, if I wait a day or two to contact the physician, no harm will come to the patient.

But then, now and again, we read an urgent case that can potentially represent the difference between life and death. Perhaps, you find a spontaneous pneumothorax in a patient with mild chest pain. Or, maybe you see an impending aortic rupture in a patient with heartburn. Regardless, good medicine and the law dictate that we must communicate these urgent results rapidly so the patient can get appropriately treated.

So, what do you do when you cannot get in touch with a physician and have an urgent case? Do you yell down the hallway? Do you stomp your feet? Or do you send smoke signals via the hospital generator? You can do any of these fun activities if you want to. (Sure would release a lot of stress!) But, today, I will go into more effective ways of ensuring that the patient receives the appropriate care when you cannot reach the covering physician. To introduce this topic, I will give you a few real-world scenarios and instruct you on what my colleagues and I would have done.

Call The Patient Or Patient’s Caretaker Directly

These are the sorts of cases that tend to occur at the very end of the day. The last episode I remember happened when I looked at the previous outpatient case of the day at one of our imaging centers. I recall looking at the final abdominal CT scan at about 8:30 PM on a late shift and seeing oral contrast density framing several bowel loops on a CT scan. Then suddenly, the anticipation of going home shifted to dread. I knew I would be lucky if I could reach anyone to let them know this patient had a bowel perforation. And, right, I was…

As expected, I called the physician covering the patient multiple times. But to no avail. All I got back was a ringing telephone. What would you do next? Well, I did the most logical thing. , I called the patient’s house and reached the wife of the patient. I told them to get checked out at the local emergency department immediately.

Fortunately for the patient, everything turned out alright. But, if I had continued to call and wait for a physician to pick up, the patient could have died. Sometimes, you have to contact the patient directly!

Send A Certified Letter

Other times, you may make a significant finding but not quite as urgent. Maybe, you discovered cancer on a mammogram. Again, you try to reach the covering physician. But, it does not work out all too well. At this point, you still need to make sure you directly contact a covering physician or patient. Otherwise, you can be liable if the patient did not follow the appropriate treatment. But you also have another option if you can’t get in touch with the physician or patient. You can send a certified letter to the address on record.

Certified letters indicate that you have made a reasonable effort to reach the patient after the initial communication failed. At least, you can make sure you have performed your due diligence.

Call The Cops/Dial 911

In other situations, the consequences of not getting to the patient in time can be dire. Let’s say you detected a subarachnoid hemorrhage on an outpatient at 9 PM in an imaging facility, but the imaging center completed the case in the early afternoon. And, again, you cannot get through to the doctor or patient. One radical technique to overcome this issue is: Call the police and dial 911. Theoretically, if you suspect that the patient may be at risk of life or limb, the police have the authority to knock down the door and ensure that the patient receives appropriate care. Fortunately for me, I have never had to resort to this option. But I know of other radiologists who have.

Final Thoughts About Communicating An Urgent Case When The Doctor Is Not Available

Usually, when you have the will to get through to a covering physician or patient, there is a way. Sometimes, you need to take more extreme tactics into your own hands. Remember… It’s for quality patient care. So, don’t give up. Instead, make sure to follow through. Because otherwise, you risk not only the patient’s well-being but your career as well!

 

 

 

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Texting- A Minefield For The Radiologist

texting

Formerly as a student, you could get away with texting anything you wanted on your smartphone or computer. Unless you bullied your colleagues or significantly abused the technology, the consequences remained minimal. On the other hand, an “insignificant” text from a medical professional, including a medical student, radiology trainee, or radiologist, can lead to dire results. Between the potential for HIPAA violations, unforeseen job losses, and discoverability of texts for evidence in legal cases, poorly thought out texting can severely damage your career. So today, we will delve into the dark side of an important technology that we all use, the unencrypted electronic text/message. And, you will see why radiologists need to use this particular communication tool so carefully. We will go through five different situations in more detail.

Patient Information Texting Taboos

Sending patient information over an unencrypted text message can lead to a disaster. HIPAA has its tentacles everywhere. God forbid… If a third party discovers this message containing sensitive private patient information without authorization, the federal government can severely fine and even incarcerate you! And, we are not just talking about a few hundred dollars. Millions can be on the line! (1) Not only that, but the patient can sue you for breaching their confidentiality. It is a lose-lose-lose situation!

Sending The Wrong Information To The Wrong Person

Have you ever texted a friend only to realize that two seconds after clicking send, it went to the wrong person or group? I suspect a majority of you, at one point or another, have encountered this problem. Usually, it is something benign. But occasionally, it can damage your reputation. Imagine sending a text to a friend saying, “I find Harry annoying.” And instead, it travels to the head of the department, and Harry is her fiance. These damaging texts happen all the time. But no longer may you lose just a friend. Instead, you may also lose your job or damage your reputation.

Poorly Communicated Intentions

Did you notice that most texts come off abruptly without context or emotion? We often misinterpret information that we intend to communicate by text as an offensive slight to colleagues or ourselves. A simple, seemingly insignificant text message to a technologist such as why didn’t you complete the study? can be interpreted in many different ways. Think about it. The technologist recipient may think that you blame him for never finishing his studies. Or perhaps, he can interpret this message as the radiologist believes that the technologist has a personal vendetta, which is why he thinks the technologist does not want to complete studies. On the other hand, it may just mean what it says: you need to complete the study and nothing more. Simple oral communication would have translated the initial intention more accurately with the appropriate accompanying facial expression and emotion.

Helping Out The Dark Side

Did you know that any text you send is potentially discoverable evidence for a lawsuit? You text your colleague, “I missed the pulmonary nodule on patient MR#123456”. Now that the text is in cyberspace and on your friend’s phone. The lawyers can recover that text from the cloud or your friend’s phone if the patient decides to sue you. All bets are off whether that text will incriminate you in a court of law!

Unintended Slip-Ups

And then, there is the essential unintended slip-up. Perhaps, the word correction software on your iPhone changed a word to something more sinister. Think about it. We see it happening all the time. I’ve seen the shift in expression from “see to sex” or “person to pee.” And unknowingly, you send the message out to the program director. (He may not be as forgiving as me!) In the wrong context, especially with the recent spout of sexual harassment charges, that message containing these words can be devastating!

Beware The Simple Text

In the modern era, avoiding texting our friends, colleagues, and loved ones is next to impossible. And, I am not saying that we should never text each other. However, based on these hazards, we should proceed cautiously and read over every text we create many times. An ounce of caution today can prevent a lifetime of work trying to recover from a poorly thought-out text!

(1) https://www.truevault.com/blog/what-is-the-penalty-for-a-hipaa-violation.html

 

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Phone Etiquette For The Radiologist

phone etiquette

Back in the day, I remember my former program director/chairman at Rhode Island Hospital, Dr. John Cronan, lecturing on the basics of the business of radiology. (if you’re reading this, I bet you’re impressed that I remember!) He mentioned the three A’s of maintaining a good radiology practice: affability, availability, and acumen. And, after all these years, I still take this to heart. Good phone etiquette also fits into the equation of the three A’s. It is one of the keys to maintaining a quality practice to entice repeat customers, fellow referring physicians, and patients.

And the rules apply not just for standing phones at your practice but also for cell phones too (We are not living in the 1980s, folks!) With the tens of thousands of phone calls, you will receive over your lifetime, the concepts behind good phone etiquette remain the same. So, let’s go through each of these threads to guide you on how to approach the phone.

Availability

Let’s address the most controversial area first. How can we be available by phone most of the time when I create a post such as Should Radiologists Ignore the Phone? Well, it creates a conflict of interest. We do need to make sure that we concentrate on our films first and avoid errors. On the other hand, it does not mean that we should ignore the phone. So, how do we solve this dichotomy? If you are not actively reading films, always pick up the phone. And, if you cannot pick up the phone now, at least you can promptly return messages that you may receive from the secretary or your voicemails.

If a clinician can never get through to you, you know where their business will go- down the street to the other guy! So, allowing your clinician to contact you is of the utmost importance.

Affability

Affability implies more than picking up the phone and being friendly. It also means an air of professionalism. What do I mean by that? If you are picking up a phone in a particular location, let your caller know they have reached that specific destination. So, if you are in CT scan, you may say Your Hospital, CT scan, Dr. X speaking.

Like us, clinicians run short on time, and we must respect their demands. They may arrive on your line through an operator, unsure of their destination. Taking the time to announce exactly where and who you will go a long way to establishing a rapport between you and the referrer.

In addition, treat your referring physicians on the phone as if they were a friend, not just another burden of the day. Even if it is 4:55 PM and you are about to leave the department, don’t be curt on the phone. Our referrers are the lifeblood of a radiology practice, so creating a relationship between the radiologist and the clinician is crucial. In the end, we need to develop friendships, or else why should the clinician refer patients to you instead of his friendly radiologist down the street? (We live in competitive times!)

Acumen

Finally, just as you treat any consult, on-phone or in-person, we need to ensure that we do our best to solve our referrers’ questions. Be direct. Make sure to answer any questions that you can answer correctly off-the-cuff. And, if you don’t know the answer at the moment, you can always look up the information and get back to the clinician. It is our responsibility to help our fellow doctors. That is just part of our job.

It is also awe-inspiring when you can give a source or a paper to your referring physician documenting why you think your recommendation is correct. It goes a long way to show that you keep up with all the literature. Additionally, it makes it more likely your referrer will return the next time.

Final Thoughts About Phone Etiquette

Many radiologists may dismiss phone etiquette as an extraneous part of our practice that is not worth their time. But, I beg to differ. Instead, it is an essential part of an excellent radiology practice. It is how we connect with our referrers, make friends with our fellow physicians, and direct our clinicians to the next step, whether ordering the appropriate test or solving a diagnostic dilemma. So, make sure to follow the rules of the phone!

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Top Eight Advantages Of Living Close To Work As A Radiologist

close

Driving 50 miles to and from work or over 1.5 hours each way is undoubtedly a recipe for a problematic residency or career. (I did that for six years as an attending!) So, I recommend that you heed the following advice. Live close to the hospital and enjoy life! We will go through eight tangible benefits I have discovered now that I live close to work to support this argument. Try to do the same!

Traffic And Stress

Arriving at work after a school bus, a large white van, and a Toyota Prius cut you off during your 1.5-hour journey versus stopping at the one traffic light between my house and the hospital. Which one is more stressful? Hmmmmm… I can say that stress levels have declined by 95 percent at the beginning of the workday. Who cares if that guy in front of you cuts you off in the parking lot when you are five minutes from the hospital. You’ll still arrive on time!!!

Forgetting Things

The feeling of forgetting something important halfway through a 1.5-hour journey still sends shivers down my spine. I can still remember filling out the medical staff renewal forms due the same day, only to discover they were not in the car halfway through my trek to the hospital. If that happens now, no big deal. I just go home in the middle of the day and pick it up!

Healthier Lifestyle

All those hours on the road wreak havoc on your body. The body should not sit in a car for 3 hours a day. Fast food outlets become your friend. Fat accumulates in the wrong places. All that time that you lose, you can spend exercising or creating a healthier lifestyle for yourself.

Taking Care Of Things At Home

Occasionally, you need to drop off something at the house. Or, you may meet with a contractor to fix your ceiling leak. When you are 50 miles away, it is next to impossible. On the other hand, if you are right around the corner, you can usually stop by for a moment!

Community

Are you volunteering for the community? No problem. Want to coach a kid’s baseball team? You can manage it. Join a local symphony? It’s possible to find the time. Living close opens up many local opportunities you would never have otherwise!

Emergencies

Sometimes disaster strikes. When you live far away, it is almost impossible to help out. On the other hand, if your child injures a leg playing soccer or falls off a horse and you live right near the office or hospital, you are no more than a few minutes away. You can even pick him up and drive him to your hospital yourself!

Family Time

Want to spend quality time with the kids in the evening? You will now have the time. Think it’s essential to go on date night with your spouse? It’s possible to make plans, even during the week. Need to plan family outings- like the school picnic or that hockey game in the evening. Not a problem!

Call Issues

Have to reduce an intussception at 3 AM? At least you are around the corner. You can get in and out in minutes. And, before you know it, you are done. Need to check a scan because the internet froze? All you need to do is drive-in for a moment or two, not 1.5 hours!

Live Close To Work!

As you can see, living close to the hospital makes a world of difference. And the advantages are almost endless. So, go ahead and try to live reasonably close to your work. You can live your life the way you want while not burdened by all the time wasted in the car!

 

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The Isolated Specialist

isolated

No, this is not another article about physician burnout. Instead, today we will talk about why isolated specialists can lead to poor patient outcomes. So, why do I find this interesting? In my own experience, I have encountered multiple instances when I see isolated specialists as the cause of deficient patient care. Let me give you an example.

A radiologist will encounter a non-radiologist physician demanding that his patient receive unwarranted intravenous contrast for his CT scans every once in a while. What is the big deal about administering unwarranted intravenous contrast on CT scans? Well, say you perform a contrast-enhanced CT scan for a pulmonary nodule. Or perhaps, you decide to approve a contrast-enhanced CT scan of the abdomen to check for a retroperitoneal bleed with contrast while on Coumadin. The patient risks returning home with a “present”- acute renal failure in both situations.

Meanwhile, both CT scans would give you the same result regardless of whether we administer intravenous contrast. And both of these cases of acute renal failure are entirely preventable. If you perform the study as directed by the physician, you have complied with the order as the radiologist. Unfortunately, these cases can lead to a lawsuit that you have no hope of winning.

Poor Communication And The Isolated Specialist

So, what does this all have to do with the isolated specialist? The ordering physicians decided to order CT scans on their patients without consulting with the radiologist in both cases. Sometimes these orders can go through the system without the OK of the radiologist. And in both situations, communication with the radiologist could have prevented unnecessary contrast administration. Or in other words, lack of communication/isolation between the ordering specialist and the radiologist was the proximate cause of a bad patient outcome.

All this brings me to discuss the topic of today- the isolated specialist. I will divide it into two different sections: What are the effects of operating “in a bubble” isolated from our colleagues? And how can we prevent physicians from working in isolation from one another?

Effects Of Operating “In A Bubble”

Untoward Side Effects

Witnessed in the examples above, two patients that should have had a non-contrast scan instead had their scan “upgraded” to an intravenous contrast-enhanced CT scan. Instead, a simple phone call from the physician could have prevented the possibility of a bad outcome. And these examples are just the tip of the iceberg. Many other cases exist where the clinician could have communicated with the physician and prevented a bad outcome.

Increased Expense

Imagine how much expense inappropriate imaging costs both the insurance company and the out-of-pocket expenses to the patient. It’s not just the additional unnecessary contrast. Instead, it is the additional weeks spent in the hospital, blood draws, nurses, physicians, and on and on. The physician could have avoided all of that with a simple discussion with the radiologist.

Prolonging Workups And Hospital Stays

In our example above, it is not just the untoward patient side effects and unmanageable expenses incurred. Instead, it is also the increased time the patient may need to stay in the hospital to figure out the patient’s disease entity. Very few patients say, “I have renal failure.” Patients may experience fatigue and other nonspecific symptoms. And a physician has to work up the clinical situation. Imagine the loss of time from work or other productive activities incurred by the patient and doctor.

Also, this is just one example. Lack of communication between radiologists and specialist cause all sorts of problems. Ridiculous unnecessary workups often ensue, wasting everyone’s time.

Radiologist Lawsuits

Don’t forget about the potential for lawsuits. All the factors from the above situation meet the criteria to allow a legitimate case. These would be breach, causation, and damages:

  1. The radiologist administered intravenous contrast inappropriately, breaching the standard of care.
  2. Contrast administration is the proximate cause of the patient’s renal failure.
  3. The patient suffered damages, including renal injury and a hospital stay.

A simple discussion between the physicians could have prevented a lawsuit.

Remaining Ignorant About Alternative Diagnoses and Treatments

Frequently, I learn about many of the most up-to-date patient diagnostic tests and treatments when I pick up the phone and discuss a case with a clinical colleague. In the situation above, a simple question about contrast could have avoided causing harm to a patient. This example is one where the ordering doctor remained ignorant about alternative methods of diagnosis (a non-contrast CT scan) when no communication ensued. Isolating oneself from phone calls with the specialist often prevents the best possible patient outcomes.

How Do We Prevent The Specialist Isolation?

Make It Easier To Contact Physicians

I think we have to blame both the ordering physician and the radiologist in these situations. Many physicians make it next to impossible to contact them by phone. Likewise, I know many radiologists who shun the phone under all circumstances. We have to make a conscious effort to make ourselves more available. Perhaps, it is a simple answering service that can solve the problem. Or, a radiology assistant may do the trick to improve communication.

Remember We Don’t Know Everything

Sometimes, we need to remind ourselves that each of our own experiences by ourselves is extremely limited. Only our interaction with others can allow us to understand patient issues best and give our patients the best care possible. We need to remain humble and ask for help from the radiologist and the ordering physician.

Computer Guidance

I hate to say it. But, clinical decision support systems have the potential to increase communications between clinicians and radiologists. When the computer detects the potential for a wrong imaging study order, it will force the clinician to interact with the radiologist. Potentially, this can relieve some of the issues of specialist isolation.

Attend Physician Friendly Events (Staff Meetings, Golf Outings)

Finally, many say that interdepartmental physician functions are unnecessary. But, I cannot disagree more. Making ourselves feel more comfortable with our colleagues allows physicians to be more likely to pick up the phone with a colleague who can become a friend. What better way to decrease isolation than sharing fun events with our colleagues?

Final Thoughts About The Isolated Specialist

Radiologists and specialists need to treat specialist isolation as a severe barrier to good patient care. And unfortunately, isolation is all too common. So, we need to make inroads to break down these barriers. Reducing specialist isolation will prevent patient side effects, reduce hospital stays, lessen patient expenses, decrease lawsuits, and increase diagnostic and treatment options. As specialist physicians, let’s all make a concerted effort to solve this critical problem together.

 

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How Much Work Is Too Much For A Radiologist? (Think RVUs!)

RVUs

You are excited to start your career as a radiologist. And, you are interviewing, hoping to find a job where you can make the most money and pay off your student debt. There is much more to find the correct position than just assessing the income. Of course, you should consider the location and job profile. Just as importantly, however, you also need to figure into your calculations the workload and relative value units (RVUs) you need to complete to reach that income.

Avoid the following situation: an insurmountable daily imaging workload with a queue of patient studies that never ends. A job like this is bound to end badly. But, what is an unsafe workload for you, the radiologist? Or, more accurately, when looking for a job, how many studies are too much to read daily? Let’s investigate these issues together by examining some of the markers of workload and then get to some more specifics about the appropriate RVUs for an individual radiologist.

The Lowly RVU

Before we conclude how much work is too much, we first have to define a unit of work. The essential measurement of work is the RVU or relative value unit. According to an excellent presentation on the history of insurance, the first “RVU” came out in 1992 (1). It defined a relative value unit as three different components- physician work, practice expense, and malpractice. Most of the cost/workload of the RVU relates to physician work and practice expenses.

So, who decides the cost of an RVU? The American Medical Association defined a committee called the AMA Specialty Society Relative Value Update Committee (the RUC). It consists of an expert panel of an individual from the 21 major national specialty societies, two IM specialists, one primary care practitioner, one specialist, and six additional committee members. They assign explicitly what the Medicare costs are for each procedure. (1)

Why Is The Average RVUs Per Radiologist Is Important? (And Why It’s Not!)

OK. So, we have defined what makes an RVU and who creates an RVU for any given procedure. The following important question: What is the median number of RVUs per radiologist throughout the country. Well, I found a relatively recent article in The Reading Room that reports just that. (2) To summarize, it says that the average radiologist performed 10,020 RVUs in a 2020 survey. Now that we know the average RVUs per radiologist, it’s a relatively simple step to ask the average number of RVUs per radiologist per year in any given practice. Usually, the business or practice manager can obtain the number if you ask. If you find that the number deviates significantly from the mean, perhaps, you are looking at too few or too many studies.

But wait… There’s more to the equation! Let’s say you are a neuroradiologist that reads almost exclusively high-value RVU MRIs. Perhaps, you may read them significantly quicker than a general radiologist. Then, you can probably handle more RVUs than the average radiologist. Or, let’s say you just started and have not yet picked up speed with dictating. In that case, you will likely read lower amounts of RVUs. Therefore, you have to put in your weighted factor to determine how much work is reasonable.

Why Are Daily RVUs Even More Important?

Finally, we have developed your individual optimal yearly RVU number where you should lie within a reasonable spectrum. But, it is impossible to conform to that number precisely every day in any given practice. Some days you will have more studies and others less.

To add even more variation, in some practices, the radiologists may take 16 weeks of vacation, leaving only 36 weeks to complete all the work. To make the appropriate calculation of RVUs in this sort of practice, you would need to take the individual practice’s annual RVU number and divide it by the number of days per year worked. In actuality, that yearly average total RVU number does not measure the amount of daily work. A more appropriate calculation would be the daily RVU number. Therefore, a practice with a seemingly ordinary yearly RVU number can have an exceedingly high daily RVU number.

The RVU Tipping Point

What happens when a radiologist reaches the daily RVU tipping point beyond which they are comfortable? Well, most practicing radiologists have had bad days like this at some point. (Hopefully not every day!) You cut corners; your mind drifts elsewhere; burnout ensues; eye strain develops. Not only is it a wrong place for you, but it is also terrible for patient care. Let’s try to avoid that situation as much as possible.

How Much Is Too Much?

Back to the original question again. Too much work can vary widely for any individual. But at least, you now have a feel for calculating how much is too much. So, go forth and ask about the RVU number when you interview for a job, calculate the daily RVU value and compare it with your comfortable RVU numbers. That way, you are much more likely to find appropriate work for you!

(1) http://www.rsna.org

(2) https://thereadingroom.mrionline.com/2020/11/radiologist-alary-update-2020-show-me-the-money/

 

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How-To Procedure Manual For The Klutzy Radiologist

procedure manual

Some of us are not born to be athletic and coordinated like Michael Jordan or Pele. It’s just not in the cards. As a part of this group, I can remember many simple radiology procedural activities challenging me that would make the average resident wonder! Simple things like putting on sterile gloves and coiling interventional wires seemed like rocket science. However, hope springs eternal. And, believe it or not, many strategies exist to allow the klutzy radiology resident to become an expert at performing a procedure. We will discuss these today in this mini procedure manual.

Read Everything You Can About The Procedure

Procedural work is not just about performing manual tasks. It involves significant preparation and planning, both from a hands-on and an intellectual standpoint. Therefore, your role is to know all you can before performing the procedure. Some of the questions you need to be able to answer before any procedure include: What is the reason for the technique? Is it appropriate for the patient? What are all the tools and equipment needed to complete it? How can you avoid complications? And, if a difficulty arises during the test, do you know what you have to do next? And, of course, what are the appropriate ways to manage the patient after you have completed the procedure?

In addition, nowadays, most procedures have an associated “how-to” article or procedure manual in the literature that can help you understand step-by-step how to perform a technique. Not only do you want to read each of these articles, but you also want to live and breathe all the information in it. What do I mean by that? If you can, mentally picture yourself performing the procedure steps before stepping into the interventional suite.

Gather All The Relevant Patient Information

Patient research beforehand can be just as important as the procedure itself. You need to be able to complete the appropriate test for your patient. If not, you can cause additional radiation exposure and potentially irreparable harm.

Therefore, gathering relevant patient information is essential before performing any procedure. What do I mean by that? Here are some of the pertinent questions you want to answer. Does the reason for the technique match the history of the patient? Is the patient able to consent? Are all the appropriate blood tests completed before starting it? Do you know of anything about the patient’s history that would increase the likelihood of complications? And so forth. Ensure that if your attending asks you something about the patient before its performance, you know the answer. It will come back to bite you if you don’t.

Practice Outside The Interventional Suite

As Malcolm Gladwell states in his book Outliers, you need to do something 10,000 hours to become an expert. Therefore, your work mustn’t end after the initial steps. If you have problems coiling a wire, practice the maneuver at off-times at work or home. When you have difficulty putting on sterile gloves the right way, take a pair and practice. If you have problems with suturing, learn needlework. Especially if you are not a member of the athletic/coordinated club, you will need to practice, practice, practice until you get it right!

Volunteer Ad Nauseum

Lastly, you need to develop the qualities of grit and perseverance. When a procedure is available, take the opportunity to participate. Don’t be a wallflower. One of my program directors during my residency repeatedly stated, “Radiology is not a spectator sport!” He was right. Procedural comfort is directly related to the number of times you have completed a procedure. So, go forth and participate as much as possible!

Read This Procedure Manual Again If You Have Doubts!

Everyone has some deficiencies, and we are not born perfect. We need to proceed with hard work and determination to overcome these weaknesses. Procedural skills for the klutzy resident are no different. So go forth and read avidly about procedures, gather the appropriate patient information, practice outside the interventional suite, and volunteer repeatedly. No matter if you are a bit klutzy. You, too, will have the power to master any procedure if you follow these basic guidelines!

 

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How Not To Incriminate A Fellow Radiologist For His Mistakes

 

 

One major theme in many of my blogs is that radiology residents and radiologists do make mistakes. We see them all the time in prior reports. We hear them from our fellow radiologists and clinicians. It is just part of the normal ebb and trough of the radiology resident or attending. I still remember one of my attendings from residency sagely saying we slowly get less sensitive over time. Then, we miss a finding and become overly sensitive until we become less sensitive again. And, this process continues throughout our radiological lifetimes, hopefully, as we try to reach perfection. Bottom line. If you are not making mistakes, you have not read enough films and you are not getting better. We acknowledge that. It’s who we are.

More importantly, we as radiologists have to protect each other from our mistakes. It is important that we don’t throw our radiology colleagues “under the bus”. Politically and ethically, treating our fellow colleagues well is just as important as writing good reports. We all need to be team players in order to protect our practice of radiology. So, what are some general rules for protecting our colleagues from their own mistakes? Well, that is the theme for today. A mini-instructional, if you will.

Contact Your Colleague Immediately

Contacting your colleague is probably the most important step in reducing the issues that ensue from a miss. Often times, I will read a bone scan and find the corresponding metastatic lesion on CT scan that can be very hard to detect prospectively. Immediately, I contact the physician who recently dictated the CT scan, usually on the same day. As a courtesy, this step allows this radiologist to create an addendum if warranted and prevents any harm from coming to the patient due to an incorrect report as well as the possibility of a lawsuit.

Sometimes, however, you may detect a miss from a while back, maybe months or years. In this situation, the offending physician can contact the caring physician or patient and/or make an addendum to his/her report to right the mistake. It may not prevent a lawsuit, but it certainly prepares the physician for the possibility. And, it also happens to be good patient care.

Don’t Highlight Mistakes On Prior Reports

This may seem obvious, but radiologists commit this offense one too many times.  When your fellow radiologist misses a finding on a previous report, the last thing that you want to do in any way, shape, or form is to say explicitly that he/she missed the finding. If the patient catches wind of this miss, you will see dark clouds brew and lightning flicker through the air, about to target this unsuspecting radiologist and your practice too. You are asking for a lawsuit to strike down all those involved in the construction of the prior report!

Phone The Clinician Directly To Discuss The Case

Instead of adding the miss directly to the report, another good idea is to pick up the phone and call the clinician. The issues behind a radiologist miss can be better expressed sometimes by mouth than on paper. It allows you to guide the physician toward what he/she has to do next without having to state it officially on a report. Also, the less incrimination on paper, the less likely the radiologist with a miss will have to answer for his/her sins.

Use The Words New, Stable If Possible

Especially in mammography, the kiss of death for a radiologist with a miss on a prior report is to write that a mass has enlarged compared to his priors. In no uncertain terms, what you are really saying is that the radiologist missed the finding. Lawyers love this stuff! Not that you should lie, but many lesions cannot be seen prospectively because they are really too small to catch. So instead, if you can, use the word new. Or, just say a mass is present with a comparison date to the previous study. Even better, if the lesion was present and unchanged, you can safely say the lesion is stable without incriminating anybody. Stability is usually the radiologist’s friend!

Summary

A radiology practice is a team and if you don’t think like a team player, your team will break apart. Incriminating one’s colleagues for mistakes made (that we all make at times) is a selfish act and is one of the most unsporting behaviors out there. So, be a team player and think long and hard about what you will finally place in your report. It potentially can save your colleague from a lawsuit and allow you to earn respect from your practice as a team player!