Tag: residency advice

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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 Do I Know Which Cases To Discuss With My Attending In The Morning?

You’ve made it through a typical night of call and the attending for the day is about to arrive. Your mind begins to meltdown from the exhaustion of it all. And, there are too many cases to discuss with your morning radiologist. It’s just going to take too long.

Moreover, you don’t want to waste your attending’s time with the obvious. On the other hand, you are not sure about what you are going to have missed during your shift. And, you want to make sure that you address all the critical issues. So, how do you go about deciding which cases to discuss with your morning attending? And what can you ignore? To increase your efficiency, let’s go over some of the basic guidelines.

All Cases That Can Significantly Change Patient Medical Management

Remember, in the end, every case that you sign off at nighttime, also will have your attending’s name on it too. By default, therefore, you should show every situation to your attending that will significantly change medical management. Now, what exactly does that mean? If your patient has gone to surgery based on your findings for any reason, that would certainly qualify. Or, if the patient needs to stay overnight because of your call, that would be eligible too.

In essence, I would have a low threshold for what constitutes a change in patient management. And, if it meets that criteria, well then, you must show it!

Equivocal Findings

It’s those cases that you hem and haw over. These are the best learning tools. So, make the most of them. Even it’s not the most clinically significant case; I would highly recommend that you try to discuss it with your morning attending. It’s one way that you may never discover that finding to be equivocal again. Think about all that time over your career that you will waste that you could have figured out immediately by just asking your attendings in the morning. Why wouldn’t you bother to do that?

Discrepant Reports With The Nighthawk

If you want to get burned, the best way to do it: Don’t go over discrepant nighthawk reports with your attending. I have been on the receiving end of one or two of these unmitigated disasters. And, the resident could have avoided it by simply telling me about it.

Moreover, even if the resident gets it right, and the nighthawk misses the case, it can still become a problem. Medically, the emergency physician can administer the wrong medication based on the nighthawk read. Or even potentially worse, she may not administer treatment based on his final report. Therefore, please let your attending know about these cases, especially if you made the critical finding, and the nighthawk reader missed the obvious!

Discrepant Reports With The Emergency Physician

Just as often as nighthawk discrepancies, if you forget to go over those cases where your opinion differs from the ED physician, you are potentially asking for trouble. Immediately, these cases should be some of the first that you must discuss in the morning. In addition to increasing the work burden on your morning reader, your attending will likely have to make a whole bunch of unnecessary phone calls if he doesn’t know that there was a discrepancy.  Your goal should be to reduce the amount of work your attending needs to complete, not increase it!

Any Other Cases With Questions

Sometimes, cases bring up fascinating points or other medical management questions. And, what better time to ask questions to reinforce what you have learned at nighttime? After residency, you will not have these opportune moments again. So, take advantage of making inquiries with experts while you can!

Whew, That’s A Lot Of Cases To Discuss!

Well, not necessarily. It sounds like a lot more than it is.  Often, these cases are the minority of what you will experience at nighttime. And, fortunately, most nights, you will encounter many normals and garden variety cases that don’t need to take up a lot of your time in the morning. However, regardless of the number of cases, it always pays to go over those cases that need extra attention and care, whether it’s for medical management issues, equivocal findings, discrepancies, or simple questions. It’s a fantastic tool for learning, and more critically, a moral duty for excellent patient care!

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Why Radiologists Should Consciously Love Subconscious Learning

subconscious learning

Given the opportunity, many of you would jump at the chance to read a new exciting imaging presentation of sarcoidosis or esthesioneuroblastoma. Sounds sexy, right? And I am the first to admit those disease entities seem attractive to me, something entirely different from the usual. But what about the seventeenth case of questionable overlapping shadows from soft tissue artifact versus pulmonary parenchymal disease at the left base on chest film? I mean, who cares about shadows at the bottom of the film, huh? We see them all the time. Or how about the 112th case of seeing a left adrenal gland that happens to have a medial limb that appears a little bit more concave than most others? I mean, this may not even register in our forethoughts as anything. However, I would argue that this second form of knowledge, what I like to call subconscious learning, is just as important, if not more so, than the sexy conscious education we all love to talk about every day- those cases of sarcoidosis and esthesioneuroblastoma. Nevertheless, many radiologist residents poo-poo, the second form of learning. I mean, why even bother with that other stuff when we can talk about that great case of esthesioneuroblastoma?

The Reality Of The Situation

Unfortunately, our reality as radiologists does not match the sexy image of a diagnostician frequently making unusual diagnoses. Instead, first and foremost, we are purveyors of normal findings that we register unconsciously every day.

For example, on any day that we may read a hundred chest films, only a small percentage, maybe 5 percent or less, will have these sexy undercurrents. The majority will have plain old garden variety mundane findings. But, it’s these common findings that we all need to either ignore or understand. If not, you will go down the tubes at your peril.

Why Is Subconscious Learning More Important?

So, why do I believe making these common subconscious findings that we gloss over during readout is more critical? Well, in reality, those findings that we see every day impact patient care more. Knowing whether that shadow at the lung base is significant on any given day may affect maybe 2 or 3 patients. On the other hand, that case of sarcoidosis, you may see a few times a month or year, or that case of esthesioneuroblastoma, you may see once or twice in a career (unless, of course, you work at an esthesioneuroblastoma center of excellence!)

Furthermore, overcalling findings can cause more harm to patients than you might think at first glance. For example, think about that patient with the adrenal gland with slightly increased concavity. You may send this patient to an MRI for an adrenal workup without knowing that this finding is within the normal range. And, of course, you find a nonspecific liver lesion. And guess what? Now you have to do a hemangioma scan. And the hemangioma scan comes back negative. The clinician then orders a biopsy, and the patient develops a subcapsular hematoma. And the complications roll on in “ad nauseum” at a cost to the patient and the health care system.

How Do We Increase Our Subconscious Learning?

I’ve said it before, and I will repeat it because it is that important. We have never found a substitute for sitting down (or standing up) and reading many films. You can only say what is within the normal range after seeing 10,000 livers, 85,000 heart shadows, and 12,000 gallbladders. And we accomplish that by registering these findings over time in our mental databank. No, it’s not glamorous, and our conscious brain may not realize it. But it works.

Conclusion

So, the next time you sit next to your radiology attending, think twice before you say that you will hit the books to increase your understanding of radiology. Truthfully, instead, you accomplish just as much by looking at your next case even though it is “nothing special.” No, you may not realize that you are learning anything new. And, no, it may not prepare you as much for the boards. But, over time, your subconscious learning will eventually win out. It is not only your sexy conscious knowledge but also your databank of common unconscious findings that will allow you to become the radiologist you want to be!