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Consultant versus image reader
I used to work closely with referring physicians and techs to improve the protocols and do the best study on patients. After doing it for 10 years, I am going to call it quits.
I am just a film reader. I read what they put in front of me. If it is a CT abdomen and pelvis without contrast for “weight loss- Looking for cancer”, I just read it as it is and put the disclaimer in the impression that it is a limited study and move on.
I am tired of dealing with referring physicians esp ED doctors.Recently received a letter from HR that I am obstructing and delaying care to emergent patients because I ask for contrast enhanced studies. It all started when ED PA ordered CT chest without contrast in a patient with history of Aneurysm repair with indication of “chest pain. Assess aortic aneurysm” and I ask for contrast enhanced study and CTA.
I am not going to disagree with anything. I Just smile and then act passive-aggressive. It is the best thing to do. It is probably the definition of EQ. Even in my personal life I am going to do the same. People don’t want to communicate. They prefer passive-aggressive personalities to upfront honest assertive ones.
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24 Replies
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I refuse the passive approach. It is against my nature. If someone is royally f’n up, they need to know they are f’n up. I try my best to let them know in a nice way.
How will anyone ever learn (and do better) if we just roll over and take it?-
I like to say that the ED shares one brain and someone else is always using it.
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Quote from Robotrad
I refuse the passive approach. It is against my nature. If someone is royally f’n up, they need to know they are f’n up. I try my best to let them know in a nice way.
How will anyone ever learn (and do better) if we just role over and take it?
You can teach people only if they want to learn.-
I feel like we each do the best we can. We all have our own tolerance and limits too how much we can give to each case. We cant be martyrs for every case, theres not enough time. But theres a space that presents itself every day, sometimes every hour, however small, for us to take that extra step and bit of diligence, knowing that we could have let it slide. In that small space of making a difference is where we keep the embers of a sense of mission lit, smoldering just beneath a layer of gray ash thats accumulated from being beat down and burnt but not entirely burnt out. Maybe all it takes is gust of wind and the right environment and poof! the flame reappears and we are physicians once again. Every once in a while, its nice to go the extra mile and be a hero to remind yourself what it feels like and to show that you still have it in you.
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I don’t know about being a hero, but if someone asks me to evaluate an aneurysm I will always make it into a contrast study.
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to OP:
There have been many times when I have received the same indication with a non contrast study. I just read the non con and put a disclaimer and a recommendation to get contrast CT. Now it is on them to have delayed the care, not you.
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Quote from OnsiteRad
Quote from Robotrad
I refuse the passive approach. It is against my nature. If someone is royally f’n up, they need to know they are f’n up. I try my best to let them know in a nice way.
How will anyone ever learn (and do better) if we just role over and take it?
You can teach people only if they want to learn.
And since no one wants to, the only fix is that the system collapses. Get ready, many things will be like that in the US and beyond in the next 3-5 years.-
What reason did the PA give for wanting a non-contrast CT of the chest?
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Quote from OnsiteRad
Quote from Robotrad
I refuse the passive approach. It is against my nature. If someone is royally f’n up, they need to know they are f’n up. I try my best to let them know in a nice way.
How will anyone ever learn (and do better) if we just role over and take it?
You can teach people only if they want to learn.
Absolutely. What I have found particularly aggravating is that the radiologists AND the techs are the worst offenders of this. Many places seem to have zero incentive to learn new skills and the rads who are in charge get angry at those who try to stir the pot and grow. Further, have any of you met ultrasound or MRI techs who behave as if they know more than you? That you are just bothering them when trying to interact? It is infuriating. And I have no idea how to reach these people. Repetition and requests and teaching have not done it in my recent experience.-
@vonbraun,
The PA ordered the study without having a clue.
I called her back and told her that we need contrast and explained the logic behind it. She said: I usually order these without contrast and “other radiologists” are OK with that. Anyway, if you want to do it with contrast please talk to Dr….
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Sounds like you’re not fighting the right battle. You advise a contrast enhanced exam, they say no, you don’t fight them there you just say ok then dictate:
“Limited non contrast exam. Cannot exclude an aortic dissection. Recommend CTA. Discussed with PA so-and-so.”
They will start listening to you rather quickly.-
It was my mistake. I refused to do non-con study since I couldn’t find the ER physician for 10 minutes and the PA was insisting on non-contradt study that I didn’t do.
After 10 minutes the ER doc called and was pissed off because I delayed such a critical exam for 10 minutes for no reason.
I had to approve the study in the first place, read it as limited and move on. -
Agree that it is a losing battle. Just read it as nondiagnostic for the indication, limited, etc. and move on. Recommending the appropriate study is the best you can do.
What really ticks me off is they don’t do the recommended study and order some other useless garbage.
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Quote from RadCog
Sounds like you’re not fighting the right battle. You advise a contrast enhanced exam, they say no, you don’t fight them there you just say ok then dictate:
[b]”Limited non contrast exam. Cannot exclude an aortic dissection. Recommend CTA. Discussed with PA so-and-so.” [/b]
They will start listening to you rather quickly.
Quote from Radguy123123
Agree that it is a losing battle.[b] Just read it as nondiagnostic for the indication, limited, etc. and move on. Recommending the appropriate study is the best you can do.[/b]
What really ticks me off is they don’t do the recommended study and order some other useless garbage.
This is my approach as well.
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Some thoughts that came to mind reading this thread:
“Grant me the courage to change the things I can, the fortitude to bear the things I cannot, and the wisdom to know the difference.”
“Two reasons not to wrestle with pigs: First, you’ll lose. Second, the pig will enjoy it.”
“The root cause of all human suffering is the inability to accept things as they are.”
Agree with preceding posts. My pet peeve is HRCT ordered for nodule evaluation (or even better is suspected hilar/mediastinal adenopathy). A noctor gets a CXR report that recommends chest CT, gets to the order page on the computer, sees “HRCT” as one of the chest CT options and (I’m assuming) the thought process is “Heck yeah I want a HIGH RESOLUTION chest CT!!! Why would I want any other???” So I do the best I can to answer their question, noting that a non-contrast chest CT is limited for hilar/mediastinal evaluation, then at the end of my report put in the following to try and educate: “HRCT typically indicated for evaluation of known or suspected interstitial lung disease. For evaluation of pulmonary nodule(s) and/or hilar/mediastinal mass/adenopathy standard contrast enhanced chest CT is the recommended examination.”-
Why waste time asking them to change it?
Just protocol the exam correctly.
Or reject it as not indicated if it’s total nonsense.-
Do you guys still protocol studies as attendings?
As a resident, I have to protocol all cross sectionals for our main hospital. It’s such a time sink, especially overnight, when I spend more time on the phone than actually reading.
Our other hospital magically protocols its own studies and they get scanned and come to me without me having to do anything. So, so much better that way.-
Quote from chilldude22
Do you guys still protocol studies as attendings?
As a resident, I have to protocol all cross sectionals for our main hospital. It’s such a time sink, especially overnight, when I spend more time on the phone than actually reading.
Our other hospital magically protocols its own studies and they get scanned and come to me without me having to do anything. So, so much better that way.
Most places have trained their techs to do the protocoling. No one is wasting an Attendings time to do routine protocoling.-
Midlevels always order crap like “CT Chest w/o and w/ contrast HIGH RES” just because they don’t know what they’re doing. Agree w/ above that I usually just change it without asking. Why would you ask someone who doesn’t know what they’re doing?
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Quote from MidwestIR
Midlevels always order crap like “CT Chest w/o and w/ contrast HIGH RES” just because they don’t know what they’re doing. Agree w/ above that I usually just change it without asking. Why would you ask someone who doesn’t know what they’re doing?
Some insurances don’t let you change noncontrast study to contrast study as a radiologist. The ordering provider has to do it.
Some referring physicians get pissed off. For example, they will call you that the delay in scan was because you added contrast.-
Quote from Flounce
[b]I feel like we each do the best we can.[/b] We all have our own tolerance and limits too how much we can give to each case. We cant be martyrs for every case, theres not enough time. But theres a space that presents itself every day, sometimes every hour, however small, for us to take that extra step and bit of diligence, knowing that we could have let it slide. In that small space of making a difference is where we keep the embers of a sense of mission lit, smoldering just beneath a layer of gray ash thats accumulated from being beat down and burnt but not entirely burnt out. Maybe all it takes is gust of wind and the right environment and poof! the flame reappears and we are physicians once again. Every once in a while, its nice to go the extra mile and be a hero to remind yourself what it feels like and to show that you still have it in you.
[b]Great Post…Each of us is trying the best they can. I try to apply this to the ER/mid-levels etc. They may not be acting ideally (non of us are 24/7) but under the specific given set of circumstances they find themselves in, I give them the benefit of doubt.[/b]Quote from Dr. Joseph Mama
Some thoughts that came to mind reading this thread:
“Grant me the courage to change the things I can, the fortitude to bear the things I cannot, and the wisdom to know the difference.”
“Two reasons not to wrestle with pigs: First, you’ll lose. Second, the pig will enjoy it.”
[b]”The root cause of all human suffering is the inability to accept things as they are.” [/b]
Agree with preceding posts. My pet peeve is HRCT ordered for nodule evaluation (or even better is suspected hilar/mediastinal adenopathy). A noctor gets a CXR report that recommends chest CT, gets to the order page on the computer, sees “HRCT” as one of the chest CT options and (I’m assuming) the thought process is “Heck yeah I want a HIGH RESOLUTION chest CT!!! Why would I want any other???” So I do the best I can to answer their question, noting that a non-contrast chest CT is limited for hilar/mediastinal evaluation, then at the end of my report put in the following to try and educate: “HRCT typically indicated for evaluation of known or suspected interstitial lung disease. For evaluation of pulmonary nodule(s) and/or hilar/mediastinal mass/adenopathy standard contrast enhanced chest CT is the recommended examination.”
[b]Great Post as well…particularly appreciate the quotes. [/b]
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Diarrhea = ruq u/s.
Weight loss, fatigue, h/o breast cancer = noncon abd/pelvis ct.
98 h/o follow up melanoma 5 years ago = pet/ct.
75 y/o knee pain no trauma = mri knee. No radiographs.Every day, all day. So draining on many of us. Others just do it without concern and place disclaimers. Cant fix a broken system.
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Quote from RadCog
Quote from chilldude22
Do you guys still protocol studies as attendings?
As a resident, I have to protocol all cross sectionals for our main hospital. It’s such a time sink, especially overnight, when I spend more time on the phone than actually reading.
Our other hospital magically protocols its own studies and they get scanned and come to me without me having to do anything. So, so much better that way.
Most places have trained their techs to do the protocoling. No one is wasting an Attendings time to do routine protocoling.
I rarely protocol cases and when I do their typically out-pt body mr’s etc…Only issue with ER ordering is when there is a contract reaction or renal function issue but even then it’s usually on a limited basis.
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