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Rant
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29 Replies
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Key question: Do you depend on good relations with these referrers to maintain your income?
Which is closer to your situation?
A) A private practice rad with your own magnet and neurology/ortho referrals keep the lights on?
or
B) You’re an academic radiologist whose ED providers and hospitalists have no choice but to use your product and you’re all just employees working for the same administrator?
If a) Suck it up and say ‘Thank you, sir, may I have another.”
If b) tell them to go f*ck themselves. (or, if you prefer the more traditional radiologist approach, become a completely passive-aggressive a**hole and be unresponsive to every request, making them hood jump and chewing a crap load of their admin time just to get a procedure ordered.)
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As for the part about trying to convince someone to order the right study …
I gave up on that years ago.-
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Utilization is something you address on a department wide basis, not individually with a referrer. If a review of dr X duplex orders shows that 50% don’t get paid, the department admin has to address that with Dr X, not the individual rad. It’s an ultrasound, why even waste the time to call on a individual study.
What grates me more than poor utilization are condescending jerks when you call to report a misplaced tube. I know, ‘you saw that’, I sure hope so that if you are in the business of intubating people you Are able to see a low tube. I am calling you because hospital policy says so. Even worse are the ones who try argue that the tube or line is in a good position when it is not.
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Quote from 67ED5CC042435
fw yours is also a good hypothetical.
No, that’s how we do this. There is a process to review incorrect orders. Now, if let’s say Dr X is a high volume oncologist who feeds us piles of high RVU work, he’ll get more latitude on ‘unwarranted’ LE venous studies than some PA from a doc in the box who sends all her x-rays and MRIs to the competition and only relies on us for US.
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Quote from 67ED5CC042435
fw I meant the calling about findings and them saying we are wrong.
Sorry. Misunderstood.
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The bad docs are doing our healthcare system a lot of damage. They are creating cancers with their unnecessary normal CT scans, and the are wasting a lot of healthcare dollars. I guess no one cares to go after these guys because they generate a lot of revenue with all their unnecessary lab tests and imaging.
There should be something like – Dr. X 90% of the imaging you ordered in 2020 was normal or didnt change management and this is greater than 2 standard deviations from your peers. We are cutting all of your reimbursements for 2021 by 50% until you fall within 2 standard deviations of your peers. Conversely, Dr. X. 90% of your ordered imaging in 2020 was abnormal or affected management, this is greater than 2 standard deviations from your peers, we will be rewarding you by increasing your reimbursements by 25% for 2021.
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Quote from 67ED5CC042435
How do you deal with condescending referring docs? The radiologists and technologists I work with have great personalities, and I really am grateful that I get to work alongside them.
But then there are the referring docs. Most are reasonable. But some are downright toxic.
I normally call the treating doctor if a study indication does not make sense to clarify what they may actually want. One hypothetical example would be I call about a renal duplex request following a CTA abdomen the patient had earlier for something else. Rather than discussing how the duplex may be still be beneficial or how the information they want is already available, they get defensive and say they ordered it because it was indicated and that is the end of it.
At the end of the day we end up doing things that are wasteful and we do not get paid for the work.
How do you deal with condescending referrers?
Just suck it up?
Take autonomy and make our own determinations about the imaging appropriateness independent of these sour apples?DR should embrace the IR model and embrace themselves being consultants. Every imaging study is a consultation and you are the ultimate one who decides if the intervention is warranted or acceptable.
It’s not like going to wendys where they order a frosty ” ya I will have one nephrostomy tube please.”
No the consultation is for management of hydronephrosis or whatever and then the IR weighs in and says if its necessary or not. Can you imagine what a surgeon would say if they were consulted for ” one appendectomy please.” No, it’s their decision if an appendectomy is offered to the patient.
Some of these things you can’t win, like you can’t stop the 20 year old who presents to the ED with a headache and they want to make a stroke alert from undergoing whole work-up. But if there’s a clear cut superior modality that was done before and it’s completely unnecessary I certainly think it’s appropriate to fight it. We obviously both know it’s going to add no value so I would simply refuse if they give you “it’s indicated” as an excuse. No it’s not. Doing it just because they want it when you know it’s completely pointless is 100 % wrong and everyone knows it, they’re just taking the easy way out. If you think the study may add some value then it’s different.
Too many rads just say yes and go hide in their closet and mumble under their breath. If you have real conversations with people and explain your thinking in an appropriate manner, it may take you five minutes but you just spared the patient an unnecessary exam (which we may find more incidental crap we have to work up) and also may educate your peers/develop relationships.-
Some of these may also just come down to misunderstandings, like if you ask them, what do you think this ultrasound could show that wouldn’t have been seen on the CTA, put the onus on them to explain why they want an additional exam
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I get lots of calls to protocol studies. Usually when the CT tech calls to clarify and I suggest a different protocol, the change happens. I guess I am in a lucky situation.
If theres an angry or stubby clinician that does not budge, I just agree. Its not that common to make me upset. There was an incident when a partner would not agree with a certain upset clinician to do a study. It was brought up to admin and led to meetings. No one in trouble at the end of the day. But, not worth it in my opinion and we should have just done the study.
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Quote from Umichfan
If theres an angry or stubby clinician that does not budge, I just agree. Its not that common to make me upset. There was an incident when a partner would not agree with a certain upset clinician to do a study. It was brought up to admin and led to meetings. No one in trouble at the end of the day. But, not worth it in my opinion and we should have just done the study.
I dont ever argue with any referrer. If the suggestion to change a test is ignored and they insist on ordering the wrong thing, I point out the limitations of what they ordered in the report.-
Watcha gonna do. At the end of the day, he who owns the cow decides who gets the milk. They get to flex their ego, we just stick to the facts and not get riled up by as5holes, refuse to roll in the mud and keep raking in the green.
But if you’re gonna piss them off anyway, might as well make it worth it and tell them if they come by the reading room you’ll kick their as5.-
Once upon a time, a student approached a wise man in search of wisdom. When he finally met the wise man, he asked:
“What is the secret to eternal happiness?”
The enlightened wise man replied:
“The secret to lasting peace is in not arguing with idiots.”
The student, not finding this satisfactory, interjected:
“That can’t be right. So many things could go badly with that approach.”
The wise man, having heard the student’s response, brightly smiled and said:
“My apologies. You are absolutely correct.”-
Except there’s a patient to protect who is being subject to unnecessary tests, radiation and work ups. Which then find more BS we have to follow.
It’s not about the work. Trying to fight exams is net more work, even if you win a lot. It’s about the patient.-
You are absolutely right. Those non-con CTs, extra MRI, US, and couple of X rays. They are dangerous.
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if you as a doctor perceive something to be completely unnecessary is it a) the right thing to try to stop it
b) pass it through bc its easier on you
not a tough call
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Quote from Insomnia
You are absolutely right. Those non-con CTs, extra MRI, US, and couple of X rays. They are dangerous.
On a population scale, yes this can all cause additional harm to the patient. Every other patient has an incidentaloma somewhere in their body.
Sure a bit of extra radiation doesn’t hurt that much. What about a lung biopsy complicated by a pneumo? Or in the worst case scenario the pathologist ****s up and someone get an organ taken out for the wrong reason.
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Quote from Umichfan
I get lots of calls to protocol studies. Usually when the CT tech calls to clarify and I suggest a different protocol, the change happens. I guess I am in a lucky situation.
If theres an angry or stubby clinician that does not budge, I just agree. Its not that common to make me upset. There was an incident when a partner would not agree with a certain upset clinician to do a study. It was brought up to admin and led to meetings. No one in trouble at the end of the day. But, not worth it in my opinion and we should have just done the study.
I think this is right.
Be reasonable and proactive, but not argumentative.
90% of the time this works, 10% of the time you do the study.
If it is somehow dangerous, OK, different story. But that is rarely the case.
Typically it is an ego issue; let that go. Good advice for life in general.
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I just unilaterally cancel ultrasounds on inpatients ordered by some dumb hospitalist or resident team when theyve had a diagnostic ct already. No one has complained that Im aware of, probably because they dont notice, because they didnt need it in the first place, its just a dumb reflex that pops up in their A/P.
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IR27 lays it out succinctly.
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A poorly timed April Fools Joke?
This thing reads like high comedy. Even the author’s bio makes me chuckle… [link=https://medicine.yale.edu/profile/jonathan_mezrich/]https://medicine.yale.edu.rofile/jonathan_mezrich/[/link]
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Quote from IR27
Quote from 67ED5CC042435
How do you deal with condescending referring docs? The radiologists and technologists I work with have great personalities, and I really am grateful that I get to work alongside them.
But then there are the referring docs. Most are reasonable. But some are downright toxic.
I normally call the treating doctor if a study indication does not make sense to clarify what they may actually want. One hypothetical example would be I call about a renal duplex request following a CTA abdomen the patient had earlier for something else. Rather than discussing how the duplex may be still be beneficial or how the information they want is already available, they get defensive and say they ordered it because it was indicated and that is the end of it.
At the end of the day we end up doing things that are wasteful and we do not get paid for the work.
How do you deal with condescending referrers?
Just suck it up?
Take autonomy and make our own determinations about the imaging appropriateness independent of these sour apples?DR should embrace the IR model and embrace themselves being consultants. Every imaging study is a consultation and you are the ultimate one who decides if the intervention is warranted or acceptable.
It’s not like going to wendys where they order a frosty ” ya I will have one nephrostomy tube please.”
No the consultation is for management of hydronephrosis or whatever and then the IR weighs in and says if its necessary or not. Can you imagine what a surgeon would say if they were consulted for ” one appendectomy please.” No, it’s their decision if an appendectomy is offered to the patient.
Some of these things you can’t win, like you can’t stop the 20 year old who presents to the ED with a headache and they want to make a stroke alert from undergoing whole work-up. But if there’s a clear cut superior modality that was done before and it’s completely unnecessary I certainly think it’s appropriate to fight it. We obviously both know it’s going to add no value so I would simply refuse if they give you “it’s indicated” as an excuse. No it’s not. Doing it just because they want it when you know it’s completely pointless is 100 % wrong and everyone knows it, they’re just taking the easy way out. If you think the study may add some value then it’s different.
Too many rads just say yes and go hide in their closet and mumble under their breath. If you have real conversations with people and explain your thinking in an appropriate manner, it may take you five minutes but you just spared the patient an unnecessary exam (which we may find more incidental crap we have to work up) and also may educate your peers/develop relationships.
I honestly can’t like this enough. I have been screaming from the rooftops that this is how IR and DR need to practice. Blows my mind how many passive and pu**yfied radiologists there are out there.
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While maybe not quite to the same level as Mark Twain’s quip about wrestling with pigs (“Never wrestle with a pig. You’ll get dirty and the pig will win.”), I’ve definitely become more detached from such situations as I’ve progressed through my career.
I never argue with a referring doc, not because I worry it’ll affect my income (it won’t) but because the emotional and temporal investment isn’t worth it.
For probably the last 20 years or so, the most I’ll do is call them and say something like “If you really want to do [this scan], it can be done, but here are some things to consider as to why you may want to do [another scan].” The reactions to such an approach vary, but I’ve never had an outright hostile one.
If they go all “May-po” (dating myself; the product’s tag line in adverts from the 70’s was: “I want my May-po and I want it NOW!!!”), I put a disclaimer in the report about the limitations of this particular study for the indication for which it was ordered. Got pushback once on such an approach and shut it down by calmly asking “Do you have any factual objection to what was in my report?”
Have had a few memorable experiences over the years. An orthopod asked me to to a “sham” joint injection (saline instead of anesthetic/steroids) and he just couldn’t seem to understand how he was asking me to do something unethical. Still wonder if I should have forwarded the incident to the med staff office. Another time a notoriously abrasive internist called to berate me because we didn’t do HIDA scans with the patient sitting upright. He called it malpractice and got so worked up he used some foul language at which point I calmly told him I wouldn’t tolerate being talked to like that and that if he ever wanted to speak to me again, the first words of our next conversation would have to be an apology for speaking to a colleague in such a manner. Never heard from him again.
I suppose bottom line advice I’d give to a younger person would be to manage what you give a $#%! about; you only have a limited capacity and most younger people (most definitely myself as a younger person) don’t realize that.
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Great post above.
To quote/repeat: “I suppose bottom line advice I’d give to a younger person would be to manage what you give a $#%! about; you only have a limited capacity and most younger people (most definitely myself as a younger person) don’t realize that. ”
As a resident, I learned from a senior resident on call the power of staying calm, detached and not bothered. It was a busy evening and I was shadowing him in preparation to take overnight call myself at the University center. He picked up the phone and there was an irate physician on the other end shouting at him for not agreeing to scan some patient who hadn’t gotten the full contrast-allergy premedication regimen (or something like that). He just listened to the rant while scrolling through the next non-con head CT and then suddenly he sat up straighter and interrupted the person: “That’s – hey, that’s really inappropriate and unprofessional for you to say. I’m willing to keep listening but not like this, please call back later when you are doing better. Thanks.”
Then he just hung up the phone and continued looking at the study he was in the middle of reviewing.
I asked him what happened and he said it was the Chief of Urology (top academic center) who was mad at him for not bending the rules and started to cuss at him. He had just hung up on the Chief of department. I asked,
“uhh, aren’t you pissed off? You look pretty calm dealing with that.”
He said,
“I can’t waste the energy. I’m getting slammed and need to think about other stuff.”
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What is the significance of an upright HIDA ? I dont understand
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Quote from IR27
What is the significance of an upright HIDA ? I dont understand
About 10-15 years ago, the local TV station had a story about a young woman with severe GI symptoms and malnutrition that was ‘cured’ after cholecystectomy. She claimed in the story that she’d had a HIDA scan performed that was ‘normal’ but when she had another HIDA scan done elsewhere, it was performed upright and was ‘abnormal’ leading to the surgery. I have no knowledge of the patient other than the TV news story.
So for a few years, we’d get requests to perform HIDA scans with the patient upright. It didn’t matter to me, though most patients don’t like standing for over an hour and positioning the camera with the patient seated in a chair could be problematic. After a few years, interest waned and I haven’t seen a request for an “upright HIDA” in many, many years.
I believe at the time I tried a lit search and couldn’t find anything on it. Not sure if anything is out there in the ensuing years.
Regarding your other post about contrast reactions, that is something I’ve chosen to give a $%&# about over the years. Have had many conversations over the years with ordering docs that ended with me saying: “It’s neither ethically nor legally defensible for me to claim that I went ahead and gave a patient an agent that they have a known, documented hypersensitivity to because ‘Dr. [ordering physician] told me it was OK and that he’d take responsibility if anything went wrong.'”
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