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How absentee radiologists can suck the financial blood from an EP’s work

WARNING:  If you are a radiologist, married to a radiologist, related to a radiologist, or even remotely like radiologists, you will be offended by this article. Be forewarned.

I attended the Gorgas’ School of Tropical Medicine in Lima, Peru.  We were treated to a wealth of clinical material including all types of worms, amoeba, malaria, fungal infections and more blood-sucking, vector-driven infectious diseases than you can shake a stick at. Subsequently, I have been asked many times “What is the most horrific parasite you have ever seen?” Those asking the question always expect to hear about some invasive, caseating, nasty infection with terrible suffering and awful consequences. However, I always respond that the worst parasite I have ever seen is a radiologist arriving at the hospital Monday morning in a black German-made luxury car (think vector here). 

Upon entry to the hospital these parasites will commence to feed on the financial juices of the lowly unfortunate EPs, who had to work the entire weekend without radiologic support or back up, particularly for the plain films they ordered. The radiologist arrives well rested, café latte in hand, and promptly installs himself in a dark room to re-read and bill for all the films the EPs read over the weekend. These same radiologists that are getting wealthy from re-reading films on ED patients long since discharged home do not understand why we do not welcome their belated input. 

With regards to radiology, never has a specialty done so little for so many and been paid so much.  Added to each read is “Recommend clinical correlation” or perhaps a self-referral like “MRI recommended” to clarify the pathology which we have already dealt with, contributing nothing to the outcome but cost.

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As Greg Henry MD, past-president of ACEP, has pointed out when discussing medical economics, the pie isn’t going to get bigger. The only question is “How big is your slice?” If you feel you deserve more of the pie, then someone else will consequently get less. Our slice should be bigger, and the fraudulent radiology slice can get smaller.

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The bills submitted for non-contemporaneous readings by radiologists are an enormous fraud occurring across the country at almost every hospital on most mornings, especially Mondays. Why does “the system” tolerate it? Where is CMS – or any of the other regulatory behemoths such as the Joint Commission, who are supposedly concerned with waste, fraud and abuse? Nationwide, the billings for these non-contemporaneous to care readings is millions of dollars a year.  

In California it is estimated that each EP provides approximately $150,000 per year of uncompensated care as part of our EMTALA obligation. I am proud of the fact that we provide this safety net.  However, as third party payers continue to down code and bundle our services, and balance billing comes under prohibition state by state, I want to be paid for these interpretive services which I render without radiologic support. I will be the one sued for missing the fracture, why shouldn’t I be paid for reading the film?

How much are these plain film interpretive services worth? In a study of a single hospital in Southern California with a modest payer mix, the plain film interpretive services worked out to $19 per EM clinical hour worked. This number comes from actual reimbursement data at a hospital where the radiologists are appropriately forbidden from billing for non-contemporaneous plain film readings. 

If you multiply that hourly rate for 140 clinical hours per month, it is $1660 or about $19,000 per year for every full time EP at the site.  Obviously, this EP group had to have the unmitigated gall to claim this income as well as the political power to stop the radiologists from submitting bills for those plain films which they were not reading contemporaneously.  For many of you reading this, that battle might threaten your contract or result in other serious problems within your hospital, so you have decided to let sleeping dogs lie (or using the parasite analogy, you have left the feeding tick undisturbed).  I would suggest that becoming a “whistle blower” would be appropriate here.

In December of 2009 CMS again made it clear that contemporaneous service matters.

Billers of diagnostic and interpretive studies are required to use only the date when the interpretation was performed as their service date and not the date the film was taken. The instruction from the Medicare Carrier Manual is as follows: 

10.6.3 - Date of Service (DOS) Instructions for the Interpretation and Technical Component of Diagnostic Tests (Rev. 1873, Issued: 12-11-09, Effective: 01-04-10, Implementation: 07-01-10)

The appropriate DOS for the professional component is the actual calendar date that the interpretation was performed. For example, if the test or technical component was performed on April 30th and the interpretation was read on May 2nd, the actual calendar date or DOS for the performance of the test is April 30th and the actual calendar date or DOS for the interpretation or read of the test is May 2nd.

The practical argument from radiologists has always been that, if the emergency physician (EP) bills, the radiologist’s claim will be rejected. Radiology billers have demanded the right to report the film date so that their bill matches the hospital’s bill.  But now, there is no doubt about the correct date of service – the date the interpretation was made.  

As a result of this instruction, what we have claimed to be true for a long time is now clear. It is effectively a fraudulent claim if a physician falsifies the date of service in order to effect payment. You might even begin to see the black Porsche in the parking lot on Saturday mornings as the radiologists begin to claim that they were right by your side at 3 am on Saturday night after you got that post-intubation chest X-ray on the intoxicated motor vehicle accident victim with a head bleed.

As Greg Henry MD, past-president of ACEP, has pointed out when discussing medical economics, the pie isn’t going to get bigger. The only question is “How big is your slice?” If you feel you deserve more of the pie, then someone else will consequently get less. Our slice should be bigger, and the fraudulent radiology slice can get smaller. If this is bitter sounding to radiologists then the pie can be key lime pie with lemon zest on top. Either that or they can begin to learn what being at the hospital feels like on nights, weekends, and holidays. I am tired of supporting their relaxed lifestyle and making car payments on their Porsches. We all know they will not adopt our lifestyle, so they need to give up the dollars and eat less pie.

At academic centers with radiology residents, the fraudulent behavior is on multiple levels. The radiology attending supposedly supervising residents at night are often not doing so. Therefore, the bill submitted by the radiology attending for the reading of a film days after ED discharge is fraudulent to the third party payor as well as to the university. Furthermore, they are educating young radiologists regarding the responsibility and ethics of their specialty. What they are teaching them is that the radiologists’ clinical contribution and interpretive services should never get in the way of their radiology lifestyle. Sure the radiology resident can stay up all night, but not the attending.

It is time to break the vicious radiology parasitic life cycle. This cycle has a vector (Porsche or any black German car), an incidental host (the ED), a nest egg component (pick the gated community where they live or the vacation home they have in Aspen), and a feeding stage (sequestered in the darkness of a reading room). So spread some albendazole around the reading room and stop this epidemic. Blow your whistle loudly. Get paid for interpreting the films you read last Saturday night. It’s so easy in fact that you’re already doing it! It will feel really good to get paid for it.

You deserve it.  

Dr. William Mallon is an associate professor of clinical emergency medicine at the Keck School of Medicine of USC. He is also the director of the Division of International Emergency Medicine, LAC+USC Med Center.

 

Comments   

# Radiologistradiologist 2011-10-04 21:14
You should look a little closer into the economics of medicine and the level of training required to be a radiologist vs an emergency medicine doctor. I fear you must have grotesquely misread so many studies that you have developed a sore spot. You might also try carrying a pager when you are not "on-shift" and working at least 5 days a week. When a radiologist gets 10-15 pages a night from EM docs, they must still show up the next morning to do a full days worth of work in an environment where reading more does not reimburse more, but continues to increase the risk of missed diagnosis. Maybe, every single patient in the hospital doesn't need a CT. Maybe, the cost of medicine is rising because EM docs are reluctant, or unable, to diagnose without a radiology final read.
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# From a radiologist/int erventionalisRadiologist 2011-10-05 13:36
This is a gross generalization. We don't all drive black German cars, mine is blue.
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# USC must be scraping the bottom of the barrel these days...LOL 2011-10-05 14:32
If they have to hire guys like this.
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# offendedmark radiologist 2011-10-05 15:10
You're correct that this is highly offensive. I could complain how ER docs work 40 hours a week or less, yet seem to believe that other physicians should to work 100 hours a week.
I'm disappointed 'Emergency Physicians Monthly' would publish this uncollegial and unprofessional garbage - this reflects poorly on your publication, not only on this the mellonhead who wrote this crap.
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# associate professor of radiology at USCalison wilcox 2011-10-05 16:26
William Mallon is a disgrace to himself, the Emergency Department and medicine as a whole. He does supreme diservice to his colleagues who strive for a collegial atmosphere in a difficult hospital. I am fortunate to know that not all the ED share his negative, insulting, self-propagatin g opinions.
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# mdBryce 2011-10-05 18:38
Pathetic. No other word for it. For starters, very few groups operate the way you describe. Much like every other physician in the US, radiology reimbursements have plummeted over the last few years. Part of the problem is, and has been for a while, the large volume of nonreimbursed ER studies. I suppose it would be easy to read XR's as an ER doc - don't know what you're looking at? Just order a CT! In fact, it's probably already been ordered by the triage nurse, since the clinical acumen of ER docs is approximately zero. Your specialty is a fraud. Really, all we need is a respiratory therapist to intubate, and a nurse to order test, and we're all set.

way to throw around the 3am card. That's rich, coming from the original shift-work doctors. We take 24 hour call, then work a full day the next day.

You want the revenue for billing ER plain films? You can have it. Enjoy getting sued for all those missed lung cancers you miss routinely, on a bunch of Xrays you're reading for free. If you have any questions, feel free to call one of your partners. Just don't call me. Ever.
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# Onion fan 2011-10-05 19:38
I can't tell. Is this article serious?

It sounds like it should be on The Onion.
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# a radiologist 2011-10-06 02:20
Well, someone did the wrong residency. (They still accept applicants). I and my group are in hospital 24-7-365, and read every case within 15 minutes. Now, there are some issues I have with the way that some ER docs cover their work, but I will abstain. It is very very easy to criticize.
If you really think that you can equal the efforts of a physician who now spends a minimum of 5 years learning radiology by anecdotal experience while doing your work, well, then I just don't know what to say. The surgeons and Internists in our institution are more strident than we are in opposition to the ER doctors reading films as the final interpretation.
That said, medicine seems to be going the way of less expertise in the interest of pushing patients through, and your ideas may have a place in a future that is based on McDonald's medicine.
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# radsresident 2011-10-06 03:34
WOW. I guess that fancy Peruvian education didn't get into the "stick to what you know" portion of medicine, and one of the many things ER docs don't know is imaging. Plain film interpretation is fine, particularly if it's a relatively healthy patient; however even as a resident I have seen so many missed neoplasms by ER docs, that I tell all my friends and family, that if they go to an ER and get a film, they need to insist a radiologist has looked at it.

The push by ACEP to do US is even worse, you hate that radiologists bill for imaging which has already been acted upon? What about if it's been misinterpreted and the wrong management paradigm has been initiated, not an infrequent occurence, I did my intern year at an institution where ER do some of their own US, and many times have missed critical findings or did not perform the scan, which had to be repeated by radiology. Now ER already billed for this study, so the radiologist would have to eat cost.

The measely 3 years of training of ER residency barely prepares you for management of ER patients, let alone allows you to compete on an even footing with a radiologist with 5+ years of training in just imaging.
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# anonymous 2011-10-06 06:06
No one is forcing you to order imaging studies which are "contributing nothing to the outcome but cost." If you know it's not going to contribute, don't order it!

Also, some clinical history would be nice from the ER for a change. Most of the studies I read from the ER are performed before anyone even sees the patient.

If you would like to take responsibility for interpreting the films, signing a final report (which would include comparison to priors etc) and collecting the revenue, then please do so. Just don't expect a radiologist to come in behind to you do the job right.
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# UN-professionalOncall 2011-10-06 06:43
Yes, I did find this article highly offensive and unprofessional. Since Dr. Mallon seems to be a master at making over-generaliza tions let me make a few of my own. Dr. Mallon has obviously forgotten the point of working in an understaffed and underfunded hospital, which is to place a greater level of responsibility on the residents so they can leave as highly competent and marketable physicians. Part of his job includes teaching professionalism and he has shown none of that with this article.

In my opinion, someone who harbors such animosity towards his fellow physicians has no place in any teaching hospital. He should seriously consider seeking employment in the private sector where he can find a job that includes a level of radiologist coverage to his liking.
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# written by a radiologistFlorida radiologist 2011-10-06 07:28
Dr William Mallon interest is in flashy cars and this is understandable in LA, what do you drive Dr Mallon?
On the personal side as a radiologists I drive an 07 Honda Civic, often stay late, do a weekend shift and we cover the hospital 24/7. At LAC-USC you have support from upper level resident/fellow s throughout weekend and night with faculty backup right? So what is your point? I second opinions that most clinicians do no want to assume responsability of reading plain films because of liability and because they are prudent and know how easy is to miss that cancer, fracture or significant surgical finding. We have a collegial relation with most ER physicians and this article is a gross distortion on radiology work.
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# ass. prof. University of OklahomaJustin North 2011-10-06 08:01
As an academic radiologist, I find a good working relationship with my ER physicians vital. It provides me excellent teaching opportunities and a chance to get real "clinical correllation". It is the only way to provide concise care in a crazy, large, acute setting. About the only thing I will not tolerate in my reading room is an unhelpful attitude toward referring clinicians including timeliness of interpretation. I am sorry you find your work environment so poor, consider working on relationships instead of throwing rocks, things might improve. I think your patients must suffer far worse than you.

And yea, my job is awesome. I hope you consider yours awesome too.
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# crossed the lineradiology resident 2011-10-06 09:09
Dr. Mallon displays an unbelievable display of being unprofessional. I do think the radiology community should refrain from trying to throw sticks and stones at Emergency Physicians as many above posted how relations are on average very good. Any respectable ER doc (or any professional) can easily see this person crossed the line and he should be reprimanded and possibly fired.

By the way, studies show that radiology residents are more accurate interpreting plain films when compared to ER attendings - for what that is worth. I am sure the USC rad residents/fello ws have saved him multiple times but that would never come to light, would it?
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# PJ 2011-10-06 09:09
The triage function of a hospital has always been performed by an attending physician. However, the attending performing that function has changed from the emergency department to the radioogy department, requiring 24 hour radiology attending coverage at most level one trauma centers around the country. The good news is that EP's won't be labelled as glorified triage nurses any longer. The bad news is that after putting in three hard years of partying (residency), you might not have a label.
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# can't we all just get alongoverseasdoc 2011-10-06 09:26
As an ER doc I can see both side of the argument, however, this article is certainly on the non-collegial side.

Aren't we all on the same team?
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# I hope you are pulled from that departmentEDRadiologist 2011-10-06 10:20
A rant against perceived lifestyle differences.... OK
A snarky tone comparing your colleagues to parasites.... fine
Describing follow-up recomendations as "self-referral" .. ill-informed, but I get it.

BUT...Allegations of fraud? Those are serious accusations, Dr. Mallon. Were you on staff at my institutions I would already have this reported to the chief of staff.

These are the kind of comments that destroy interdepartment al relations and can wreak havoc for years. I hope they pull you out of practice there ASAP.
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# County radiologist 2011-10-06 10:50
Patients are ultimately the ones who suffer from this undue animosity. Shame on Dr. Mallon for writing this about his colleagues and shame on EPM for publishing it. In the words of someone I know who has years of experience working with him, "Dr. Mallon has a long and consistent history of being obnoxious!"
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# RichRads 2011-10-06 10:58
u mad? u mad!
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# Radiologistradiologist 2011-10-06 11:05
Dr. Mallon of Gorgas’ School of Tropical Medicine in Lima, Peru, your ignorance is embarrassing.
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# RadiologistJim Rosenthal 2011-10-06 11:55
Our medical group serves twelve ED contracts. Some of them have peerless radiology coverage- some could use improvement. But in no case is the service what Dr. Mallon claims to have seen. His article is an embarrassment to decency and professional behavior.

More to the point, those deciding the overall size of the pie that Dr. Henry has spoken of are laughing in their sleeves at Dr. Mallon's outstanding example of divisiveness and inter-specialty sniping. I don't know anyone in medicine who doesn't work quite hard indeed- any medical specialty that doesn't cater to diseases of the rich is no walk in the park these days. Radiologists work hard and make what the market will allow- if you have a problem with that, complain to those who regulate the market. That would certainly not be the radiologists.

Most radiologists who read for EDs and EPs are in small groups who serve at the pleasure of the hospital administrators. They worry, as do we, about their group getting thrown out, about being asked to do more with less, about the risks of litigation etc- all the same things we worry about. In short, they are more like us than unlike us. That being the case, Dr. Mallon's polemic is especially wrong and notable only for its cruelty and inaccuracy. Congratulations to EP Monthly for giving him a platform. Now- how about the apology to all of us and our radiology colleagues?
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# Emergency MedicineHorsedoc 2011-10-06 11:59
MY GOODNESS GRACIOUS! The number of wadded panties here is TNTC! I find it ironic that so many of our good radiologist brethren (and sisteren) are claiming superiority of training over ER docs. Then the same folks turn around and claim, straight faced, that they can do nuclear medicine as well as any board-certified nuke! In radiology training, you get six-months of nukes training (assuming the program director is honest). You can then go out into the world and shut out virtually every residency-train ed board certified nuke who isn't also a radiologist! The hypocrisy here is breathtaking!
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# ED physician in practice 20+ yearsTerence Alost 2011-10-06 12:07
Obviously, this made more than a few radioligists angry. Some of the responses show a level of immaturity. Truth be, I rarely need their help and I never wait for it. Of course, they read the films, plain, CT, MRI, US long after I already have. I never wait for them. Often, the virtual radiologist calls the ER and demands that I come to the phone so that they can dictate that they have told me about the abnormality. By that time the patient is already on the way to the OR by my reading....
Kind of silly, isn't it?
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# Ex ER doc now radiologistJim Coleman 2011-10-06 12:08
As one who practiced Emergency Medicine for 12 years in high volume ED's, managing one or two, and acting as Operational Medical Director for a few ambulance services in Virginia back in the early 2000's, I left a successful practice and returned and did a second residency. My second residency was in Diagnostic radiology. Sir, if you are so miserable, I suggest you do the same. Many reasons I left, but one which has not changed was the decreasing quality of physicians I was forced to work with. If you know a study will be negative, grow some nuts and don't order it. Believe it or not, you can actually make accurate AND timely diagnosis largely based on history and physical exam. That is if you get off your ass and see the patient. Increasingly few people do that. Basic knowledge of disease processes posessed by ED people is decreasing rapidly. Frankly, it is true that well trained FNP can do as good a job calling the specialists. I used to work in an ED that would not let the ED doc order certain tests. They were reserved for the specialists to order. I now know why. It is still not too late for you to go back and find out, if you have not burned all of your bridges.
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# Who Knew?Mallon 2011-10-06 12:08
Who knew so many radiologists read Emergency Physician's Monthly? If only they would spend some of that time reading contemporaneous plain films......

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# Wow.Academic Rad. 2011-10-06 13:19
I may not agree with, but I understand that everyone will have differing points of view.

However, this is disgusting, and grossly inaccurate. I cannot even begin to delve into the grossly distorted view this gentleman has of radiology work, as I do not want to ruin my Thursday night.

At our very large, academic institution, we have a fantastic relationship with the ER attendings. And from what I know of the author's institution, the radiologists as well have a fantastic relationship with the ED department (save for Dr. Mallon). We respect their expertise (heck, several of us have gone to them for acute, personal health problems) and their respect our expertise.

I have quite sure that this bad apple will be dealt with quite quickly, and I certainly decisively. This shows extremely poor judgement on the part of Dr. Mallon.

This also shows extremely poor judgement of the publishers of this journal - shame on you! I have half of a mind to lodge a formal compliant with your publisher or supporting society.
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# Thank You... for stating the truth. RR 2011-10-06 13:44
AMEN! FINALLY someone speaks the truth about this speciality of fraud! Solution : Flood the CMS auditors with evidence. Document every case non contemporaneous interpretations .
Write to your reps. in DC
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# Disgruntled resident 2011-10-06 14:05
If you can generalize, I can too.
If I want an opinion from a triage nurse, I'll give you one after you incorrectly order a study. Every clinical service hates the ER for their vague interpretations and gross misuse of resources when ordering radiologic exams or consulting actual doctors. Maybe you should have audited an extra year to your tropical school of bugs.
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# not cool bro. not cool.you mad bro? 2011-10-06 14:39
will be interesting to see how ER and rads interact in the future with this apparent animosity. I expect it will be continued bitterness as every person from my class who went into ED did so because of "lifestyle" with the easy hrs and number of days off and a "churn and burn" attitude towards patient care. Don't blame me for saying it, they were accepted to some of the best programs you have. While radiology again attracted the brightest and hardest working of my peers.

I'd fix your furniture before you start throwing rocks in a glass house.
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# I'm embarrassed for you.....truly I am.Crash 2011-10-06 14:41
I work in a family-run Radiolgy center and have been a part of the organization for 20+ years. I can assure you that our Radiologist reads ALL of his own images and arrives M-F at 7am, rarely leaving before 9pm. Saturday hours are 7:30am-3pm. He also reads dozens of stat, portable images throughout the week and ALWAYS has to read stat, portables on his one day off.

As for cars, I know waiters that drive Beamers. Does that make them scumbags, no, it might mean they actually saved their $ for something they desired. Your reference to what Radiologist drive is drivel....nothi ng more.

Vacations....ri ght, our Dr. has been on one of those in the past 15 years. Days off dont exist for him. If he calls in sick (he never has) the office would close for the day Vacation Homes? Nope...none.

As a family-run, smaller imaging company, trust me...we're lucky to be paying all of our employees and bills in these tough times. If you had any clue about what some imaging facilities go through financially, you might have a better appreciation for the scope of work that Rad's provide. Then again, I doubt that. You've clearly demonstrated that you are a socially-awkwar d, bitter person.

I do want to say, that I'm not truly offended.....he ck, I'm not a Radiologist. More than anything I'm embarrassed for you and am shocked at how unbelievably stupid you just made yourself look.

Well done Sir, well done!
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# Medical Director, Program at Home, PVAMC, Portland, ORSteve Acosta 2011-10-06 16:34
As a board certified (x 3 now) EP in practice since 1978 in both private and, now, an academic situation, I would have to agree with the Radiologist's outraged comments. I was always impressed by Dr. Mallon's acumen about the state of medicine in the ED and how it should be practiced for the benefit of our patients and colleagues.

I am startled by his accusatory, whining and over-generalize d comments as well as the snarky, grade school 'Gee, I didn't know so many radiologists read EPM' comment.

Billy, you need to get some kind of eval. Your blood sugar was too low when you wrote this (and the EPM editor who gave it the green light needs to eat some carbs, too).
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# ER AttendingM. Shamma, MD, PhD 2011-10-06 16:47
Every specialty, like everything else in life, has many good people and few bad ones. Every specialty deserves its due credit and respect. We all work to serve our patients. We all spent many years studying and training, and continue to do so, until we call it a quit. I chose to work in the Emergency Room 19 years ago, and I chose to work the night shift for 16 years and counting. I respect my colleagues in Radiology and all other specialties. They all respect me and appreciate me. I read all the plain films at night. Some films are read by the Radiologist before they leave (especially, when patients wait for few hours), or when I stay late in the morning. Throughout the years, I missed some findings, but I discovered few finding that were missed by Radiologists as well. NO ONE IS PERFECT. After finishing my night shift, I sit down for breakfast, for rush hour traffic to get better, and to talk with other physicians. We discuss our profession, which has changed as drastic as computers, in the last few decades. Each specialty has its own strengths and weaknesses. No specialty should claim exclusive right to superiority or distinction. Patients need our cooperation, not confrontation. Our profession demands from us, more than any time in the past, to rise above antagonism and bickering. Lawyers, Lawmakers and some greedy patients and families are tearing up our profession. We need our profession to mature and stand for our patients. If we do the right thing for our patients, we will be doing the right thing for ourselves. Please, humble yourselves and throw away everything that stains our profession.
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# To Terence AlostRad1 2011-10-06 17:13
Terence Alost claims that he reads his own MRI, U/S, and CT.

Wow. The stupidity of that comment takes away his credibility in an instant.

I'm glad he posts his name - God forbid I would ever go to an ER where he's working, with the arrogance to think that he can interpret MRI, CT, and U/S.

A wise mentor once taught me:

Ignorance in medicine is bad, but common.

Arrogance is medicine is bad, but common.

Combine the two, however, and there is nothing more dangerous.
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# Dr. AlostAlex 2011-10-06 17:30
You must be great at interpreting CT, US and MRI if you rarely need a radiologist. Will you teach me?
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# SurprisedNortheast 2011-10-06 17:41
I think that enough others have commented on this thread to get the point across.

I must say, however, after 31 of years, it's rare to see something this unprofessional, and uncollegial (not to mention misinformed).

This reflects very poorly on USC, and in particular on the USC ED Department. Mallon seems to be one.

You can be sure that I will send this diatribe to the appropriate officials at USC, as well as at the relevant ED Society responsible for this publication.

Quite disappointing to say the least.

Medical school applications are stringent indeed; however, there are always a few who sneak through, that probably should not have.
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# Happy 2011-10-06 17:44
Whoa - this mellon seems like a very unhappy man.

Someone tell him that noone likes an eternally unhappy person.
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# ED DocERDoc 2011-10-06 18:02
I think the thoughts could have been introduced more diplomatically but, there is some truth. I am not sure that many Radiologists are willing to admit that Medicine is now a 24 hr gig and there are some specialists who are needed 24/7. Radiologists are on that list. I have always said that I don't wack out an acute appy because it's 1 in the morning. Many of the comments from the Radiologists above comment that they are better at reading the films, can find the concerning nodules than Emergency Physicians. I agree, and that's the point. They are better, that's why they need to read real time. In the absence of real-time reads, the EP is left holding the bag to interpret and use the reading to treat the pt. This being said, when the film is ordered stat (as all are in the ED) that means immediately, not the next day. If the Radiologists aren't delivering the service, why should they be paid to read it the next day? The answer, Radiology Hospitalists, agreements between multiple practices to read real-time at the affiliated hospitals 24/7 with call every 2 months or something. Bottom line, the service demanded is real-time reads. Who ever delivers that service should be paid.
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# Childish rantFlounce 2011-10-06 18:13
Be nice.

The need for contemporaneous interpretations is real, and there's a way to discuss it that will bring you closer to getting it. I'm a radiologist, and I want to add value, for both altruistic and selfish reasons.

By focusing on the reimbursement, you lose the high ground and your argument is weakened. If you had focused on patient care, your argument would be more persuasive, e.g. "Emergency Physicians are clearly not as good as radiologists at reading imaging exams, and patients at 3am often need a radiologist to look at the study, not a Emergency Physician."

As it is, you are no closer to fixing the problem of non-contemporan eous reads and have diminished it to a squable over money; you've made no friends; you've given a bad name to your department and this publication; and you seem poor, petty, foolish, and powerless.

Some radiologists are angered by your post, but by the time I finished reading it and realized that this was about $19,000 dollars a year and you wanting a better car and lifestyle, I felt sorry for you.

You picked the wrong field, buddy. And I don't mean the wrong subspecialty i.e. Emergency Medicine - I mean choosing to be a physician.
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# Everybody take a deep breath...ER Resident 2011-10-06 18:56
I'd like to echo the surprise that so many radiologists are reading EP Monthly - gives me hope for a good relationship amongst two specialties that are often-times dependent on each other to best treat the patient. After all, isn't that why we all went into the medical field in the first place?

One large point of contention: though I realize a bit abrasive on some points, I have had the good fortune to both train under and work with Dr. Mallon, and he is undoubtedly one of the finest minds in the field (who for the record, drives a blue Mazda). If anyone, radiologist or otherwise, were to find themselves in an Emergency Department for any reason, your prognosis for a good outcome would increase substantially if this gentleman walks into the room. Don't agree with me? Try talking to your local EM doc, no matter where in this WORLD you are...I guarantee they've heard of him, and probably sat in on a lecture or two at some point.

Another point of contention: one of the readers wrote above that EM docs don't carry pagers. While that may be true in the typical sense, you forget that we carry a different type of pager - one given by society. True, ours is shift work and we're not electronically connected to the medical center, but we do possess a responsibility to society to be on call outside of the hospital. Whether this is being first on-scene at a traffic accident on our way home or helping a random person out on a flight when that loudspeaker crackles with the "Can any doctors on board please push your call light"...ours is the unique spectrum of knowledge that allows us to start with nothing and get the medical ball rolling. Our knowledge base is useful on any terrain and within any walls that mankind experiences, so don't make these immature comments about a superior level of training required to be a radiologist. If that's really the way you feel, let's see who you send your parents or children to when they're really sick in the middle of the night, or in some unfortunate traffic accident...some thing tells me it's not going to be a fellow radiologist.

Keep in mind that when it comes to modern medicine, there is no such thing as the one be-all, end-all doctor, and I, as well as every other physician, should take great offense from any physician claiming that their specialty is superior to another. EM serves its roll, as does radiology. We both serve unique purposes in the medical field and just like we can diagnose the appy but can't cut it out, radiology possesses the same inadequacies. That's why we both work as a team with the surgeons, who in turn work with the anesthesiologis ts, who work with the pharmacists, who work with the...you get the idea. Now let's just all do a little bit better to keep that in mind.
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# A dying specialtycan you imagine if I actually put my name here 2011-10-06 19:40
As technology progresses to the point that computer algorithms will read 98% of our CT/MR studies I warn medical students to stay away from this specialty. I really don't think it will be around in 15 years. Ultrasound is increasingly more portable/afford able and will therefore be in the hands of every clinician - the way it's inventors intended. Ironically, its the plain films that will take the longest for computers to tackle.

I what think Billy was saying in HIS special way, is that many specialities (not just EM) already act on their own readings. This is evidenced by the fact that various GME programs spend increasingly more time dedicating education to relying on their own reads. Ask any young surgeon or hospitalist where the pathology is - they are quick to point it out. Its just a matter of time until the computers do this.

If you don't believe this, think about how far technology has come since YOU started practicing medicine. Its not hard to imagine a massive set of "normal" and a few "definitely not normal" images that a computer picks through as thousands of images are coming off the 1024 slice CT scanner from your patient. You simply click on the abnormal ones, verify the pathology, and act accordingly.

This is patient-centric because it provides the most timely read, and saves money. Yes, it does take that personal touch out of the doctor-patient relationship that only a radiologist can provide but I think the our future patients can get over this.

Can you see now why its hard for me to support any medical student's decision to enter radiology?
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# Wow! What an extremely prejudiced comment by an ignorant EP. Westcoast 2011-10-06 19:45
It's funny how this EP only mentions plain films and forgets to mention that the majority of ER patients get panscanned with CT or MR!!! And of course the EPs can't read those or even prelim those studies, because these are higher level studies that only radiologists are comfortable at reading. The radiologists are busy preliming and providing final reads on the CTs and MRs that are being ordered on the majority of the ER patients, as the patients are being rolled out of the scanner. You call us parasites for allowing residents to prelim cases at night while we do final reads in the AM. Why don't you say that to all the FP, IM, peds and surgery physicians who have residents covering the hospital overnight and cross-covering patients for one another, while the attending is available at home for questions? I hope your chief of the hospital reads you article and disciplines you for your negative and non-collegial comments to your local radiologists. You owe all of them an apology.
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# Thoroughly embarrassed. Dr. Mallon should not be allowed to continue working at an Academic InstitutionDN 2011-10-06 19:55
I don't know how medicine is taught in Peru, but comparing one's colleagues to "parasites" in a published forum, demonstrates a gratuitous lack of competency in professionalism , systems-based practice, and interpersonal/c ommunication skills. These represent 3 of the 6 ACGME core competencies (http://www.acgme.org/acwebsite/RRC_280/280_corecomp.asp) that form the backbone of the current residency training process. Dr. Mallor is supposed to be creating an environment that continually teaches and evaluates these core competencies. How can Dr. Mallor be allowed to work at an academic insitution when he voices his (obviously controversial) opinion in such an egregious manner that violates so many codes of professionalism and the foundation of the resident education process? And using a forum that is supposed to promote a scholarly environment?? I am thoroughly embarrassed.
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# This sets us back in terms of progress and reputation as a specialtyChris 2011-10-06 20:04
Dr. Mallon should not be an associate professor at a teaching hospital, much less a reputable one such as USC (at least before this posting). The future success of emergency medicine as a specialty will demand continued close relationships with consulting physicians, and there is no greater relationship that needs to be nurtured than the ED-radiology one. It's unfortunate that some of the best ED residents are being taught to carry such an enormous chip on their shoulder. If this individual is not immediately fired, then County-USC has some serious soul-searching to do as a supposed leader in the field of emergency medicine.
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# ERMixer 2011-10-06 20:19
http://www.youtube.com/watch?v=3efnZc0rYDg&feature=youtube_gdata_player
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# can't we all just get along?BrandonMD 2011-10-06 21:08
As an ER doc, I would agree with the radiologists that this is a very unprofessional article. I don't for a second pretend to be anywhere near as good as a radiologist in interpreting films. That being said, some of the responses have been equally as incredulous and insulting.

Aren't we all on the same team here? Seriously. Or are we all in high school fighting over who has the biggest pair?

This is a (scholarly?) medical publication, not cnn.com. Let's act like it.
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# Whatever !Recent rads grad. 2011-10-06 21:32
I have worked as a radiology resident at a Level 1 trauma center. The Pan scan ordered by the triage nurses, the nurse practitioners and the ER physicians themselves , many times without examining the patient with ZERO regard to their radiology peers is amazing. Sifting through thousand of images every hour with few breaks for bathrooms...I have slogged and slogged as radiology resident. I hate Level 1 trauma centers because I hate those damn fool ED physicians who order pan scans of patients who walk through their doors and WE get in trouble if we missed a 4 mm lung nodule. ED docs are crazy.....they have made all us radiologists crazier. I hate their ignorance and their nurse practitioners more so who work with them.
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# MDEM attending 2011-10-07 01:47
Can we all just get along. I been studying for my EM concert exam. Ifeel like I know Billy but he doesn't know me. Billy is a great teacher. USC is lucky to have him. Afterall we are in medicine to treat and take care of our patient. Beside we enjoy a comfortable living in most field of medicine anyway. In my opinion radiology should be available more often. Sure radiologist has 5 yrs of experience in residency. But, they only have 1 yr of experience at bedside. I have seen some radiologist miss film simply because they didn't examine the patient.(not their fault) Taking care of them, needs a teams of doctor and staff. From the tech who made sure the films are done right. ED staff who toke care of the patient. The radiologist helps by suggest the best test, coming in for interventional treatment when called. Bottom line we all need to work together. Who cares about the 15$ per hour ! Uncle sam takes half anyway!
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# majority of ER docs and radiologistsRadiologist 2011-10-07 02:52
I'm a radiologist.

99% of the ED docs that I've worked with, I've had and have nothing but the utmost of respect.
They work in an extremely difficult environment, and must deal with anything and everything that walks through the ED doors - anything from a simple cold to a ruptured aorta.

Similar for 99% of the radiologists that I've worked with.

I don't know think Dr. Mallon knows how the financials in radiology have changed, but that's a moot point.

Calling us both 'frauds' and 'parasitic' feels something like a kick in the face would likely feel.

It's been a pleasure to have worked beside so many outstanding ED physicians, as well as so many outstanding radiologists (and every other type of physician) in my career. I'm just glad that I've never worked with Dr. Mallon.

Mallon's attitude cannot be good for patient care, and reflects quite poorly on his department and his university. But I think we should just collectively ignore him and focus on the overwhelming positives.
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# Night shift radiologist 2011-10-07 04:59
If Dr. Mallon's institution's radiologists do not promptly interpret studies relevant to immediate treatment decisions 24 hours a day, then he is absolutely right. My group has been doing this at least 14 years. Even in one-radiologist shops, this can be arranged remotely. Frankly, I think any emergency department that operates as he describes should be shut down - or limited to dermatologic and psychiatric emergencies

On the other hand, I am surprised that none of the comments so far have made the distinction between findings that need to be acted on promptly and those that don't. It doesn't matter if the coughing smoker doesn't find out about his cancer until the next morning. It matters even less if the finding is incidental to the symptom - like the breast cancer at the edge of a chest CT image. Even back when the radiologist did not see the film for days, his input added something, even if the immediate management was already done.

Finally, aside from the training issue, the problem with ER specialists being paid to read imaging studies is that they are the ones who order them, so it's an obvious incentive to overutilize. (In most places, radiologists can recommend, but not actually order the tests themselves - a rule that should be extended to the many other specialists who have encroached on imaging.)
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# to ED residentradd 2011-10-07 05:02
ED resident makes the underlying point that we all need to get along to serve the patient best.

Definitely. ED physicians have a very tough job. We do as well. And every other specialty does as well.

The reason that you're seeing all of the angry responses by radiologists is because of what mellon wrote, insulting to our entire specialty. He threw the barb, and radiologists, rightly offended, are responding.

BTW, the 'pager given by society' talk is almost poetic...;-)
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# Re: Dying specialty EDRadiologist 2011-10-07 05:56
I can remember being advised against entering by an older anesthesiologis t who told me that "computers will be making all the diagnoses in 10 years. You need to *do* something."

That was in 1992....... and we're not much closer to computerized interpretation even the simplest imaging studies (no where near on MRI/CT) than we were then.
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# EDdoc 2011-10-07 06:16
Dr. Mallon your article is simply unproffesional!

My issues are this:

1) To compare any human being let alone a professional colleague to a parasite is disrespectful and niave.

2) To argue over $19,000 seems childish. Most radiology physcians I know work more than 40 hours a week easily 50+. If you would like an extra $19k, do a couple more shifts.

3) You work at an academic institution of high caliber. If you dont want to deal with residents I suggest you go to private practice.

4) I highly doubt you are reading ultrasounds, MRIs and CTs overnight by yourself at a level I trauma center so your argument seems mute.

5) Since you admit there is a radiologist on call pick up the phone and consult the radiologist on any difficult plain films. Lets use our standard ED model. If we have a patient with a headache, we wil not consult neurosurgery every time. If there is an issue then we consult neurosurgery and even then at academic centers the neurosurgery attending does not come to see the patient, an intern will, not a PGY4 resident as in radiology.

6) You have fallen into every government officials trap! Instead of arguing for a larger pie you have already admitted the pie should be smaller and that you just want a bigger piece. Please never ever be a lobbyist!!! Your political skills are not your strongpoint to say the least.

7) Finally, the facts are radiology residency is longer than ED residency. I am not saying they are better trained but the length is an opportunity cost. They give up several years of attending salary and hence should be compensated slightly more for the loss.

Overall Dr. Mallon if you had a bad day or bad experience I suggest you not generalize it and then put it in writing where it can be critqued and analyzed as false. There are no enemies. We entered medicine so we dont have an enemy our goal is to treat the patient!!
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# ER PhysicianER physician 2011-10-07 06:39
In our medical system, each physician speciality has only a piece of patient care. We’re all specialists now (including the ED physicians and the radiologists) and we rely on each other to provide excellent, although fragmented, medical care to our patients. Oslers are few and far between in most settings.

Even in rural communities, virtually nobody practices full-spectrum medical care any longer. At our facility, we put this battle to rest many years ago and the radiology group (while not onsite) stepped up to provide time-of-service accurate 24/7/365 reads which are not always necessary but quite frequently provide indispenable information that would have otherwise been missed or delayed.

We should not allow billing and coding rules to divide the medical community. We rely on each other's expertise to get the job done and there is no place for insulting one another. We all want pie, but it is below us as physicians to shove our colleagues face in it to get our piece!

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# Hahahaha 2011-10-07 08:12
Hahahahahaha. If Mallon's concern is truly about health care economics, it should be pointed out that the biggest, most profligate waster of the health care economic pie due to ordering of unindicated high-dollar imaging studies is the ER by a longshot!!!! Millions of wasted dollars in false "rule out cord compression" MRI studies alone, typically justified by either incompetently obtained or obviously fabricated clinical histories on request forms by docs who are either unable or unwilling to do a proper physical exam.
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# Companion article?MD 2011-10-07 08:27
This piece may be a companion article to Dr. Silverman's article that was published the day before in Emergency Physicians monthly. It was on the front page two articles below on the day of publication.

http://www.epmonthly.com/features/current-features/teambuilding-101-just-say-no-to-jerks/
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# Brian 2011-10-07 10:08
A few comments:

"Parasite" implies we receive an undue benefit. Reading ER plain films is hardly one. Most groups would be more than happy not to have to read them.

As a radiologist, I have enjoyed very collegial relationships with most of the ER docs. They have a tough job, and I respect that. With most, that relationship is reciprocal. Just remember that us hedging is the equivalent of you ordering a test you know will be negative for CYA purposes.

@ a dying specialty: clearly you've never heard of CAD with mammography. Despite millions of research bucks, and multiple companies attempting to create a high-functionin g CAD, no one has yet created one that functions remotely like a human. Like all of medicine, radiology is far more art than science. Machines can help, but won't supplant humans in the near future.

@horsedoc: that the best you got? The nucs analogy doesn't work. For starters, most rads would agree a nucs fellowship prepares you better than a general radiologist. Same goes for a neuroradiologis t being better at reading head CT's than a general rad. Many larger rad groups have dedicated nucs people. The only reason all don't is a lack of volume. Most of the hospitals we cover do about 2-3 nucs per day, can't sustain a full time position. Simple fact is that radiologists are better at reading ER plain films than ER docs. Not an insult - they have a whole lot else to train in and worry about. Sad fact is that an argument with some validity has been tarnished by a bunch of name calling, in this case.

@ Terence Alost: darn right we're calling to say we told you about the abnormality. In my experience, about a third of the time you guys didn't see it (thoroughly scientific estimate). If the call bothers you so much, try putting a prelim report down. I'm calling a big BS on you reading CT and MRI without contemporaneous reads from some radiologist. If you are, you're doing your patients a tremendous disservice, and opening yourself up to quite a lot of liability, especially given the availability of telerad services.

@ER resident: Mallon may be one of the "finest minds in the field". I clearly have no idea. What I do know is that he's one of the biggest jerks walking the planet, with a maturity level of a second grader. Sorry to see such a petulant child occupying a position of authority.

Let's all pool our money and buy the guy a german car, for God's sake.
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# When physicians fight, everyone else wins.Cynic 2011-10-07 12:43
Of all the challenges and legitimate battles emergency medicine has to fight, this is not one of them.

The comments section of the article is as equally depressing as the article itself.

Meanwhile, CMS, insurance companies, bureaucrats and attorneys run roughshod over the decade plus of your life and thousands of dollars you spent training.

Bicker away. There's at least a dozen industries happy to let you think that the radiologists are the parasites feeding off your hard work. And while physicians sit around fighting, they win.
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# EM Doc :o 2011-10-07 13:06
I am ashamed for all of medicine.

Dr. Mallon should be ashamed of himself.

And you radiologists who responded in kind on a PUBLIC forum should be ashamed as well. Sure he went way over the line, but it is equally unprofessional to fight his fire with more fire.

Grow up, guys.
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# JS 2011-10-07 14:22
It has been a long time since I have read an article by a physician who is so arrogant, that he thinks he is the only one contributing to the health of patients. I am a radiologist who is highly valued and respected in my community. When we are on call, we are in house, twelve hour shifts, like you. I can be in house reading 24 hours in two days. I read, with years of experience and expertise, innumerable studies with outcomes critical to patients well being and management. How incredibly narrow minded you are to think the your plain film interpretation is the key to all. I started keeping count of the number of missed significant findings by our ER docs and the number was not small. The interpretation skill of our ER docs varies widely. I feel like I am your safety net, catching your mistakes and not getting paid. Most ER docs I know do NOT have the skill to be rendering final interpretations , even on plain film. Truthfully, you should be focusing on direct patient care.
While I read multiple modalities, I am a breast imaging specialist. I do not know a single colleage who would call me a parasite. I have the respect of every single general surgeon I work with. I save lives everyday with my skill, training and committment to medicine. How selfish an article you have written. In the end, just boils down to money and ego, inflated.

Oh ya, I drive a 7 year old American made car. I never leave work before 6 p.m. I am available to the breast center 5 days a week, and am on call a weekend a month for 12 hours at a time, in a high volume hospital, with at least 17 hours or more in house. I work hard contrary to your warped sense of what you think you know about my world and my job.
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# Wow, not appropriate...EM Doc... 2011-10-07 15:32
As an attending at a very large South East academic center, and having a brother as an attending IR Doc at a large academic center as well, I can't imagine where Dr. Mallon was coming from. Needless to say, I appreciate my rad's companions, and enjoy their company. Of note though, there are plenty of smaller ED's that have no reading from Friday 4p to Monday 9a, which I'm not sure if he is directing his angst toward?
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# Please forgive meAnother Despicable radiologist 2011-10-07 18:05
Dr. Mallon,
Please forgive me and my group of swindling Radiologists for participating in the care of patients at our 1200 bed hospital in Central Ohio. We have demonstrated a very dubious level of service for the last 15 years by providing a continuously manned ( or womaned) seat in our department, 24/7/365. This has included contemporaneous readings of all imaging studies at our facility. We did this, not because it was expedient from a financial or lifestyle standpoint, but because it was the right thing to do from a patient care standpoint. We knew this was necessary, since so much of medical triage in the modern system is done with imaging. Apparently, this effort was insincere and useless on our part. Because I feel so guilty about all this "fraud" that our group has committed at 3 am over the last decade and a half, I will propose that our group make a contribution to Dr Mallon's car fund, as he obviously sees his individual worth via his automobile. It must be a ghastly site...... And I bet the auto looks pretty bad too.

As for Dr Mallon, I have but one more question, When your mother or other family member has an emergency that requires imaging diagnosis ( are there any that don't?), are you really going to forego the expertise of your local fraud mongering radiologist? Really? I am sure you can perform cardiac caths and laparoscopic cholecystectomi es, just like the actors on the TV show, "ER"

Good luck to you. I have to get back to taking care of patients at 3 am. And I will never apologiize to you for doing it
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# Wisdom for the massesThe Wise Sage 2011-10-07 18:41
Why is this kind of internecine warfare happening?

Who stands to gain when specialists fight with one another? Over money.

Understand the force. Do not fight it.
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# Inferiority complex 2011-10-07 19:58
Inferiority Complex blocks people's eyes and brains.
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# Emergency DocWhite Coat Investor 2011-10-07 20:06
Whoa now. Everyone settle down. I used to work at a hospital where the US/CTs were read by nighthawks at night and on weekends. We read plain films, then did call-backs Monday morning as needed. I now work at a hospital with contemporaneous radiology reads of all films. Both systems had their pluses and minuses, but I think my current situation is far better. If the EPs have to make the initial read, they should be paid part or all of the fee for reading it. That's fair, anyone can see that.

Parasites? I wouldn't go that far. But if we need radiology to read films, we need them to do it 24/7. Why have a lower standard of care after-hours?
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# erdoc 2011-10-07 20:17
I'm glad we have a great relationship with our radiologists. They read CT's/ultrasound s in-house 24/7, and read plain films 16 hours of the day.

Yes, I make most of my decisions based on my own plain film reads, but I like having radiologists over-read my films. There's been quite a few small fractures I've missed, and I couldn't even tell you how many lung nodules I've missed that were caught by the radiologist and sent to our health system's section that deals with patient callbacks.

What's next? Are we as emergency physicians going to do our own heart caths and say interventional cardiologists are no longer needed?

For those radiologists that think we order too many tests, you're right. I know I do. It's defensive medicine. Give me good tort reform and you'll see your number of studies decrease, which unfortunately will lead to a lower salary for you.

Please realize Dr. Mallon's opinion and rant is not shared by most emergency physicians.
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# Wow - Im embarrased 2011-10-08 00:10
As a EM physician at a large academic institution trained in both specialties all I can say is that I'M embarrassed by Dr. Mallon's comments as well everyone here on both sides making wide sweeping generalizations . Anyone who doesn't value the work of our radiology colleagues or think that they don't have the same ethical standards as anyone else is a fool. Anyone who doesn't think a well trained EM physician is a real doc or simply gets CTs because they don't have clinical acumen is an even bigger fool. Re-read some of your comments (residents, faculty and private attendings alike) and ask yourself if this is the way to act? Do any of you making these sweeping generalizations teach medical students? If so, I hope you teach them better ways to solve problems then the comments many of you have made here. You should be ashamed.
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# Several People Here are the Problem 2011-10-08 00:39
I am on the same playing field with the radiologists and ED physicians here who respect the work of each other. Those that are making the generalizations are the problem. I spent 2 years in radiology before doing a 4 year EM residency. I know the importance and value of the specialty of radiology. but I also know the stress of having to deal with a large volume ED. But here is the comment I need to address:

From Bryce - "the clinical acumen of an ER doc is zero". really Bryce? Where I work we identify the subtle posterior wall MI, not cardiology. We institute early goal directed therapy for sepsis, not the ICU. We manage diaXbetic ketoacidosis, not the internist, we treat the unstable beta blocker overdose and we reduce the dislocated shoulder, not ortho)...I could go on and on. You are different than Billy Mallon...cut from the same naive cloth. I respect your knowledge. Perhaps you can respect mine and not act like the person who wrote this article.
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# There is validity in the articleRad in practice 2011-10-08 02:54
I have worked in the ED department for a period of time before switching to diagnostic radiology, and although the article is somewhat inflammatory, there is validity is several of his points. The clinical management of the patient is dependent on a lot of times on the imaging findings, and this is extremely time sensitive as the patient waits for your decision. Having a report come in 24 hours later, or lets say even 2 hours later, is often irrelevant as the management of the patient has already been decided.

The amount of negative comments on the article, in my opinion, lies with the impression that Mallon is "dissing" the speciality, and if I can say, a subconscious feeling that what he is saying actually holds a grain of truth.
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# Go ahead read and bill for your own filmsNo thanks 2011-10-08 08:59
Please accept all liability that goes along with that.
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# RadiologyKCrad 2011-10-08 12:06
You might want to do some additional financial calculations before you decide to claim your bigger share of the "pie." As "no large pneumothorax" and "no big fracture" and "no pneumonia'" aren't going to cut it when you go to court for missing the findings you will certainly miss. The cost of your malpractice insurance and legal bills will easily outstrip your newfound windfall profits.

I work at an academic hospital and also cover remotely a couple of our sister institutions for advanced imaging. Radiology provides comprehensive coverage of our discipline and as others have pointed out we don't work a few shifts a week. We do this in addition to our regular workday responsibilitie s. So when you are leaving in your fancy SUV (because let's not act like you are on the bottom of the physician pay totem pole) in the morning after your shift, I am coming in to continue to do my work.

Given that our ED performs fast scan ultrasounds, I am familiar with ED competency levels of image interpretation. You would think as advances are made in medicine that you might be better served focusing on what you are already paid to do....examine and actually take a history from the patient. If you still have a desire to stick it to the radiologist, there is plenty of opportunity to do so; simply puruse the appropriateness criteria for the studies you order and stop ordering the ones that aren't indicated which are a huge drag on the medical system.

I am glad to know that you are concerned about money grubbing parasites in medicine. I am sure that US physician salaries had nothing to do with your decision to leave beautiful Peru.
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# SpeechlessSpeechless 2011-10-12 07:54
While there may be a modicum of truth to both (allbeit egregiously inflammatory) sides of this argument, it remains true that the cost of imaging studies is skyrocketing. I often will call the ED and speak to the ordering physician in regards to an acute finding- on a head CT or brain MR, or even to correlate findings with the physical exam. Many times the physician- resident or attending- has not even seen or examined that patient. Instead the study was ordered by a nurse practioner or PA under the attending of record's name, from triage in the waiting room, having only done a truncated history and physical. If the above discussion refers to most radiology practices as "fraudulent" this practice is not too far off either. Furthermore, in my institution a stroke workup now often includes a c-spine and sometimes total spine mr exam, because the ordering physicians cannot posit a level of possible injury- and then provide reasoning such as "I don't want to miss something" or "can you 100% rule out the possibility." Needless to say these are not in line with ACR appropriateness criteria.
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# Really ?!?TXrad 2011-10-12 10:00
Put a surgeon, radiologist, ER doc, and IM doc in the same room and see who doesn't think that their subspecialty works the hardest or is more deserving than the others. This is human nature. The truth is we each do our part in patient care.

All this article proves is that Dr. Mallon was asleep during his Medical Ethics and Professionalism classes. USC should reconsider the type of physicians they chose to represent them.

BTW, I'm sure if you do a poll, most radiologists (including myself) would be happy to let an EP read their own plain films -- our worst imaging modality, yet full of liability.
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# Hueydoc 2011-10-15 19:19
I've always wondered why radiologists get paid more for reading a film days later than I get for seeing the patient, treating them and reading the xray myself!
I've also had to call up radiologists after their days later read and say " So you think that subdural bleed was Normal? The one the neurosurgeon took staright to the OR ?" or " So you consider that bullet in his parietal lobe to be "Normal"?"
I say whoever reads it first should be the only one to get paid.
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# Radiologist, covering ER's at nightNightRad 2011-10-16 21:34
An article like this is not meant to be taken seriously. It is provocative. It is meant to start a discussion. ED medicine is the toughest practice extant. ER doctors get nothing but patients who fail to tell the truth, actively pursue non medical agendas, and are willing to sue at the drop of a hat. They have high level hospital administrators screaming at them to admit more and payors who scream at them to admit less. They have low level hospital administrators screaming at them to wash their hands, chart more, visit the patients more, use medications in only certain ways, use absurd procedures to adhere to supposed JCAHO guidelines. The list goes on. I cannot imagine the courage they come up with just to walk in the door for their shifts. If one of them wants to blow off steam about radiologists, hard to get too excited.
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# Inflammatory, validity, low levelem physician 2011-10-17 01:49
as a practicing EM physician, also at a large academic institution, it is important to acknolwedge that there is an important relationship between EM and radiology. at the end of the night, it is not the ego that matters, but what is best for patient care. as a bedside clinician, i have the responsbility and acumen to assure that i order labs tests and radiographic as best for my patient. to those EM physicians who believe such a relationship is parasitic, i ask you, including dr mallon, to reevaluate the importance of such a relationship. to those radiologists who target the speciality in reposnse to this article, i state grow up and act like the professionals that you may be.

i think most will agree that the article was inlammatory and unfair. while the article does make an important point (regarding clinical worth and immediate versus delayed diagnosis) most radiologist, and em phsycians for that matter, will have a difficult time reading past the inflammatory remarks. after the fire settles, perhaps think about the point of the article and not how it was written.

dr mallon plays an important role in the EM community and his opinion is much valued. he above article represents an opinion, not the rule.

before posting, take a cold shower, sit in a dark room, and let's together continue to improve the medical system, the spiraling costs of healthcare, and patient care as opposed to setting it back with an above such article or above such comments.
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# EP BillerJim Blakeman 2011-10-17 09:52
Well, and necessarily said, Dr. Mallon.

20 years of civil discourse with radiologists has gotten us nowhere. A little flame now might actually bring light. Dr. Mallon is right that unless CMS threatens to take away the money if readings aren’t done to benefit the patient, radiologists will not do the right thing on behalf of the patient.

Want proof? Just read what they say.

In 1993, the OIG said after-care reads should not be paid for; they’re not patient care, they’re Q/A, and that’s already been paid to the hospital in the DRG rate. You want money for Q/A, go talk to your hospital administrator, was CMS’s (then HCFA’s) point. The flame-throwing in the ACR’s response is actually enlightening to this discussion, I think.

Here’s what they said in a letter to the Agency after the OIG study was published (Gary Price letter to Tom Ault, Deputy Director, Bureau of Policy, 1/14/1994). The hypocrisy is remarkable. “It is important that the long-standing tenant in the Medicare program be recognized: the physician who performs the service should… be paid for the service.” God forbid that we radiologists might actually have to perform a service that we can’t get paid for. Welcome to emergency medicine, boys. This is where we live every day.

Then, they turn ugly and conclude their 7 pages of accusations that emergency physicians are incompetent with this gem: If you stop paying us, this “would halt the interpretation of emergency department x-rays by expert radiologists… A substantial number of abnormalities would go undetected daily, resulting in unnecessary pain and suffering and unnecessary loss of perhaps hundreds of lives each year. ” ACR letter, page 7.

So, I can’t conclude that Dr. Mallon is saying anything other than the American College of Radiology has already said. For them, it’s all about the money, not the patient. Unless we advocate for taking the money away if the patient care is compromised, we won’t see timely, reliable (not second guessing two days later when they change their mind about the stat read they never documented) interpretive services from the “experts”.

Emergency physicians work in a fishbowl, everybody gets to second guess your decisions. That goes with the territory. But, taking your money to tell you you’re wrong is just a little much. Thank you, Billy, for pointing this out.
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# Stop WhiningMarried To a radiologist 2011-10-17 10:15
If your intent was to sound like another "Rush Limbaugh", you've probably succeeded. Like so many have already stated here (and very eloquently), quit whining, go do another residency and get your Porsche or whatever you fancy.
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# CarsAtul Gupta 2011-10-17 20:32
Hey if you guys are pooling money to buy him a car can you put in a little extra for me? I'm an attending radiologist 4 years out of training, working at a VA hospital. I drive a beat up puke green 1997 Honda Accord that just got a used $800 transmission put in to replace the old leaking one. Some of the door locks dont work. Im pretty sure the AC is releasing toxic chemicals into the cabin. My kids have spilled milk and god knows what else in the back seat. I would really like an Aston Martin but to be honest anything less than 10 years old will do, preferably with an airbag, anti-lock brakes, and latches for the carseats.

Please though, buy this guy a car first it seems very important to him.
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# This guy would be great on FOX news!!!radmd 2011-10-18 05:45
Is he besties with Rupert???
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# Wondering 2011-10-18 12:43
Where exactly are radiologists reading the films "Days later" I've worked at numerous institutions and have never seen this. I asked many radiologists I know and have never seen this.

Are you in a rural area? There may only be 1 radiologist in that particular county

We read all studies (ER, Inpatient, and Outpatient) contemporaneous ly with a short-term around time. Sounds like you guys need better radiologists.
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# Where is my share of the pie?ED PA 2011-10-19 10:14
I am a PA that works with the now infamous 'DR' Mallon.

I too have an issue with reimbursement, and my fair piece of the pie. We (PAs and NPs) do just as much, if not more work than the ED attendings. We work the same shifts and total hours, for 1/3 of the pay.

I can order X-rays and consult specialists just as well as the next guy...why can't I get similar pay? Sure I don't have an MD, and assume less liability, but why can't I make 2/3 of the pay for the same work!?

In fact, as you can see in most hospitals as in ours at USC, a majority of the ED staff are mid-levels, like myself. Why? Honestly, because most of the ED work is pretty easy (off meds, colds, fractures, drug-seekers, psych) and the rest is algorithm based.

Trauma=CT scan; negative-discha rge, positive-admit

Chest Pain=EKG/Enzyme s +/- PE study; negative-discha rge, positive-admit

"Bad" Headache=CT scan; negative-discha rge, positive-admit

Abdominal Pain=CT scan/labs; negative-discha rge, positive-admit

Pelvic Pain=US/labs; negative-discha rge, positive-admit

Plus we are taught by the ED attendings to read our own Xrays and do our own Ultrasounds. Most of the time its just, "no acute" or "fracture, no fracture," but, still, I am the one looking at it real-time--so, show me the money!!!

I am doing the work--not the ED attending (PGY-4), not the blood-sucking radiology resident/fellow (PGY-5/6), not the absentee/out-of hospital surgery, cardiology or critical care attendings!!!

ME, me, ME!! That's why we all went into the healthcare field right, DR Mallon--$$$$$$$
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# ttt 2011-10-20 09:44
thanks, nightrad, your perspective is appreciated. i think Dr Mallon crossed the line trying to be provocative/fun ny, but many of the responses were even more destructive to our delicate interspecialty relationship. to the pissy PA, i am aghast at your attitude. can't even begin to tell you what's wrong with the way you think. you are unfixable and certainly not worthy of assisting any physician. please do the right thing and out yourself to Dr. Mallon so he knows he is working with an enemy. i am so glad we don't have PAs in our ED. you should be ashamed of yourself.
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# neuroradiologis traddoc 2011-10-23 13:01
Dr. Mallon,

I'm a Neuroradiologis t. In our practice, we work 15 - 22 shifts a month, including days, nights, and weekends, and our shifts are 10 - 12 hours. We are also on home pager call for emergent procedures. For what it's worth, this is why I make more money than my friends who are Emergency Physicians, and work 12 8 hour shifts per month. Nevertheless, they, too, drive German luxury cars. But more importantly, they love their jobs, and I love mine. We both perform an invaluable service for the patients, and even more so when we work together. My EP colleagues appreciate and respect my presence, an I appreciate and respect theirs. I'm sorry for your that many of these concepts are lost on you, and that you chose to use insults and hyperbole to be divisive.
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# red 2011-10-25 18:35
hmmm...I think its interesting how many radiologists are mis-interpretin g the argument. Dr. Mallon's point is that radiology (in some hospitals) will bill for films after they have been read and acted upon. Which is fraud, and useless. I love my radiologist and nighthawk that is available 24/7 and gets me reads in 30 minutes, even on higher level studies. I don't like the one that calls me the next day with a final read...thanks for nothing, that would have been useful when the patient was in the hospital.

I don't know what rads schedule is like, but if a hospital is ordering films 24/7 then coverage should accommodate on the weekend for final reads. I
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# Can't we all just get along?NEO Rad 2011-10-26 10:54
Everyone just take a deep breath and relax. Dr. Mallon has managed to transform a serious issue into a cat fight, no better than a screaming match on daytime talk shows. His opinion is insulting and juvenile. Responding in kind is equally unprofessional.

Every specialty has it's own pet peeves and often targets another specialty as a source of aggrevation. Have we all forgotten that at one time we all went through medical school with high ideals and a pledge to improve society? We need to strive together as a team to help our patients, not stab each other in the back.

Several People Here are the Problem:

You didn't go to IU and Louisville for residency did you?
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# Closer to Self-destructio ndisillusioned MD 2011-10-26 12:51
The residency system was meant to deliver medicine from the "just wing it" era to something...a little more scientifically rigorous. Right?

The real inevitability is an American medical system dummied down by mindless algorithmic decision-making , fraught with carbetbaggers, confounded by an ever-expanding community of alternative medical "providers," strangled by bean-counters, and crippled by government bureacracy-- all inadvertently delivered to the public by self-destructiv e, self-promoting physicians who just can't seem to agree on anything, i.e. "disorganized" medicine.

A future where ER physicians and hospitalists are largely replaced by midlevels is certainly conceivable (by bean-counters and bureacrats), although almost certainly not advisable. Unfortunately for the above excitable, disgruntled, hardworking PA, his/her salary will likely drop, not increase thereafter.

back to the grind.
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# Mark - physician 2011-10-27 20:17
As a medicine physician who takes frequent overnight call, I often get called at 1AM on a given weekday/weekend to confirm placement of a central line, NG tube, r/o PTX, etc. Since there is no radiologist there at night, I'm forced to look at the CXR and decide what to do, despite having not a whole lot of confidence in my radiology abilities. I never went to radiology residency and will be the first to defer such expertise to the qualified physicians that spent 5 years of residency training learning to properly read a CXR (vs my haphazard, non-comprehensi ve approach). This is why I sort of agree with the article -- why isn't there a radiologist on during the nights to make these reads? I'm the one that gets screwed if the central is actually in the right ventricle or the NGT is actually tracheal and I've already ok'd IV infusion or tube feeds. Now I'm sure the radiologists reading are probably thinking "what idiot can't tell proper placement of such things?", but if you think it's so easy to read these things, then why do you keep insisting it takes so much expertise and that we shouldn't be reading them alone? Basically, I think every hospital should have at least 1 attending radiologist on call during the nights (my hospital certainly doesn't) to read images as they come (vs 10 hours later after clinical decisions have already been made).


Of note, I do think it is very ironic that ED physicians are bitching to radiologists about not working enough. You guys are triage docs that work 40 hrs a week, and you're giving radiologists a hard time? Gimme a break! Stop ordering CT scans for everybody with a cough, and maybe you wouldn't need to rely on radiologists that heavily.
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# ED Radiologistdergon 2011-10-28 03:13
@red-

Studies finalized after overnight preliminary is NOT fraudulent. This has been been clarified by CMS. It is exactly this allegation that Dr. Mallon makes which is wholly incorrect and that you are trying to perpetuate.

You and Dr. Mallon are both wrong. (at least you weren't a d*bag in the way you made your point though)
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# Contemplate this on the tree of Woe...disallusioned MD 2011-10-28 08:25
No man is an island,
Entire of itself.
Each is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less.
As well as if a promontory were.
As well as if a manor of thine own
Or of thine friend's were.
Each man's death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.

--John Dunne
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# ER doctor turned RadiologistER doctor turned Radiologist 2011-10-30 13:43
Dr. Mallon,

As a practicing ER doctor who went back into residency to become a radiologist I can honestly say that you have everything backwards.

Please walk a mile in a man's shoes before you criticize. Undergo a radiology residency, do a radiology fellowship, and practice a few years as a radiologist.

You will realize that radiologists actually think when they work (unlike Emergency medicine where it is all binary decisions that are algorithm based) and that radiologists are true specialists who also happen to work longer hours than a trenchworking ER doctor.

Walk both sides of the fence, only then can you criticize either side.
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# m.d.ed 2011-11-01 17:32
Dr.Mellon reminds me of Rodney Dangerfield:

" No respect ,I'll tell you, no respect"
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# UnbelievableD Johnson 2011-11-04 04:07
The accusatory comments written by Dr. Mallon border on slander. I work in a radiology practice that provides 24/7/365 coverage. I drive a Honda truck and have parked next to a number of those German cars owned by physicians who are not radiologists. I often wondered how they could afford those.

As for Dr. Alost who claims that he reads all of the CT, MRI and US studies that he orders, the most dangerous physician is the one who thinks he knows everything. I don't know of any self respecting surgeon who would operate on a patient based on the interpretation of a cross sectional imaging study by an ED physician.

I also doubt that the radiologists responding to this article actually read this periodical.
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# IR RadSinger 2011-11-07 14:52
For 22 years I have been the slave to inept ER physicians who are unable, too lazy, or claim "uncertified" to do on call lumbar punctures, paracentesis, and thoracentesis on their patients. They call me to place a pigtail catheter for spontaneous pneumothorax or place a PICC line because they can't or wont place a cental line. Attempts to train ER docs to learn how to use imaging to do these rudimentary procedures go rebuffed every year. CT utilization grows each year as triage nurses and extenders get regional CT studies before a physician has seen the patient. Radiology groups pay for night teleradiology readings that benefit the ER doc. Uninsured patients cost radiologists and hospitals multiples that they cost ER docs. Dr Mallon should return to the parasites he knows best in Peru. At least he could relate to his own kind.
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# Be careful what you wish for Dr MallonDr H 2011-11-15 12:12
Dr Mallon--I cannot speak to your situation, but where I work the radiologists are reading all of the cross sectional and ultrasound exams as they happen, plain films are etiher read as they happen or at the very latest the next AM. I would agree that if indeed films are not being read for a day or two later, that is not an ideal situation. Your inflammatory blog is not going to help however.

You sound like a jack of all trades--are you board certified in radiology? Why hasn't your hodpital credentialed you to give final reads on radiology exams? Are you involved in radiology peer review? Are you involved in a maintanece of certification process in radiology. How about a practice quality improvement project? How much radiation was your patient exposed to during that chest x ray or CT, and what are the risks to that patient down the road? How do you follow up a 4mm chest nodule or an 8 mm nodule for that matter? Is that a lung carcimoma or is that just scar tissue? Just wondering, and oh by the way--you just missed that posterior mediastinal mass...
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# ED Physician 2011-11-16 07:09
I have spent 45 minutes reading all of these comments on a plane (Virgin America wifi).

Half of these comments were unnecessary. All of you radiologists who work ay 24/7/365 locales, Dr Mallon praises you if you could read between the lines here. He is on your side. THANK YOU. THANK YOU. THANK YOU. You are actually CONTRIBUTING to the timely deliverance of emergent medical care. That's all he is asking for.

The other group who are NOT 24/7/365 are the ones who are potentially committing fraud and stealing from the government and insurers by charging for and representing themselves as having taken part in this delivery of EMERGENT HEALTH CARE. And you know it.
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# ER DocDick Featherstone 2011-11-20 03:19
This is some precious material. My stomach actually hurts from laughing from reading these hate filled comments that are mostly irrelevent to the arguement. As the last person wrote, Billy is commenting on a particular behavior/attitu de exhibited by SOME radiologists or radiologist groups.

Here are two more problem I have with some (however in my experience all) radiologists. ER doctor A gets a chest xray and reads it negative. Radiologist comes to work the next day, presumably with Latte in hand, and over reads the xray as showing a "suspicious mass, follow up recommended". Here is where it gets awesome. Radiologist then writes this on a piece of paper and has it sent to ER doctor B (usually me) who has never seen the patient to follow it up. Now if I read most of the above comments correctly Radiologists are unbelievably clinically astute (much more so than us glorified triage nurses), so why doesn't this radiologist who thinks he sees something call the patient up? How is Er Doc B any more qualified or prepared to address this new information? Does not a radiologist go to medical school? I guess that might require time out of your revenue generating reading session and we all know that T-times are hard to get.

A radiologist is just as qualified to look into a patient's chart and contact that patient if necessary because of HIS finding on xray as the person who just happens to be working the ER the next day; more so actually since the radiologist is actually involved in the care!

Problem #2 with our current relationship with radiology. When I order a plain film, I look at it and interpret it and write it down in my note. Then I am supposed to walk to another part of the ER as some point in my "free time" and reread my xray in a computer so that it is convenient for the Radiologist to see what I though the xray showed when he sees it the next day. Dude, you are sitting in a quiet room all day while we are running around managing patients in a chaotic environment for 12 straight hours. Would it be that hard to have your staff pull our charts to get our readings.

I have worked with some great Radiologists in the last 10 years. Ones that are always available and professional and very very helpful. Team members and invaluable. Willing to make a reading without saying "clinical coorelation" at the end of every reading. Radiologists that actually call me and ask for the story while they are reading to help us both take care of patients.

I have also worked with radiologists that clearly want nothing to do with anything clinical. Who think they have some sort of right to be able to have everyone around them work to make their lives eaiser. They can't imagine doing a follow up that they would be most appropriate for and throw a tantrum if everything isin't organized perfectly for them so they only have to get out of the chair for latte refills and bathroom breaks. They wont read an appendix without contrast even though their own literature has shown over and over that it isin't needed. These are the parasites that piss ER doctors off. And the more they take, the worse off this relationship will become.
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# NP,Ph.DJS 2011-11-20 14:42
I am an NP (Ph.D) who has 19 years in ED's. I do agree with the PA who responded (1/3 pay). Yes,we are responsible for the care we give our patients and yes we do read and interpret our own x-rays prior to them being read. At times, I will admit radiologists has missed a few simple fx's and foreign bodies. On occasion, I have called the radiologist to inform them of their missed call and I have never been disrespectful and occasionally have recieved a thank you. I do have to laught as it appears it is a universal statement in the replies "MRI recommended or Clinical Correlation). It always appears to me that my validity of my cases outweight the added comments of "clinical correlation".

To conclude Dr Mallon makes his point that has opened many an eye with thoughts and frustrations kept "secret" in our minds. This is a peer related journal, so lets look at the statements and grow from them, respect all, and move on. Medicine only hurts itself when egos have to be heard and there were more than enough "egos" expressing themselves here.
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# don 2011-11-23 13:55
I must admit i too am amazed at how many radiologists read this magazine!!
Billy was a little harsh but raises a good point; the disparate and illogical pay in our healthcare system. I love the comment in one of the letters about radiologists not calling their own follow up- good point. Our community hospital has a good rad system and 24 hour nighthawk as back up- so i am satisfied. That a radiologist gets paid more than i do (as an ED doc) however is a real pisser. But, i am doing pretty well and so hope we can all unite and work together to improve this health care system that is really a pathetic mess
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# ED FMG Needs to Finds MannersJAG, Former Rad Chairman 2011-11-25 12:49
I read the article published in your journal and as a radiologist I would like to make a few comments.
At our hospital we have radiologist coverage for our colleagues including the ED 24/7 and read all imaging studies performed. Our average turnaround time for ED and STAT cases is typically under one hour from the time a study is completed. These results are published at quarterly medical staff meetings for all departments to review. I am always proud of our department with these results compared to the average patient waiting times in the ED that can range from 2 - 4 hours, on a good day for a patient to see some kind of health care provider, often times not the ED physician.
The radiology department enjoys a close relationship with the ED and we often work together to adjust our schedules to provide immediate imaging for patients deemed more STAT than the typical STAT cases from the ED that often have no significant findings and often have not been evaluated by any doctor. I could throw stones back at the ED author of this article noting the many ultrasound exams we have performed to rule out cholecystitis only to find that the gallbladder was removed years prior, or the numerous CT scans we perform to rule out intracranial bleed that are rarely positive however in the spirit of improving patient care, which I would think this magazine is dedicated to as well as to the physicians reading this, I will not expand this list that could be several pages long.
Currently we have experienced recent attempts by ED physicians to perform ultrasound themselves claiming they have some type of training in imaging modalities to make diagnoses, only to miss obvious findings such as raging cholecystitis that have resulted in near patient deaths. Clearly with radiology ultrasound techs in the hospital and board certified radiologists to read the exams, one might look at this as an attempt for ED physicians to make money for themselves while putting patients at risk who come to the hospital looking for help rather than encountering a greedy ED doctor looking to enhance RVUs and personal revenue.
We as radiologists are thoughtful and do not criticize our busy ED or other referring physician colleagues when they come to our department to check on the results of a CT scan of a patient they have been assigned to care for and have ordered cross sectional imaging without seeing or examining them thus exposing these patients to ionizing radiation without any physician interaction. As radiologists we understand that now in today’s environment it is the radiologist who actually performs the “first” physical exam.
It seems to me from this article that the author’s frustration would be better directed at the ED leadership in his own hospital or at hospital administration, who frankly routinely make much more than the radiologists in salary and bonuses that seem to allow imaging studies to be performed and or interpreted by non board certified radiologists 24/7. This policy I would suspect would increase patient errors as well as hospital liabilities and it amazes me that this physician would not mention this or address this in the article.
In summary we are all there for the patient 24/7, and if this is not the case then hospital policy needs to be reviewed critically rather than write an irresponsible commentary.
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# Rad 2011-12-01 17:30
A few points
1. Ed studies are the lowest reimbursement cases of all. As radiologists we provide free for service on Ed reads.
2. Most practices where size allows provide 24/7 radiology coverage or go deep into night with only a few hours overnight uncovered when volumes are too low to justify such coverage in most places.
3. Radiology is a constant high alert practice where we focus and work with high intensity for hours at a time to the point most of us cannot think straight when we leave the hospital we are so beat up. To try to read a study or studies with thousands of images cumulative over the course of a day is ridiculously mentally fatiguing. I have done 90-120 hour weeks when interventional got busy but I get much more tired after a 50 hour read week. It is easy to look at studies when you do not have to take responsibility for everything on the study but when you sign off as final reader you look at everything And it is tiring. You cannot safely read in this mode more than 6-7 hours a day but most of us put in quite a bit more than that.
4. Majority of Ed x-rays are either normal or obvious. Only a small percent have findings that are subtle but critical to make either in the acute setting or longterm. Radiology's value added is in such situations where we intensely interrogate the image in a way in which a busy Ed doc will never be able to. Means we pick up on the small treatable cancer which our Ed colleagues understandably did not pick up on as that was not there focus. I am proud to help the patients and my Ed colleagues by providing this service even though reimbursement wise I am not spending my time productively. I have also seen numerous missed fractures, pneumonias, etc that I have called directly to my Ed colleagues most of whom appreciate it.
5. Regarding misses- yes it happens to the best of all physicians and PAs and NPs. Miss rates in radiology are anywhere from 3% for critical findings to 30% for minor findings. I go out of my way to be respectful for the preliminary reads my Ed colleagues give- frankly it is easier for me to read such cases without the Ed doc's note but when it is there I give it as much consideration as I can to avoid causing them an unnecessary difficulty.
6. We are specialized in radiology which means that all though in any given instance we may not be any better or possibly worse than our Ed colleagues, in the aggregate we do a better job and we do it more efficiently because that is our specialty justas acute care is the Ed doc's specialty.
7. From my point of view, it would make my life a lot easier and more productive to skip the Ed xrays altogther. Due to pacs what will happen is when there are misses by the understandably busy Ed doc of critical but not urgent findings, we as radiologists will see the misses when they come for there followup ct or mr. I will do my best to minimize the damage in my reports to my Ed colleagues for their misses but I also owe the patient my best professional care which means I will comment on the misses if they will impact patient care.
8. Regarding not being available I am confused. Since I came out of residency fifteen years ago, I have gone in for multiple interventional cases after hours and then gone in the next day and worked as best I could on cognitively challenging cases. I have also driven in for diagnostic studies as my colleagues requested. Some of us wok shifts because you cannot safely read high cognitive load studies such as cts, Mrs, mammograms, etc if you cannot focus due to fatigue. We are not trying to find the 5cm mass but rather the 5mm nodule and it is tiring.
9. I know the Ed doc's work shifts and do not take call afterwards and I understand their fatigue. At the same time, I can assure you a few hours of intense focus is also tiring so we are not exactly cruising.
10. If the Ed doc's want to take responsibility for the studies and bill for them, I support this fully. They just have to understand what they are getting into. It is understandable to be confident when 95-98% of the cases are straight forward as long as they are also willing to accept the consequences for the truly critical. This means switching from an adrenalized go go state to a calm cerebral state and as an IR I have found such to be pretty hard and slows you down considerably. Radiology's leverage is the ability to batch read such in a focused uninterrupted intense manner.
11. I have a lot of respect for my Ed colleagues but if they do not understand or appreciate what we offer, please final read your own cases.
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# What......Rad resident just finishing overnight 2011-12-06 07:28
I am a PGY 3 rad resident and I just finished an overnight call. I have never worked at the hospital that Dr. Mallon is at, but I cannot imagine a hospital, especially one as large as USC running the way he has described. My hospital (university affiliated community hospital) has 24/7/365 coverage. The "on call" residents put in prelim notes within 30 minutes from 5 pm to 7:30 am on all CT and MR as well as perform all the ultrasounds. Also, we perform immediate over-reads for all plain films in the ED and inpatient studies that we are called on that the ED may have questions or medicine has concern for line placement (policy is to answer the page within 5 minutes and have a note in by the time we hang up on plain films). we have 4th year residents (PGY5) for over-reads 24-7 as well attending over-reads until 11 pm and night hawk after 11. The hospital associated with my medical school functioned the same way, as well as the hospital I did my intern year at. I find it hard to believe that a hospital as large as USC goes an entire weekend without finalizing plain films when my hospital never goes more that 15 hours (plain film from the night before are finalized by noon the next day if no the ED had not called on them).

Also, the ER doc who said that he reads everything and the patient is "already in the OR" from his read is VERY CONCERNING if he thinks that he can not only perform the job of an ED physician, but read CT's, MR's and US as well as fellowship trained radiologists. He has not been trained in the modalities. He may understand the basics, but no one can know everything about everything. The scariest thing I have seen in the medical field is the physician that doesn't know what he doesn't know. The person who made that comment DOES NOT KNOW WHAT HE DOES NOT KNOW if he think s that he doesn't need any radiology input on cross sectional imaging. I am not saying radiologists are smarter (to all of those people who may try to twist my words), but radiology is what we know. Just like a radiologist should manage ED patients (I have forgotten so much about medication doses since I haven't written a prescription in 2 years) ED physicians should welcome input on imaging when it is available.

Dr. Mallon. you are unprofessional, the story you portray has to be embellished and your attitude is not conducive to a work environment that benefits the patient. I hope that you do not get to work with residents and pass on you attitude and misconceptions.

This entire article is a farse, a satire. it's sad you do not see this.
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# RadsDoc 2011-12-17 04:30
I find it amusing that the only folks who agree with Mallon are the mid-level providers (NP w/a PhD-give me a break). One of the most dangerous scenarios in medicine is not knowing what you do not know. Folks without much training in imaging often have no clue what they are missing, and have very little insight into the level of performance from the true professionals. When they do find a "miss", which is much more rare than they are letting on, they often over estimate the clinical importance of the finding and are bringing it to light to point out a shortcoming of a very overworked colleague. A colleague, BTW, who would love to not be quite so busy with endless ER studies that don't meet ACR appropriateness criteria.
Surgeons, internists, sub-specialists from a variety of backgrounds all very much appreciate the input from radiologists, but somehow the PAs and NPs think that they could do a better job. My advice? Spend some real time in a reading room (perhaps one where more complex modalities are being read) and think about whether or not you really want that job. Is the answer still yes? Then apply to a radiology residency and get to work.
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# A Modest Proposalunemployed 2011-12-17 10:08
It's a pity that the actual point of the article is missed and instead people focused on the negative/ironic /sarcastic tone.

Apparently many doctors have either forgotten the, or never took any, university level literary criticism or English courses... I hope everyone here is equally as outraged by any article they come across in The Onion. (The disclaimer should have been the first hint).
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# ER Doc at many community hospitalsER Doc 2011-12-22 04:40
Ahh, radiologists. I love you guys, but you are all missing the entire point of this article. I'm gonna say it in a nicer way, but - be forewarned - I'm going to shout it (for drama). OK?

WE DON'T READ FILMS AS GOOD AS YOU GUYS DO. NOT AT ALL. WE'RE NOT PRETENDING THAT WE DO. AND SO WE REALLY, REALLY WANT YOU THERE AT NIGHT TO DO READ THEM, BUT IN MOST HOSPITALS IN THE COUNTRY, YOU ARE SLEEPING. AND SO WE'RE KIND OF FRUSTRATED THAT 1) WE HAVE TO READ THESE FILMS ON OUR OWN AT NIGHT, 2) WE THEN TAKE ON THE LIABILITY OF ACTING ON OUR OWN NON-EXPERT READS, AND 3) WE CAN'T EVEN BILL FOR IT.

That's all. Don't worry, you guys rock. No hard feelings?

And by the way, cardiologists - same thing with EKGs...
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# joe 2011-12-22 10:01
it would be nice if this was parody; i'll assume it is as almost everyone else who is outraged has pretty much said what I was gonna say...so assuming this is parody, I would just point out to Dr. Mallon that I, a Radiologist, do in fact arrive at work some mornings in a chauffeur driven black Mercedes. Swear to God. Problem is, it belongs to my fiancee, head nurse in our local ER who sometimes drops me off. I drive a VW Jetta...
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# joe 2011-12-22 10:04
as for people upset with the disparity in pay, which survives this article's satiric or serious nature, we didn't make the rules, The AMA did. The Fed's did. Medicare did. Stephen Hsaio (invented of the DRG) did. If you think we're over paid for getting $18 for a chest X ray, you need therapy. If you think $200 for spending 20 minutes on 1000 images of a CT of the neck, chest, abdomen and pelvis ordered by the ER is too much, well, that goes both ways. We've just figured out how to maximize our gain from the system we've been handed.
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# joe 2011-12-22 10:41
so on further reading, there's no chance this was intended to be satire or parody as "unemployed" suggests. None. The vitriol just doesn't fit. There's little humor. I suspect "unemployed" is actually Dr. Mallon, who was allegedly let go after this showed up, and now, politician style, is trying to say "I really didn't mean it."
I like the parasite analogy, however calling radiology "fraudulent" is fighting words. People go to jail for fraud.
On a personal note i've practiced in maybe 20 medical centers, been licensed in 12 states, done some locums, ran a group, worked in huge and tiny centers. I really haven't seen much of what he's ranting about. In fact, I've been involved with several hospitals years ago who have fired their rads for not coming in on weekends. So I think there's a bit of "history" here for poor Dr. Fallon. I'm sure he's a good Mazda driving ER doc. I am impressed with how good many ER docs are at reading plain films. $19,000 worth a year? I'm not going to fight over that. But there are a lot of ER docs who are truly frightening with radiology. I've seen on a daily basis just laughable and horrifying calls. And reading CT, MRI, or US? God, please don't make me laugh...
Remember, we don't order films. Referring docs do. And ER docs, for understandable reasons sometimes and obscure ones other times, order lots of films, many of which we know are contraindicated - rib films, facial bones, L spines. So we may be living large, but the person shoving the cattle into the chute is the ER doc. We normally work well together and have a lot of mutual respect. Dr. Mallon seems to be a bit of an atavistic horror show. He's entitled to his opinion. I'm just shocked that a journal other than The Placebo Review would publish it.
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# Oedipal complexED physician 2011-12-30 14:25
seriously, have you been dumped by a radiologist before because you were not bright enough or RICH as she (or HEEEEE!!!!!!) expected? Get over it mate. From AUS
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# Not the brightest spot on the film, is he? Mrs. Radiologist 2012-01-12 21:37
Dr. Mallon has proved that he is not a bright man by publicly offering up this Jersey Shore's style rant against a whole group of people he has to see and work with on a daily basis. I sincerely hope he enjoys every second of the hostile work environment he has created for himself. I can only hope this monument to poor decision making skills was the byproduct of a long standing feud, or a bad break up, or a napoleon complex of some sort, and that he is not actually self important enough to think that people will take the things he has to say in this piece seriously after an introduction like the one featured here. If he thinks he has illuminated an issue, or changed the mind or heart of a reader, he is stupider then Snookie ranting about Obama taxing her tanning bed visits then claiming she has made a contribution to a political discussion.
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# Clinical RadiologistPotterBucky 2012-01-13 22:12
How often does Dr. Mallon looks at the lab and radiology work up before examining the patient?
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# I have worked with Mallon.Anon 2012-01-15 05:48
Unfortunately, Dr. Mallon doesn't quite know his limitations. While he is quite adept at running certain algorithms, he dangerously refuses to seek consultation when he is in over his head. He can be quite effective in the day-to-day, bread and butter Emergency cases but languishes when specialist knowledge is required. I won't give specific examples.
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# Buddy Leach 2012-01-27 09:05
I read articles like this.

And it makes me sad.

Sincerely,

Dr. Buddy Leach
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# TypicalDoctors Doctor 2012-02-02 18:14
Hmm..parasitica l foreign med grad comes into the US, leached off our govt for training, and then proceeds to talk about his slice of the pie?

LAUGHABLE.

ER docs know how to consult..Radiol ogists know how to diagnose and treat. End of story.

Go back to Peru.
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# Biller Coderellen 2012-02-28 16:47
To all the I.R.'s out there. Stop putting Modify 62 on my Vascular Surgeons procedures 934802-04). Bill for what "you do", not for what my guys do.
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# GruntFeatherstone 2012-07-19 20:10
Hey Jag. Nice try with the EDUS digg. I know some radiologist who miss cholecystits too but that doesn't mean you are all stupid. As I'm sure you know there are over 60 1 year EDUS fellowships in the country. Do you know why Jag? Because at night time when you are sleeping after your intense day in the dark, people sometimes come into the ER with life threatening conditions that really need an ultrasound to treat optimally. Ectopic pregnancy, AAA, Sepsis, PE, acute CHF are among a host of conditions where having US images can completely change treatments and dispositions. Only in a select few places are we getting paid for this. We have just recognized that you won't be here to help us so we have decided to follow the OB and Cardiologist lead and learn for ourselves.
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# We need rads help in medicineER Doc 2012-08-30 11:20
When I order a study I'm actually consulting radiology. And I welcome any radiologist who will leave their chair and come down to see a patient with me, ask about the patients history and physical exam findings, and even talk to the patient. Ortho does it, ENT does it, Vasc Surgery does it, OB/Gyn does it, Psych does it. I've even had pathology do it, but I have never had a radiologist do it.

Your livelihood relies on these consults, and you've pissed off most other specialties because you're looking to read more and make more money. You've even began to cannibalize younger rad docs by increasing residency spots when your grads can't find jobs, increasing fellowship spots to 2 years to get another year of "free reads", and this glut of rad docs has made it now so that private groups can charge $250K to $500K buy-ins after 2 to 3 years of low salary pay. It's a sad state in the profession of radiology.

It would behoove medicine to see primary imaging reads fall back to the ordering physicians and rads become a real consult service.
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# to Doctors DoctorER Doc 2012-08-30 11:50
The problem with radiology is nothing a future EM fellowship can't cure. Today it's an ultrasound fellowship tomorrow it's a CT fellowship. There's no need to consult when you're trained to handle it yourself.

ER docs consult because our ER's are stock full of patients and we can't find enough board certified EP's or competent mid-levels to help. When that demand is met EP's will be looking for new responsibilitie s, and nothing is more in need than someone read an image real time who knows the patient because they've actually seen them, collected a history, and completed a physical.
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# docer doc2 2012-09-08 14:06
While many of you are complaining about unprofessional radiology bashing, how about the things said by radiologists here? ER docs are triage docs,have no clinical acumen, don't do work etc...you guys are no different from Mallon, even if you are responding to him.
We both have gripes. We know you read these films and scans better than us--you did a 4 year (at least) residency devoted to just that, and now it's your practice. we would like radiology reads that are useful to the patient for the reason they are presenting to the ED, which means that have to happen while they are there. We acknowledge that your incidental findings of nodules, cancers etc are important.
ER docs as a whole need to take back their profession--sto p letting admin people dictate metrics like time in dept without giving you more resources, because that's what leads to blood work and un-needed radiology studies being ordered. Stop letting them under-staff the ED so we can't think about patients and have to use algorithms and people like the PA above who presented his/her dangerous practice patterns.
Working in an ED is stressful and constantly challenging, but it is easy to be bad at it and hard to be good at it. Good care happens when we all work together.
The inflammatory and poorly communicated message of the article is that: if the x-ray or CT is done for an emergency room patient, it should be read by SOMEONE (who is good at it )while they are still being evaluated. Otherwise, what's the point? And that person should be paid for it. That does not happen in some community hospitals.
To the great radiologists who call me and puzzle over cases with me on the phone, thank you.
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# Radiology is a sham specialityER resident 2013-03-06 14:29
Radiologists should not be considered true doctors. They do not care about patients because they never see them. All they want is to make money and get home by 3pm. The reads are despicable at my institution and only serve to cover their liability (correlate clinically) or garner more studies (follow up ct for a 4mm nodule in a patient actively crashing from a PE). They should be ashamed they took someone's spot in medical school who could actually be doing good. Solution to the Medicare crisis, strip all radiologists of their MD and make them dig ditches!!
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# ER resident 2013-03-06 14:50
Radiologists should not be considered true doctors. They do not care about patients because they never see them. All they want is to make money and get home by 3pm. The reads are despicable at my institution and only serve to cover their liability (correlate clinically) or garner more studies (follow up ct for a 4mm nodule in a patient actively crashing from a PE). They should be ashamed they took someone's spot in medical school who could actually be doing good. Solution to the Medicare crisis, strip all radiologists of their MD and make them dig ditches!!
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# DiscussionER Academic Attending 2013-03-26 08:23
This discussion is riveting but I'm gonna take some action and drop a grenade into the reading room. They are the worlds worst doctors and human beings. I've never met one who knows anything.
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# I can't waitMed Student Matched to ER 2013-04-08 02:00
I can't wait to be making bank and driving a fancy car because I will be making $$$ from reading chest x rays, CTs and MRIs! Radiologist SUCK!!!!!!!!!
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# What a cat fight..Shamegik 2013-05-01 08:04
I am a healthy person and will definitely avoid ER where docs are so unhappy and definitely refuse xrays and CT scans because no one is accountable. Shame on medical profession and shame on this website to publish this nonsense. I am glad I am not one of these morons, disgustingly discussing their work politics openly on the web. If this is what they have earned after 15 years of so-called "education" and many many years of unprofessional "profession", then I would definitely not encourage my kids or anybody to take medicine as their career. Shame Shame Shame. Dr Mallon, you should shoot yourself in head for writing your frustrations and seek psychiatric care.
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# ER medicine is an oxymoronSpaming MD 2013-05-01 12:41
3 years is not enough to learn to be "the jack of all trades". A nurse will do a better job doing triage than this overpaid shift workers. Their only job is to prescribe narcs...

I will install a CT on the door of the ER and a secretary to call consults. More efficient and safer and cheaper than the ED "docs"
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# WOWEr 2013-05-07 17:42
It seems funny to me that radiologists are still posting about this article. They won't work past 4pm but can bitch about how important they are and how much Er docs suck at all hours of the night. Wake up rads, you speciality is dying and you have no skills and don't do anything worth being paid for!!!! Have fun mopping the floors of my trauma bay in 5 years.
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# CrazyPete 2013-06-13 12:44
I read the article and the petty posts above and all I can wonder is how after all this education can there be this much stupidity in medicine. I used to complain that medicine was always being ruined by outside parties (insurance companies, attorneys, government, etc), but it's plain and obvious that it is rotting from the inside by catty fighting, rivalry, and neglect of a patient centered model. Damn shame.
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# Paul MD 2013-07-08 10:29
I am a radiology resident working in the ED right now, I just diagnosed a tibial plateau fracture that was missed by the ED docs on their prelim read. Good thing I called them before the patient left the ED
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# radiologistPhil 2013-08-19 17:25
I've been a radiologist for 15 years staffing an incredibly busy ER in a group that provides 24/7/365 interpretation of all modalities. In an inappropriately clumsy and insulting manner, Dr.Mallon raises valid points. Contemporaneous interpretations are a must. It's a shame he picked such a classless way to try to make his points.
As for some o the other ER docs who think radiology is a dying field and we'll be mopping your trauma floor in 5 years, whatever. Hope it some how makes you feel better to think that way. If you're convinced you can read the US better than rads, then take your pictures and document what you did so that it can be reviewed, just like we have to. Our ER docs tried doing their own US and the hospital shut them down because they never documented their work. It was a major liability for the hospital when a suspected ectopic was missed but there were no films to review, just an ER docs "impression" in the chart that the pelvic US was normal.
Fortunately, my group gets along great with the ER because we realize its better patient care for us to play nicely together in the sandbox instead of throwing onto one another.
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