WhiteCoat

Differences in Opinion

There’s a relatively new radiologist on staff at our hospital. He and I just don’t seem to see eye-to-eye.

The radiologists like to do real-time readings of xray studies from the emergency department during business hours. Then the radiology tech brings us a report. I tend to look at most of the radiology studies I order regardless of who reads them or when. Many times I have picked up abnormalities that the radiologists have missed … and vice versa.

The new guy doesn’t seem to like the ED physicians very much. Once he called me and berated me for ordering a CT scan of the lumbar spine to rule out a fracture on a patient instead of just doing an MRI. I told him “Fine, change the order.” He couldn’t change the order, though, because he had waited until the CT scan was completed and after he read the study before calling to “discuss” the matter with me. His preliminary interpretations – which are made part of the medical record – include written statements such as “sinus CTs are never an emergency procedure.”

One report I got this week really got me ticked.

A patient comes in with severe dyspnea. She had trouble finishing her sentences without gasping for air. Her blood pressure was good and her heart rate was a little fast. I ordered labs and a portable chest x-ray. I went and looked at the xray and it was fairly normal. Maybe a little CHF, but otherwise good. The report comes back saying “Limited study. Why did you order a portable exam?”

I grabbed the report and walked over to his lair.

Sooo … I got your report. Just wondering … did you examine the patient?
“Did I examine the patient? No.”
“Did you take a history from her?”
“No.”
“Do you know anything about her condition?”
[Cocking his head to the side as if he is now getting annoyed with me] “She’s short of breath.”
“Anything else?”
“No.”
“Then why would you write something like this on the chart?”
He just looked at me.
“Does the reason for a portable film have any bearing whatsoever on your interpretation of the film?”
“Yes. Portable films are more difficult to interpret.”
“Listen to the question. Does the REASON for a portable versus PA/Upright film have any bearing on the interpretation?”
“No.”
“Then please leave the commentary to yourself. OK?”
He just looked at me.
I have him a half smile. “Thanks.”

Next time, I’m going in there with a Rey Mysterio mask on.

 

 

 

 

21 Responses to “Differences in Opinion”

  1. Anonymous says:

    “include written statements such as ‚Äúsinus CTs are never an emergency procedure.””

    Well is the dude right or wrong?

    “Does the REASON for a portable versus PA/Upright film have any bearing on the interpretation?”

    If you’re doing it to waste time, then why should I bother doing a serious interpretation? So your berating question to the guy was flawed.

    • Guiac says:

      Are you seriously trying to suggest there is not a a reason to obtain portable films rather than a proper PA and lateral?

    • Steve says:

      Assuming this isn’t sarcasm (and I’m not detecting any)…clearly not anyone with ED clinical experience…

    • WhiteCoat says:

      “Is the dude right or wrong?”
      Obviously if I thought he was right, I wouldn’t have posted his inane comment.

      Yeah, I do tests to waste time every day. In fact, I try to set records by keeping all rooms full in the ED with the same patients so I can sign over a full room of patients to the oncoming docs.
      If it weren’t for the darn nurses getting on me about dispositioning a kid with otitis after waiting for 8.5 hours, my plan would come to fruition.
      Mwuuuuuuhahahahahahaha

      Get a clue.

  2. SeaSpray says:

    Must be frustrating. “Lair” and “mask” ..FUNNY. :)

  3. Sarah says:

    I was recently instructed to intubate a near 90 year-old full code septic patient who was improving with IVF and had a respectable gag because the MICU fellow told me to based on an “ABG” that was really a VBG his resident had drawn. The fellow had not actually seen the patient, whereas I had been closely managing him for about two hours. I am all for some doctor/nurse, doctor/doctor debate about patient care–I think it makes us better doctors and I think it improves patient safety. However, when someone who has not seen your patient recurrently tries to manage them, I think they should have to come work in the ED for a shift and see what we’re actually doing.

  4. Just reading this post made me nervous. We, too, have radiologists that hedge on every reading. Absolutely everything. And our next day follow-up nurses (those who place calls and check on patients from the previous day or place follow up calls with culture and “official” x-ray reads) can tell you, with disdain in their eyes, who is the least popular of the radiology groups…the ones very similar to your wiseguy.

    Great post, bud! Right on spot!

  5. Steve says:

    I once had a radiologist tell me “I feel like we got a CT scan on this guy just to get a CT scan”…I’m sorry but I have actually seen the patient, taken a history, and done an exam. Unless you are willing to come out of your lair, see the patient, make a clinical judgement, and write a note on the chart- just read the damn CT.

    I’m all for collaboration and I call the radiologists a lot to get their advice on what is the most optimal study for a patient. In the end I am the one who is making the decisions about the patient’s clinical course- not the radiologist.

    What this guy is doing is not only a waste of time but its also rude and unprofessional- no one should ever make snide comments like that on a read. It will lead to nothing but problems.

  6. B.RAD says:

    With 20 years of experience in the “lair”, I certainly respect the physician’s requests for exams as I’m not there to see the patient and never would put such a stupid statement in the record. However, collaboration is key and I think radiologists have to know what you are looking for. “Just read the damn CT” is crappy attitude as we are all on the same team trying to help patients. Countless times, wrong or incomplete studies are requested, not answering the question at hand all because a lack of communication ( CT scan of breast in a woman with 2 weeks of breast pain). Radiologists are not just film readers and actually have a lot to offer if one asks.

    • Guiac says:

      This is very true – I’ve often asked radiologists regarding the best imaging.

      ONe of the issues is the stupid rule out rule – can’t order a study to rule something out, which is of course why I’m ordering the study, so instead I have to hint about it in a ridiculous round about way to ensure the radiologist knows why I want the study.

    • Steve says:

      Fair enough- I guess I should clarify what I mean by “just read the damn CT”…I agree- collaboration is essential and I welcome any phone call to clarify the clinical picture because from reading my own films I realize how important that is.

      The situation that I run into more often is that I am clinically concerned for a certain disease and I get quizzed by the radiologist over the phone about the clinical picture and whether the scan is necessary. In the case I mentioned I was concerned for a carotid dissection. Had a middle aged guy who had sudden onset neck pain that wasn’t easily explained by a simple musculoskeltal cause. The nature of the pain and the history made me concerned about a dissection and the EM literature says we need a “high index of suspicion” for this disease (although that seems to be the case for just about ANY serious process). On the other end of the phone, the radiologist was quizzing me as to whether he had certain exam findings. This lead to my frustration and my want to tell him to “just read the damn CT” since I was the one who actually saw and examined the patient (and the one ultimately responsible for the patient’s care and workup). Maybe an MRI would have been the test of choice (although my reading of the literature said that a CTA with a latest generation scanner is ok) but that’s not what he was advocating- it was about 2nd guessing my judgement over the phone

      Does that make more sense? I am all for working together but in the end I am the one seeing the patient so if I think a scan is necessary and it will answer my clinical question then I shouldn’t get pushback from the other end of the phone.

      • WhiteCoat says:

        When getting that type of interrogation, just invite the radiologist to come over to examine the patient himself.

        Or, you can ask the radiologist whether the presence/absence of clinical findings he was looking for will exclude the disease you are looking for. If he doesn’t know the literature, then call him out on it.

        If he thinks that physical findings alone will obviate the need for a test, invite him to cancel the test himself. Actually had this happen with a radiologist 10 or so years ago. He refused to authorize a CT of the head during the night and made the patient wait until the CT tech arrived in the morning before getting a CT. Ended up being a SAH and the patient seized and was intubated before being transferred. Fortunately, I documented the chart well. Radiologist and hospital settled for mid-7 figures.

    • WhiteCoat says:

      For the most part, you’re right.
      If there is a CXR done for someone SOB, I think that common sense should dictate what the ordering physician is looking for.
      In more obscure cases, I will write a “R/O” diagnosis on the order.

      I also agree that “Just read the damn CT” is a crappy attitude. Often that attitude stems from a bad attitude on the radiologist’s part. If a radiologist calls up and asks “what type of symptoms are the patient having and what did you find on physical exam” I don’t think that you’d ever get a “just read the CT” response. When you question a diagnosis or make snide comments about why a test was ordered (after reading it and knowing that it shows no pathology), you’re going to get that attitude a lot.

      Your point about giving advice to docs about what tests to order is an important one, too.

  7. joebob says:

    I don’t think we are disputing that radiologists play a valuable role in the care of emergency patients.

    But this guy is basically leaving official documentation in the patient record that stated “the ED doctor does not know what he is doing.” Imagine if the patient suffers a bad outcome. The ambulance chasers would be salivating over the courtroom shouting match they could set up between the EP and the radiologist. And everyone will pay handsomely.

    • MamaOnABudget says:

      This is exactly what I was thinking.

    • Pattie,RN says:

      Exactly my thoughts as well. As a nursing instructor, I stress to my students that the medical record is a tight legal document and like the old “Dragnet”, it is JUST the FACTS, Ma’am!

      Nothing that can’t be seen or verified goes on record, and especially nothing that points fingers, no matter how badly one would like to.

      Heck, I won’t even let my students chart “Patient sleeping” most of the time…all they can SEE is “patient resting quietly in bed with eyes closed, even respirations.” Yea, I’m anal about it, but if I ever saw ANYTHING like “repeat H&H ordered despite third day of normal findings and no signs of bleeding or anemia….”

      Heads would roll.

  8. joebob says:

    I do have to wonder if this lashing out has to do with burnout on the part of that radiologist. I had a brief phase once when I was overworked and frustrated that I wrote things in the chart that in retrospect would probably only be interpreted as being angry at particularly uncooperative patients and did not benefit me at all by writing it in the chart. Perhaps this radiologist needs help from someone.

    That or he’s just an a-hole. In which case you should have a friendly discussion with the head of the rads dept and ask if he/she feels it is appropriate to leave remarks like that in his reports. If that gets you nowhere, bring it to risk management and let them talk to the doc.

  9. KatC says:

    As one of my attendings [gen surg] tells us, ” don’t write any thing in the medical record that you don’t want to see blown up on a screen on display in a courtroom.”

    However, given the above snapshot of Dr. Waffle’s attitude, I imagine he wouldn’t be able to give such appropriate forethought.

  10. Hueydoc says:

    Some of our radiologists are so damn wishy washy on their reports that one day I couldn’t resist repaying them. We had a guy with a knife blade broken off in his thigh, stuck into the bone. On my ER prelim sheet I wrote ” Possible foreign body embedded in leg , but cannot rule out anatomical variant. Recommend clinial correlation , may need further imaging such as MRI or ultrasound. Reccomend follow up xray in 6 months”
    The radiologist popped his cork !

  11. joe says:

    I know I am a bit of a dinosaur, but I miss when radiologists were considered “the doctors doctor” I miss radiology rounds and those quaint X-rays where we would go through scans together. Now I go down there and by and large I get the “who the hell are you” attitude from the younger radiologists. Not the geezers like me, and that is who I confer with. By and large I have lost a lot of respect for the present crop of younger rads. They seem to be in it more for the $$ than anything else.

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