Summary: All of us take our jobs seriously, and we all can appreciate and
understand the concept of getting a “critical” finding to a responsible
clinician. Well, the critical finding part is serious. The concept is
serious. The actual delivery of the critical finding is another matter,
as is the actual criticality of the finding.
Dr. Phillips is a Professor of Radiology, Director
of Head and Neck Imaging, at Weill Medical College of Cornell
University, New York–Presbyterian Hospital, New York, NY. He is a member
of the Applied Radiology Editorial Advisory Board.
All of us take our jobs seriously, and we all can appreciate and
understand the concept of getting a “critical” finding to a responsible
clinician. Well, the critical finding part is serious. The concept is
serious. The actual delivery of the critical finding is another matter,
as is the actual criticality of the finding.
How many have called
the responsible clinician to find that they are out of town/dead/out of
the country/not taking calls/no longer seeing that patient/unsure of who
you are referring to/etc., and not been given a forwarding number/new
responsible person/word of encouragement/etc.? I have. And how many have
stat delivered an incidentaloma? Or wrenched yourself into knots for a
modestly bogus stat request?This leads me to today’s little chat, which
began as a Freudian slip by a resident. I loved it. We had looked at a
normal outpatient exam, lumbar spine, which was scheduled (don’t you
just love the modern data trail?) 2 weeks earlier, with the request
“stat read please.” The words from the resident were, and I quote, “Do you want me to call the cynical results to the clinician?” Ha! Critical finding? Nope, cynical finding. Let’s deliver this hot piece of info.
These are typical cynical findings. In each case, request reads: “Please call report ASAP.”
Normal
exam, incidental finding in a patient who, it turns out, has other and
more pressing problems. You call the listed 4 numbers. You finally reach
a colleague of the physician who gives you their private cell number,
which they don’t answer, but at least you leave a voice mail with the
cynical finding: “Mrs. Pfarr’s scan is normal. There is an incidental
finding, which you can call me about, and we can discuss. I’m following
protocol for the cynical finding.”
Minimal spine
abnormality in a patient who was in a tennis outfit in the waiting room,
and who left immediately, bounding out of the imaging center to their
sports car and off to the club. Your fourth call gets an operational
voice mail service: “Mr. Throckmorton has a small disk bulge at L4-5. I
tried to stop him and give him the results, but he’s quick, and he
outran me to his car, and I couldn’t follow him to the tennis club. I’m
just following protocol for the cynical finding.”
Cynical
incidentalomas on an ED patient are the most problematic, for different
reasons. Whatever the incidentaloma is, it MUST be explained away prior
to the patient being discharged from the ED. Trauma. No significant
findings. But in calling in the cynical finding,you can literally feel
yourself teeing up the “emergent—ASAP” follow up exam. “The exam is
normal. There is a small skull lesion, likely a dermoid, which I’m so
sure you’ll want an MR to correlate that I’ve already sent the patient
to MR. I’ll call you with the cynical finding on THAT examination when
the MR is complete. Please put in a request for the MR please, and don’t
forget to write ASAP on it.”
Keep on plugging, folks. Mahalo.