We’d better care if it’s right or wrong

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That first warm and sunny day suggesting that winter is probably behind us is an invitation for the populace to go a little crazy. A lot of people just seem to thaw out and celebrate by riding the motorcycles a little too fast, getting into fights, falling off cliffs and flying out of cars---in general, getting a little too frisky.

If you happen to be the radiologist on ER coverage, you know what I’m talking about. You know you are going to get slammed on a day like this.

And I did, just the other day.

Our section has three CT scanners for emergency patients, and the rapid flow of studies we experienced that day could easily overwhelm any radiologist. I personally go into “survival mode” at times like this: I abandon my nice, organized approach to reviewing cases for a more rapid-fire, total image sweep, praying that my experience at spotting pathology can function in auto mode and pick up the important stuff. For the most part, I’m happy to report, history indicates this to be the case. Nevertheless, anyone interpreting studies this way should be uncomfortable, a bit anxious, and even somewhat panicky, no matter how many decades of training and experience may be in the rear view mirror.

And I was.

In the midst of this chaos, while my resident and I were trying to keep up with the parade of patients arriving for their obligatory whole- body CT scans, about 40 electronic studies, primarily CTs, arrived with a patient transferred from another hospital—a rather common event at our institution. Our section radiologist ordinarily reviews and dictates such studies to provide a second opinion, but these definitely needed to go on the back burner for the time being.

About an hour later, a visibly annoyed nurse came to the reading room wondering why the studies were not yet dictated. I could have chosen any number of potential responses, mostly of the four-letter-word variety. However, I maintained decorum and explained that I would get to the patient at some point, but acute admission studies were my priority. I also reminded her that the patient had radiologist-interpreted studies from a reputable institution, and that she would have to wait unless her patient was dying (which she wasn’t). Not surprisingly, the nurse went off in a huff.

A few minutes later, my favorite covering surgeon from trauma bopped over, presumably to check out the reason for the nurse’s dismay, or just to be sure I was not freaking out. In all likelihood, both.

“Having fun?” he asked in what seemed to me to be a concerned but friendly tone.

I replied that I felt as if I were being bodily assaulted (I actually spoke a bit more graphically). I also shared my concern about missing sig- nificant findings while reading at such a hectic rate.

Keeping his tone light, the surgeon responded, “It doesn’t matter to the surgeons if the reports are right or wrong. We just need something to write down.”

Distracted by the rush of studies coming my way, I simply chuckled at my colleague’s comment. Apparently assured that I had not be- come more of a lunatic than usual, he then returned to his own lair to await more patients with which to bury me deeper.

It was only later that evening that I finally had the chance to reflect on our conversation. What exactly did the surgeon mean by that com- ment—that it doesn’t matter if the reports are right or wrong; that “we just need something to write down”?

Please understand: This surgeon is a guy who does not waste words. Virtually everything he says usually conveys meaning. So just how was I to interpret his statements? Did he mean not to worry because all those extra eyes on the trauma team would spot any significant mistakes?

Radiologists certainly do make mistakes occasionally, and I am happy to have them pointed out or discussed for a subsequent amended (corrected) report, especially with regard to potentially relevant misses. We radiologists want—and expect—our imaging studies and re- ports to be reviewed by the team MDs. The mistakes are usually minor, but it’s realistic to expect them, especially given the circumstances of initial interpretation.

But what if the surgeon’s comment was not meant to be reassuring or altruistic, but just self-serving, instead? What if he meant that surgeons need a radiology report on the chart to defend their own clinical decisions or to provide a reason for being misled by an incorrect official radiologist report, which then becomes the primary cause of a medical error?

It’s not like this concept has never occurred to me—but I don’t believe I actually heard it expressed to me this way by a senior colleague. During my long career, I have consulted in many malpractice cases, mostly on behalf of the defending physician, but also occasionally for the plaintiff. In my experience, whenever a radiological interpretation issue is involved, the nonradiologist physician acts as though he or she has never seen an imaging study, would never interpret one, and would always defer to the expert radiologist’s opinion with respect to making any clinical decision.

In other words, they’re saying, “The radiologist is who you are really looking for.”

No doubt some experienced nonradiologists do a great job interpreting images common to their specialties. After all, they get to have the patient’s clinical information and images together right there in front of them. Other physicians, however, rely heavily on the radiologist’s report to guide them.

And the notion that it’s fine for the official radiologist’s report to be right or wrong, so long as there is “something written down” is anathema. All physicians tasked with caring for a patient should strive to do everything they can to help generate an accurate diagnosis, including providing signs and symptoms, asking specific questions, reviewing the studies, double-checking accuracy of interpretations, and discussing complex cases with the radiologist.

As radiologists, if our principal product is to provide referring physicians with cover from malpractice claims and indifference to interpretation accuracy, we all detract from patient care as well as from the integrity of our profession.

If you ask me, that’s getting slammed.

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Mirvis SE.  We’d better care if it’s right or wrong.  Appl Radiol.  2016;45(4):6-8.

By Stuart E. Mirvis, MD, FACR| April 04, 2016

About the Author

Stuart E. Mirvis, MD, FACR

Stuart E. Mirvis, MD, FACR

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

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