“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Monday, July 16, 2007

Why does radiology have to be difficult?

“When angry, count to four. When very angry, swear.”
~Mark Twain

With orthopaedics being a high volume user of radiology, you would think that they wouldn't give you such a hard time when ordering studies. I understand that I am in an academic center and other services have residents calling for studies without an attending even seeing the patient. But, that is not how I roll. So, today I had to lay the smack down on a attending radiologist. When another service disrespects my residents, it makes me go volcano. So, here's the brief story.

I was minding my own business when 2 dudes ... oh sorry, that's a trauma story. Let me start again.

I am in clinic seeing my usual Monday morning 35 patients. I have a patient come in with a complaint of one foot problem (foot turning in) and we find another problem (probable PFFD). The mom is a poor historian and we have no charts from the outside hospital. On clinical exam, the patient just doesn't look right. He had dysmorphic facies and lower extremity anomalies. Something just wasn't right with this kid. We obtain the x-rays and realize that the other leg, which mom is not complaining about, has no hip. I further questioned the mother about his past medical history without any more information gathered. I thought about it and thought well how do I further evaluate this hip. I could do and MRI, Arthrogram, or an Ultrasound. Probably the least expensive and risky procedure would be an ultrasound. I ordered it and asked my nurse to see if it could be done today. I didn't think it would be such a big deal. Do the ultrasound and send the patient home with follow-up. Yeah, but no such luck.

As I go in and out of rooms, I hear my nurse trying to get things set up. There is some kind of back and forth. Then I hear they want to talk to the doctor. I said, OK; but my resident said he was all over is. I went into the next room. I come out again and my resident and nurse are saying how they don't want to do it because the kid is to old and they won't be able to see anything and yada yada yada. He gave one excuse after another. My resident said well Dr. P would like this done because it would be the most helpful and repeated what I had told him (this was confirmed by 2 others in the room at the time of the conversation). The radiologist said well I don't care what he wants, so forth and so on. (pause) "Oh no he didn't."

So, I walk over to radiology clinic. I walk into the reading area where 2 radiologists are reading films. I can't say everything I said. But, let's say if it was on TV it would have been bleeped out. I chewed him out for being rude to both my nurse and resident and for being a general @ss&*!#. The other radiologist got scatter from the fray as he tried to chime in on the case. I asked the just to do their f#%k!ng job and stop trying to act as if they are actually providing useful patient care. They should do the procedures they are asked to do like good technicians. In the end, I got my point across and the proper test was done.

Radiologists are like shadow merchants offering one expensive procedure after another and waffling on every diagnosis. They are like pathologists who need just one more stain or immunofluorescence to make the waffle diagnosis. Have some balls, make the call, and stop giving those who actually are taking care of the patients such a hard time.

"Anger is never without a reason, but seldom with a good one”
~Benjamin Franklin

PS. I actually have a lot of love for my radiology and pathology colleagues.


Midwife with a Knife said...

I love how you stick up for your residents! :)

Reminds me of the fight I picked in radiology about their refusal to do an abdominal series on a 34 week pregnant woman with a Crohn's disease exacerbation and a suspected bowel obstruction. I kicked ass and took names.

Anonymous said...

both of you are such badasses. you guys are my heros! i can only hope to be a stud doctor like both of you by telling stories about how stupid other people are and how brave and clinically superior i am than everybody else.

Anonymous said...

or titling a post to teach an actual valuable lesson "not everyone will like you" and then describing how someone likes you so much they cry when you enter the room

"...but they will love me." is meant to be the rest of that post.

orthopods always go straight to the radiology reports when something is missed to make sure the radiologist missed it too... preparing to share/deflect the blame. If there is a lawsuit, do they tell the lawyers, though the radiologist also missed it, take it easy on them, they aren't that smart to begin with?

Someonect said...

i guess the benjamin franklin quote was lost on anonymous #1. i will re quote it for you

"Anger is never without a reason, but seldom with a good one”
~Benjamin Franklin

this was a vent for me. it truly happened. it was actually the second time i had it out with this radiologist about taking his anger out on my residents.

Doc Holliday:I'm your huckleberry.~
Johnny Ringo: My fight's not with you, Holliday.
Doc Holliday: I beg to differ, sir. We started a game we never got to finish. "Play for Blood," remember?
Johnny Ringo: Oh that. I was just foolin' about.
Doc Holliday: I wasn't.

and as far as stupid, i don't think i even called them stupid. sometimes misguided, but not stupid. like the time the same radiologist tried to argue about me over a diagnosis of osteosarcoma. a diagnosis that had been made by tissue diagnosis. he reason was that the MRI didn't was still questionable.

anonymous #1, i guess you have never had a superior stick up for you. for that, i am sorry. one important thing is to know your role. i am a bone doc. i know what i know. i ain't trying to prove anything more.

to anonymous #2, well may be i should have titled it differently. it was a true story. just like golf, every once and a while i hit the ball straight. that was a good day. my point was not to pat myself on the back, but to make the statement that you should not do anything so a patient (or person) will like you, because not everyone will. you should treat everyone the same. like i said that day i won. it happened to be my day, i felt like sharing.

as far as radiologists are concerned, i personally don't read the reports of xrays unless there is something questionable. usually the reading comes a day after you have seen the patients. i read every other report (MRI, CT, Bone scan), as well as look at the films,to see it the clinical picture matches the reading. as most readings will end with "clinical correlation needed."

thank you both for your comments and look forward to your next anonymous posts.

MWWAK: i will always stick up for my residents, unless they were obviously at fault. i usually check 1st the facts of the situation and see who may have been at fault. for nursing issues, i have my nurse speak with her colleagues. your "team" needs to know that you are with them and "have their back."

Midwife with a Knife said...

anon1: My beef with radiologists isn't that they're bad docs or anything like that. My beef with them is their tendency to try to keep us from getting important studies done just because a patient is pregnant (particularly when the literature about the safety of radiologic studies in pregnancy comes from their literature). If the radiologist had said something like, "You will get more bang for you buck from a ct scan" that would have been fine with me. Instead the radiologist backed up the techs' refusal to do a clinically indicated study on an ill patient because they were worried about the fetus. The appropriate thing for the radiologist to do would have been to educate his tech and do the study, or to have suggested to me a better way of getting the information.

Anonymous said...

I have to agree with your anonymous dissidents.

Take this quote/suggestion:

"The appropriate thing for the radiologist to do would have been to educate his tech and do the study, or to have suggested to me a better way of getting the information."

Compare it to this action/account from that same suggestor:

"Reminds me of the fight I picked in radiology about their refusal to do an abdominal series on a 34 week pregnant woman with a Crohn's disease exacerbation and a suspected bowel obstruction. I kicked ass and took names."

I have no idea what the incidence of those types of x-ray orders are at your hospital. Personally, I would have to look up what to do in that case. Similarly, I am not an authority on all the literature that comes out of my field - even if it affects other fields. Further, I have no idea how many inappropriate studies have been ordered and performed in your institution. You radiologist might have though and allowed a gut reaction or reliance on past patterns to guide the decision. The radiologist could have had deceitful motives for all I know and needed to be kicked and have his or her name taken. When you compare those two quotes though, it seems that the radiologist might have been held to a higher standard than OB.

Last, the reference to further anonymous posts was a bit passive aggressive. Obviously, myself included, people feel protected to make different comments under the veil of anonymity. A lot can and is said of the people willing to put their names and reputations on things they say and write. Argue as I am sure you will, but that comment about anonymous posts seemed like an unnecessary backhanded slap to those who utilize the anonymous post option that the moderator provides. No such quip has followed a supportive comment.

Last, the comment about the title of the previous post was dead on. I have enjoyed many of your entries. I think you have been overly criticized for your take on the next generation of physicians, but that one was a bit self-rewarding. Oh, well.

Thank you for allowing me to anonymously read and comment. But, Dice-K is on the hill, and I am off to other endeavors.

Someonect said...
This comment has been removed by the author.
Someonect said...

well i apologize for poking fun back at someone for posting anonymously after they had just posted a backhanded/sarcastic "badass comment" about my post and MWWAK's comment. i guess the point was lost by actually trying to tell a story (true) about actually sticking up for my resident. this is not about being badass. in ortho, we have battles back and forth with radiology and ER about different things. i posted previously on SDN how a ER attending called me to get a resident in trouble for not seeing a patient for a radiologic reading of a coccyx fracture. i reamed that attending out too. have i done that to one of my residents, not so much; to the nurses, nope. it is level to level. "I'm your huckleberry."

as far as my "not everyone will like you" post, it is not about self-rewarding. not a ooohhh look at me kinda post. i am not that kinda guy. i am thankful for praise, but i do not think i am special. when someone says something nice, you say thank you and move on. the not everyone will like you title was not for the story of the boy i treated, but it was for the point that we should do things so your patients will like you, because not everyone will. having someone say something nice is like hitting the ball straight once and a while playing golf. just hitting the ball well a few time swill keep you coming back. i, try my best to, treat everyone the same. in my practice, most are thankful, many expect it, but few actually express it that way. this was a good day and i thought i would share. maybe i should go and change the title of the post. it surprises me that people have such a problem with that post.

(this statement is truly not trying to be backhanded or sarcastic)i am sorry that i posted something about real hospital dynamics and how you team including your attending should have the back of everyone on the team (i will delete my post on the ED, i am sure that will upset folks, just jokes). i will also stay away from anything that makes it seem like i am a good person or physician, or even that i do a good job. i thought i would share something more personal than most of my posts and a little off previous topics.

Anonymous said...

Come on now. If you read Dr. P's comments, one of the overarching themes is humility (which is why I try to keep up reading from time to time). It is a precious commodity in many medical and surgical circles, so please try to appreciate it when it truly exists. Nothing would make me, as an intern, feel more proud about my position on the team than having an attending take an, "I'm your Huckleberry" attitude towards some jackass that was abusing their authority.

Thank you from your residents and nurses. My guess is that it is very difficult for an attending physician to identify when utilizing such a tactic is the appropriate method, best of luck in continuing to do so.

Someonect said...

thank you md007

MSHN said...

I've thought about what I'd do someday when I was an actual doctor and someone was disrespectful to a nurse or fellow doctor I respected. I'd hope that I would stand up for them like you did.

Someonect said...

cstew: although i still believe in standing up for my "team", i have learned to be less caustic in my approach. maturation is a wonderful thing :).

Anonymous said...

As a radiologist, I can say that it was very unlikely you got any useful information from the ultrasound of the hip.

Also, it is faster and more lucrative to just do exams as ordered. We take the time to confer and re-direct studies as necessary out of concern for the patient and not our pocket books.