Clinical Histories in Radiology: Could They Get Worse?

Sometimes, one needs a smidge of comic relief. I have referenced one way for radiologists to get (or give) it in this blog: sharing crummy clinical histories we receive for imaging studies. After scrubbing identifying information, more than a few rads post the nonsense they encounter onto social media.

Most don't bother sharing the same-old, same-old. Commonplace not-reasons for exam like "R/O pain" and "eval" are the conversational equivalent of pocket lint. For good or ill, a typical day's work provides plenty of other, more exotic stuff from our "garbage in" pile.

Sometimes the postings are fertile ground for entertaining replies. For instance, someone recently groused about a scan he had gotten to "R/O befoer [sic] discharge." It was a worthy gripe. What was he supposed to be ruling out before the patient got to go home?

Any given rad's perspective on the situation relates to how long she or he has been in the field. A resident still in training might react in outraged disbelief. I went through all that schooling to do this, people's health care is on the line, and we've just thrown in the towel on getting reasonable clinical histories? Folks a decade or three out of fellowship, like me, tend to settle into a grim acceptance that this is just how things are if they don't opt for humor.

Those with sufficient experience know, however, that isn't entirely correct. This isn't just how things are. The quality of clinical history has deteriorated and will continue to do so. I am old enough to remember when a far greater percentage of clinical histories were reasonable ones because physicians expected better (of themselves and one another). From my perspective, things are on a long-term, gradual downhill slope.

It's not just me. Rads 10-20 years my senior, having seen medicine when it was even more professional than on my first day in the field, probably consider things further gone than I do. Those fresh out of training right now have today's state of affairs as their baseline, and no way to know that our field was ever any better unless they listen to (and believe) the complaints of older codgers.

This doesn't just go for radiology, or even medicine in particular. Everything slides towards entropy if sufficient mechanisms aren't in place to prevent it. If you live long enough, you probably regard certain aspects of civilization as completely broken compared to what you recall as the Golden Age of your youth.

Is there any more ground to be lost here? Sure, we still get some decent clinical histories but if trends continue, they will become vanishingly rare. Would that be rock bottom?

"Rock bottom" might not exist in this regard. Talking to the "everything's ruined" elder statesmen, one hears a common refrain: They never imagined things would deteriorate below point X. It seemed inevitable that common sense or collective societal sanity would have provided some sort of safety net but, somehow, that didn't turn out to be the case.

Let us assume I can't imagine just how bad clinical histories will ultimately get. The next best thing I can do is think up the most absurdly bad endpoint, continuing the trend from good clinical histories of yore through non-existent ones of the near future. What could come after that?

Could the day arrive when referrers have so little respect for the system and such absent fear of consequence that they start providing intentionally bad or wrong histories? Could it degenerate down to the equivalent of prank calls or the clerical equivalent of flipping off the rads?

My imagination ran wild with the idea, and I started getting chuckles from lousy clinical histories that haven't even happened yet. (I was on an airplane with nothing else to think about, okay?) I thought I might share some dystopian future clinical histories here.

"Scan this patient because I said so, and if you hassle me about it , I will make things unpleasant for you."

"Patient has radiation deficiency. Please correct this."

"Do the imaging study. All the clinical information is available in the patient's chart. I'm not spoon feeding it to you."

"My patient has too many vague complaints I can't do anything about. Perform whatever imaging you want so I can look like I'm still trying."

"Patient insists she has an allergy to iodine. I told her that's not possible but she insists. Give full dose of contrast without pre-medication so she understands who's the doctor here."

"I hear radiologists give kickbacks to their best referrers. Image these 100 patients sometime this month so I can be one of your VIPs."

"The doctor told me to order a scan, but I'm just a clerk and have no idea what to write here. Please don't get me in trouble."

"Patient has phantom limb pain below AKA. Scan area below the stump to humor him."

"Evacuation proctography needs to be performed this week. There is no clinical reason, I just don't like the rad who's on fluoro."

"Pan scan for patient who says she has cancer. STAT read as is. Priors coming in out of state, but you can reinterpret the whole thing and make an addendum when those arrive. Who's your daddy?"