The Dos and Don'ts of Dealing with Referring Physicians

CHICAGO - Referring physicians have simple needs. All they really want is for you to read their minds, deliver exactly what they desire, and pinpoint what's wrong with the patient every time. Oh, and if you can stop the MRI from making so much noise and freaking out the patients, that would be awesome.

Don't panic. Your referring docs know that's impossible. But there are things you can do to keep them happy - and other things you can avoid to keep them from going nuts. The referring docs shared their dos and don'ts at RSNA 2012 this week.

Do give them all the relevant information.

You're the imaging expert, and the physicians wants your input. "A description of the findings with a differential diagnosis does help me," said Sally Reynolds, MD, medical director of the emergency department at the Ann and Robert Lurie Children’s Hospital of Chicago.

Incidental findings are also important, said Stephan Wyers, MD, assistant professor of surgery at the University of Chicago. "If there are incidental findings, which are increasingly picked up as imaging gets better and better, and those incidental findings require action, that needs to be in the summary at the very bottom of the report."

Don’t go overboard.

"The busy internist has 12 minutes to see a patient," said Mary Mahoney, MD, director of breast imaging at the University of Cincinnati Medical Center. "They can't spend 20 minutes to read the radiology reports. And don't be pixel catalogers. We don't need to prove that we've looked at every single corner and speck on the image and cataloged every pixel that's there."

Reynolds agreed. She likes differential diagnoses, but "a differential that's 72 things long isn't going to help me."

Do share your expertise on radiation.

"It would be helpful to get some sense in a layman's term: How much radiation is that really?" Reynolds said. "A radiologist a long time ago told me a chest X-ray is the same amount of radiation that you get flying from Chicago to Denver round trip." More of that, please.

Also share your expertise on contrast.

"This issue of 'do we need contrast or not' is a one for primary care doctors," said Jeffrey Kopin, MD, medical director of the Northwestern Memorial Physicians Group. "Anything you can do to help your docs know whether to do that or not would be very, very helpful."

Don’t share your expertise on things you don't actually know about.

"I don't have a problem with people telling patients what they see on an X-ray," Reynolds said. "The trick to this is don't tell them what's going to happen next. Sometimes you don't know what's going to happen next. We've had radiologists say 'The orthopedic surgeon will come see you.'
We have a list of things that I do and a list of things that the orthopedic surgeon does. The list of things I do is pretty long, and they don't come see everybody with a fracture."

Do use structured reports and standardized language.

"I like reports to be structured. It gives me the sense that the radiologist has a checklist and they've looked at everything," Wyers said. "That makes it easy to go back and find specifics."

Don’t use terms they can't act on.

"What does peribronchial cuffing mean?" Reynolds asked. "I don't know. I always look at that and say 'Jeez, I shouldn't have ordered that chest X-ray; I'll never be able to explain this to the patients.'"

Do embrace technology.

"I think it's the best thing that's ever happened to medicine," Kopin said. "We need to leverage the technology that we have. It's happened so fact that we haven't had a change to properly digest it, and we haven't had a way to properly acculturate all this technology into our patient care that truly benefits our patients while making our lives as the physicians that much easier and that much more fulfilling."

Don’t let things fall through the cracks.

"There's nothing like a physical inbox to remind you to check that final report, so significant pathology that really wasn't integral to the acute problem is addressed later," Wyers said. "We need to find a way to push important information in a timely fashion. ... There is an inbox on our EMR but I don't think the radiologists use it, and not even all the clinicians have adopted it."

Do remember that everyone loves a phone call.

"If you page a primary care doctor and you say 'I need to talk to you about Mrs. Jones' CT scan', I'll have to pull myself off the floor because I'll be so surprised and delights that somebody wants to actually talk to me directly from radiology," Kopin said. "That's a game changer to do that."

Don’t make it difficult to get in touch with you.

"If you're part of a big radiology group and people rotate through various parts of the group, publish telephone numbers for referring physicians," Kopin said. 'And if you can publish your schedule ... if you share it with your referring physicians, you're going to be amazed at how efficient it's going to make you and how happy you're going to make your referring doctors. If you make it easy, you're going to be the radiology group that everyone is going to want to send their patients to."

Do push for universal imaging standards.

"If I could do one thing, I would make all the imaging be the same so I can actually open all those crazy discs," Reynolds said. "If I have an intubated trauma kid, and I have a disc with a head CT on it, I really need to look at that right now."

Don’t ever use this one phrase in your reports.

"Please banish this sentence from every report: Clinical correlation recommended," Wyers said. "It would be as if I came to you and said 'Please look at the images before you prepare your report.'"