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Navigating the Ebbs and Flows of Radiology Protocols
While standard approaches to imaging may be elusive amid shifting protocols from different facilities and different specialties, there is a balancing act of flexible accommodation and pushing back against unreasonable requests.
I mentally carry a collection of “teaching moments” from my med school and residency days. Some are of actual clinical value, others are philosophical, and some are just plain funny.
Within the second category, one of my best mentors spoke about temporarily “knowing” things as a science-related individual. Notwithstanding recent abuse of the phrase, there is rarely such a thing as “settled science.” There may be consensus but as time goes on, it is common for further research or new discoveries to reveal that what was previously “known” is, in fact, wrong. (Woody Allen fans might be reminded of Sleeper’s jest about smoking being proven healthy in the future.)
The attending doc, in the later portion of his internal medicine career, estimated that the half-life of medical information was about 20 years. That is, after a couple decades’ work as a physician, it was his experience that 50 percent of things he had been taught as facts, things he thought he had known, turned out to be wrong or, at least, rendered uncertain. He mused that, since a doc working 40 years might be down to 25 percent true knowledge, it was probably a good thing that most would be retiring by then.
At the time, I had only been in the medical field for a few years, even if counting from my first day of med school. I had already gotten to see some examples of expiring “facts.” Soon after, I would see it even more, especially with protocols.
As a med student, even if you are not downright hungry for knowledge, you know you had better gain it if you want to progress and be competent in the field. Stuff gets presented to you, whether from it is from instructors or textbooks, and you do your best to absorb it. It is most efficient and reassuring to consider it all gospel truth facts. Otherwise, your mind gets filled with “could be this, could be that” notions about everything, which won’t fly well on your exams.
When you start learning protocols that other accomplished people have developed based on those hard and fast facts, it makes sense to consider the protocols pretty factual as well. Although CPR and ALCS do change over time, at any one point there is a right way to do them, and if you deviate without a very good reason, you are in the wrong.
Moving on into hospital life, you start encountering more protocols, both in your own specialty, and elsewhere. That includes “house rules,” things that you had better be doing in Hospital A but would be a violation in Hospital B on account of the facility’s own different protocols. Whatever illusions the student/resident might have had about protocols being factual are thus shattered.
I think the first time I recognized this was with cancer-staging schemes. Initially, I learned and abided by the “TNM” protocol. It was what was taught to me, it made sense, and it seemed applicable to most stuff I could think of. However, I was soon being bombarded by other approaches from different subspecialties, and they each wanted you to do things their way. I pretty much threw my hands up in the air when I saw that, on occasion, subspecialties would even change their own staging rules. You could be carefully abiding by how they did things last year, but then they wanted you to learn and adhere to a whole new rulebook without a clear justification.
Under those circumstances, at least there was supposedly some science underlying the protocol shift. Working in hospitals showed me that there didn’t even need to be such rigorous justification. If other personnel with enough clout wanted to do things their own way, it didn’t matter what protocols were being broken. They could make it happen.
Radiologists will be familiar with this. Our department protocol says that indication X should be investigated with imaging Y. However, a doc in surgery or the ER acts angry or loud enough, insists on Z, and gets his or her way. That can mean inappropriately using (or withholding) contrast, calling in the MR tech in the middle of the night for what should have been a non-emergent case, or skipping a pre-medication protocol in a patient who is known to have bad allergies.
One of the nice things about going into telerad is that I removed myself from such situations. Settle your issues with imaging protocols however you like with the people onsite. I will just get the pictures and render a report for them. If you have read my other blogs, you know that I didn’t always feel this way, but I have adapted to my reality and learned to appreciate it.
That doesn’t mean I got out of the protocol world entirely. Although I no longer have the displeasure of trying to enforce my own protocols, I still get to abide by the protocols of others. You want this routine study to be a “stat?” Fine, I will read it before the one that just got sent from the ER. You need me to include contrast dosage in my reports? This is simple enough for me to do although if you give me a way to automate it, that will help.
There is, however, a limit to how much rads are willing (or able) to accommodate. I remember, for instance, hearing about a famous cancer-care network requiring all of its rads to routinely name and measure every single lymph node on every study, normal or otherwise. If true, that would be the network’s prerogative, and presumably whatever rads chose to work there would abide. I, and many rads like me, would go insane trying to do that, and thus self-select to work elsewhere.
More than once in a blue moon, that kind of thing tries to creep into other workplaces. A study turns up with a clinical history saying, “measure every lesion in three dimensions and compare with prior,” for instance, and there are a gazillion lesions on the study.
In another recent example, a rad commented in a social media group that he had received a lumbar MR with referrer instructions to include a level-by-level laundry list of all sorts of details, normal or otherwise, including tedious (and irrelevant) measurements.
The rad and many responders all had the same opinion: “Not going to do it.” I am sure whoever actually bit the bullet and refused in real life would be hearing about it from the referrer’s office: “But that’s our protocol!”
There is a bittersweet thing about seeing your own specialty’s protocols steamrolled over many years: You get familiar with the precedent, and eventually comfortable cutting with that blade’s other edge. Of course, you don’t do it too blatantly. Rock the boat enough and eventually you will find yourself unpleasantly wet. I consider it one of our “non-clinical skills:” finessing such situations so as not to roll over for every unreasonable demand, yet not forcing a consequential power struggle.
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February 11th 2022Richard Duszak, MD, and Mina Makary, MD, discuss a number of issues, ranging from demographic trends and NPRPs to physician burnout and medical student recruitment, that figure to impact the radiology workforce now and in the near future.
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