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Navigating the VIPs and Addendum Grubbers in Radiology
Emphasizing that forewarned is forearmed, this author discusses his approach to handling egotistical referring docs and extraneous addendum requests.
Very early in my radiological career, even before completing residency, I saw that some referring clinicians got treated differently than others. The most blatant example was a “VIP.” A case bearing such letters might be prioritized for reading, be earmarked for certain well-regarded subspecialists, or inspire reading rads to be on their absolute best behavior.
The reasons why weren’t hard to understand. A VIP might refer lots of patients, have a rep for being demanding, be close pals with top muckety-mucks in the department or hospital itself, etc. What it all boiled down to was that the VIP had to be kept happy, even if everyone in the rad department had to contort themselves and divert efforts from other referrers.
Understanding and compliance with such things don’t wipe out one’s underlying distaste for them. Especially as a newbie to the field with intact ideals, I didn’t think medicine should have any room for favoritism. Referrers and the patients sent by them should be treated equally.
Fast forward a couple of decades, and my attitude has changed a little. I still don’t believe in rolling the red carpet out for Dr. Bigdeal’s patients at the expense of Dr. Noname’s patients, but I have come to appreciate the mechanism by which stuff like “VIP” is communicated. In other words, I think it is valuable for anybody dealing with a case (rad, tech, or ancillary staff) to be forewarned when they are about to deal with particular personality types or other situational quirks.
A VIP, for instance, might get absolutely zero extra official accommodation but I am about to deal with one (or someone who thinks he or she is), it might be good for me to have warning that a towering ego is about to cross my path. I could opt to walk on some eggshells around him or her. This is not because the VIP is deserving. I would just rather save myself time and trouble by not setting him or her off.
I have imagined flags in the RIS, similar to alerts for patient allergies or immunocompromise, which would give us a “heads up” upon opening a case. Some of it could be for personality issues like the VIP or an addendum grubber (AG) (discussed below), but other aspects could be more clinical. For instance, I might tailor my report on a shoulder CT a little differently if I see a flag saying that the referrer is “ORTHO” rather than “ER.”
The inspiration for today’s column is courtesy of a flag I believe many of us would find useful: the aforementioned AG. Rads reading this with more than a few years’ experience in the field probably need no further explanation.
For the rest of you, diagnostic radiologists have a certain lather, rinse, repeat cadence to our workday. Much of our workflow consists of opening imaging studies, reviewing their images, creating reports of our interpretations, and then signing those reports when we are ready to move on to the next one. At that point, the reports are “final” finished products.
Sometimes, we subsequently have to add or correct something. Maybe we had another thought after the fact, or a previous imaging study turned up that needs to be compared against the current one. Whatever the case, we can’t alter the signed report. Instead, we have to make an “addendum” to it. This can happen any number of times.
Rads tend to be less than thrilled about having to make addenda for various reasons, one of which being that there is no mechanism for compensating the extra work that is being done. Imagine your mechanic’s reaction if you brought him or her your car and the mechanic did what you asked for, but then you told him or her that you wanted something else done and didn’t expect to pay an extra cent.
A lot of addenda are done at the request of referring clinicians, often with fair reasons. Perhaps the report says the patient had pain on the left side, but it was actually on the right. The report says the gallbladder is normal, but it was actually removed 20 years ago. The report doesn’t mention comparing against previous scans but there are several available for that purpose. There is no disincentive to stop a referrer from asking for as many addenda as he sees fit.
Most don’t abuse the privilege but some do, and I have come to think of them as addendum grubbers (or AGs for short). Some don’t seem capable of accepting any reports as initially rendered and get locally infamous by constantly demanding more.
Recalling a good example from a job I had a few years back, Dr. AG always wanted an addendum about what kind of follow-up the rad was recommending even when the rad’s report was stone-cold normal, containing absolutely nothing to follow. The first few times his requests got relayed to me, I was baffled. Who the heck needs this much hand holding?
Eventually, one of the ancillary staff advised me of the extent of Dr. AG’s notoriety. Every rad got the same nonsense from him, I shouldn’t feel singled out, and I should definitely never expect him to change. Once I knew this about him and was able to keep an eye out for his name, I started putting something like “no findings prompt any recommendation for further action from an imaging perspective” at the end of reports for him.
Not all who grub for addenda are so benign and sympathetic. Part of this sub-population seems to be of a petty, passive-aggressive mindset. They derive some sort of neurotic satisfaction from fault finding and/or making others jump through hoops. Their requests stand out in that none of them serve a discernable purpose other than interrupting another professional’s work and maybe taking him or her down a microscopic peg.
Forewarned is forearmed. Seeing an AG tag on a case wouldn’t make me jump for joy at receiving it, but at least I would know what I was dealing with, and maybe take an extra moment or three in fine-tuning my report. Let the grubber have no easy excuses with which to waste my time.
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