Questioning 'Obvious' Notations from Prelim Readers

A decent chunk of my daily radiological workload comes with “prelim” interpretations. Sometimes they come from residents. Some of them come from other health-care personnel. I don’t know that I would be able to identify the source for any particular case. It is not readily apparent. Maybe this is by design but there is a lot to be said for double-blinding in quality assurance (QA). Without knowing, I tend to assume it is coming from a resident rad but that is pure instinct.

After the most important aspect of prelim reads (identifying when there is a difference of opinion and communicating it to the clinicians), it seems to me the second priority is for the prelim reader to get feedback about when he or she has done well, or when the prelim reader has something to learn.

I don’t expect the prelim folks to always be enthusiastic about it. Given the usual structure of QA systems, I wouldn’t be surprised if the majority of participants preferred to opt out of it. One can’t be thrilled with the constant lurking threat of peers or superiors reaching out to say “Hey, you screwed up.”

Still, I perceive the whole prelim/final interplay to be mutually beneficial, a kind of professional handshake. The prelim reader gets to do a cursory read, learn stuff, and potentially have errors caught/corrected by someone else, and the final reader gets an extra set of eyes reviewing things while not having to work 24/7/365.

As a final reader guy, I therefore consider it my part of the bargain to provide whatever value I can, sometimes communicating stuff to the prelim readers beyond the mere (in)accuracy of their reads. This may be in the form of pointers or interesting tidbits. I do concede though that sometimes my days are so hectic that I don’t communicate as much as I would like to.

A recent case in point has prompted me to share my advice with my readers since I never caught up with the prelim reader who inspired it. There was a random emergency room (ER) or urgent care X-ray of an extremity. The prelim reader noted “No obvious fracture.”

I didn’t see one either and moved on. However, something about that prelim stuck in my mind. After a little while, I put my finger on it: Hey, prelim person, is that the limit of your value? You’re only willing to say there is nothing obvious on the images?

The study was good quality. There wasn’t any diagnostic limitation. Indeed, it was a simple three-view X-ray, not advanced imaging of any kind. I know folks can say stuff like “No gross pathology” if they want to underscore that they’re not getting the best view of things.

Could it be that the prelim reader wanted to emphasize that the final read guy has greater skills/experience to the point where there is subsequent appreciation of subtle pathology the prelim reader isn’t equipped to identify? Recognizing one’s own limitations is a good thing, and people like a reasonable dose of humility.

Let’s go with that notion for a moment: I still have issues with throwing in that “obvious.” What do you suppose it says to everyone else involved? As the final read guy, it puts the notion in my mind that maybe the prelim readers didn’t look too carefully. Maybe the referring clinician gets the same impression or, if the referrer wrote the prelim him- or herself, everyone else involved in the patient’s care gets that impression about the care that was rendered.

What if the patient got a look at the prelim? If you went to an ER because you thought your leg might be broken and the person responsible for treating you, someone you trusted to be an experienced professional, shrugged, and said you had no “obvious” injury, would that reassure you or would you feel like your case was casually dismissed?

I hear “obvious” applied to a fracture, and I think of something that doesn’t take a radiologist, physician, or other health-care individual to identify it. Google images for “fracture” and most of the pix you see will be things that a grade-schooler could look at and say, “That’s broken.”

I think we can hold ourselves to a higher standard than that—and this includes residents, physician assistants (PAs), and even medical students. If you are in a position to be rendering even preliminary interpretations, you’ve accomplished enough in life that you don’t need to be hedging by saying you’re only liable to find “obvious” stuff. Your opinion is worth more than that.

Alternatively, if you believe you can or should only be on the hook for seeing “obvious” abnormalities, you probably shouldn’t be rendering even preliminary interpretations.

Besides, when you do inevitably miss something, nobody’s going to consider your error any more forgivable because you used hedging terms like “obvious” or “gross.”

One other thought struck me with the “obvious” prelim comment. Some folks get so accustomed to throwing around words like that, it becomes a thoughtless reflex. It stops meaning anything to them, but others still hear it.

Possibly my best preceptor from medical school, a guy I have referenced in this column before, regularly corrected or otherwise commented on the verbiage of his house staff and students. H would tell interesting stories of word origins, and even address grammar and pronunciation. One of his enduring lessons was words matter, if not to you, then at least to your audience.

One of the interns on my rotation with that preceptor routinely used “basically.” Any time he was presenting a patient or giving an update on developments since previous rounds, he would launch with that word. He made it surprisingly far into the first week of that month before the preceptor called him on it. “You use that word a lot,” he observed. “Does it add anything to what you’re saying? It seems more like a nervous habit. You’re not simplifying anything for our benefit, are you?”

Of course, he wasn’t and knocked it off almost immediately. Darned if he did not immediately sound more professional and confident in his presentations.