Is That Really Your Final Answer?

Being aware of some of the factors feeding into how, when and why a radiology report might be “Preliminary” instead of “Final” was all well and good. My more immediate concern, entering telerad and on the verge of furnishing both types, was what needed to actually be in the darned things.

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“Finals,” of course, were no mystery - I had been generating those ever since I had completed fellowship. Unsurprisingly, that had been precisely when my “Prelim”-generating career had ended (or, as things were working out, gone on hiatus). Especially now that I was about to dictate a nightly mix of the two varieties, it seemed I had better know what was allowable not to put into a “Prelim.”

In the abstract, this doesn’t seem too much of a philosophical toughie - stuff that makes an on-the-spot difference (such as whether a patient will get admitted, anticoagulated, surgerized, etc.) should be in the “Prelim”. A bone island or a lung granuloma, stable for 10 years, not so much.

But then come the case-by-case specifics. Not going to mention the circumaortic left renal vein in your “Prelim”? How do you know the patient won’t wind up getting an IVC filter before the morning? That extra vein could be relevant to such a procedure. Is a noncalcified 1 mm pulmonary nodule safe to not mention? What if the patient gets discharged before the “Final” report is rendered, and nobody ever tells him he needs to get it followed?

Fortunately, I didn’t need to ponder these matters on my own - the telerad world was already populated by plenty of folks who had been playing this game for years. So, while being interviewed by a Medical Director for a telerad group, I asked what their official rule was. He hemmed and hawed…for they didn’t have one. Yes, they were paying X percent less for a “Prelim” than a “Final,” and yes, there should be a different standard in terms of what constituted a QA-worthy error. But no, he had no specifics other than the notion that, for a “Prelim,” he might report fewer measurements than in a “Final.”

It wasn’t his fault, nor the telerad company’s. Nobody had solid rules on the subject. Even the on-site radiologists (and the clinicians referring to them) couldn’t seem to agree what constituted a satisfactory “Prelim.” Some wanted as close to a one-line summary (“No acute disease”) as possible. Others wanted exhaustive detail, a report good enough to be “Final” (while enjoying the discounted reading-rate negotiated for “Prelims”). Yet others held a double-standard, generating one-line “Prelims” when covering their own call but filing QA complaints whenever telerads remotely covering them did the same.

I didn’t want to run afoul of such things. I also didn’t want to be distracted while reading multitrauma cases at 4 AM as to whether a given study was “Prelim” or “Final.” So I decided, for myself, that I was just going to read all cases as if they were “Finals,” and if that meant my productivity-numbers (and paychecks) wound up being lower than they otherwise might, so be it. Surely, onsite docs wouldn’t complain about the extra level of effort I was putting in…

…Or maybe they would. Not that I’ve gotten any negative feedback regarding my “Prelims” being too Final-like in the past two and a half years of telerad work, but I’ve heard commentary out there, from the “boots on the ground” rads, that the longer, quasi-Final “Prelims” create extra work for them when they come in to the hospital the next day and review the overnight cases.

This puts me in mind of the “mission creep” with which far too many of us have become familiar, regarding the usage of STAT. Necessitating, in some cases, truly emergent cases to be nicknamed “real STAT” or “super STAT” to distinguish them from the constant stream of routine studies bearing the STAT label for no good reason.

Maybe it’s worth subdividing the “Prelim” entity to clarify what is expected from a covering radiologist, local or otherwise…and have the fees associated with them reflect this. Call the one-liners TPs or PPs (True “Prelims,” “Prelim Prelims”), for instance, and the Final-in-all-but-name reports PFs (“Prelim Finals”). I normally cringe at such bureaucratic attempts to formalize the intrinsically-informal…but unless “Prelims” vanish from the post-training world (which would make me very happy, as noted above), defining our terms a little more might be good news for us all.