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Recognizing the Frequent Offenders of Bad Imaging in Radiology

August 21, 2023

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When facilities routinely forward X-rays for “pain,” vascular ultrasound studies without Doppler or chest computed tomography (CT) scans devoid of breath holding, patient care suffers.

After a few years’ hiatus, we resumed throwing our annual summer party at my home. The pandemic was initially to blame for the lapse but even after that died down, our social momentum had been disrupted and it took a bit to get back on our feet.

The way things panned out, most of the folks from my side of the guest list weren’t able to attend. Although it would have been nice to see them, this made things a little easier for me. Hosting dozens, it is very easy to feel like you haven’t got enough time to spend with anyone in particular, even personal friends you are dying to catch up with. When all attendees are relative unknowns, you can drift around and mingle without any agenda.

I thus found myself talking with someone who was contemplating a career switch, and wanted to know what I thought of her becoming an ultrasound tech. I would up spending a bit of time talking about what makes someone a truly good sonographer, in part because I have seen more than a little bit of the crummy alternative.

Many moons ago, my early telerad work had me credentialed far more extensively than at any other time in my career. At the time, I wrote in this blog about how various referring facilities came to exhibit, for lack of a better term, personalities. Hospital A might be an academic stickler, hospital B was a busy, chaotic mess and hospital C was a high-volume center of bread-and-butter stuff, etc.

This a higher order version of what one might experience from working in a single facility, wherein one sees that tech A does high-quality work, tech B doesn’t quite have those skills but is willing and able to learn, and tech C doesn’t seem to give a darn. (Yes, that goes for the radiologists too.)

A naive or idealistic person, especially one new to the health-care machine, might not see how this can/should be allowed to happen. Why is anybody doing less than work when lives are on the line? Shouldn’t the system be geared towards recognizing its crummy elements, whether it is to improve or replace them?

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I have sounded off in previous blogs about some of the reasons why this doesn’t occur, and how that might be changed. In the meantime, we rads have to live and do our jobs in this imperfect world. So, if we read stuff from any facilities for long enough, we tend to learn where the crummy cases come from.

Off the top of my head, here are some frequent offenders I have seen.

• Urgent care centers, even ERs, sending 100 percent of their X-rays for “pain.” In these cases, there is no mention on the location of the pain. Is this for trauma? Infection? Foreign body? Alien abduction? If it was just an occasional case, we might call it a careless tech or an unusually busy day, but every single case screams out “This facility’s staff doesn’t know/care, and its leadership isn’t any better.”

• Ultrasound services that routinely send vascular cases without any Doppler. “R/O DVT” cases are presented with nothing but grayscale. If the techs bother to write any explanation for this at all, it’s “due to patient condition.” Now, I might believe that occasional circumstances force a study to be cursory. However, when 100 percent of cases from a particular source are deficient, it looks an awful lot like crummy work.

• Chest CTs (or body MR) devoid of breath holding. Once again, it’s totally understandable that not every patient will be able to take and hold a deep inspiration for a pretty scan. Yes, there are some “free breathing” protocols for CTA out there. However, what if there are hundreds of scans for a place over a course of years, and there are absolutely ZERO scans with a good breath hold, even when I’m supposed to be following subcentimeter nodules? I can’t help but wind up mentally labeling the techs there, and whoever’s supposed to be watchdogging their quality, as crummy.

If just one rad seems to find fault with all of the imaging he or she is fed, it’s reasonable to think that maybe that rad is just a grouchy perfectionist. (I would still suggest that you at least look at his or her complaints to see if there’s any substance to them.) Any time I have started thinking of a particular tech or facility as a source of crumminess, I have checked myself by seeing if my teammates agreed. More often than not, they have had more gripes than I did and I’m the forgiving one.

Suppose you’re in charge of the place, and you’ve got multiple rads identifying the same sources of crummy imaging. Maybe you size up the cost/benefit of fixing things and decide that subpar patient care is an “acceptable loss.” Maybe, to you, there are valid reasons for this. I hope I never agree with you.

Have you thought about the “crying wolf” phenomenon? That is, rads start to take it as a given that facility or department X always provides crummy cases, and their scrutiny of those images diminishes as a result. Would that lower patient care quality be enough to merit action?

Do you suppose referrers might catch wind of the crumminess? You don’t need a rad to tell the referrer, “Hey, this place does lousy work. You should send your patients elsewhere if you care about them.” All you need is for those referrers to notice that every single report they read is “limited” by crummy technical factors. They will eventually get the hint.

(By the way, if you think you can fix that by ordering your rads not to say anything about limitations in their reports, good luck. You’ll need it.)

It’s also hard to hide the demoralization exhibited by rads who know what good radiology is and that they aren’t immersed in it. A truly cynical leader might actually prefer maintaining an environment that squelches professional pride in his or her rad group, lest they get uppity notions of self-worth but that won’t attract and retain the cream of the crop.