Striving for Radiological Sophistication in a Sea of Workflow Inefficiencies

I have referenced the late, great Douglas Adams (of The Hitchhiker’s Guide to the Galaxy fame) in this column a couple of times. One of his particularly enduring bits is a commentary on certain phases civilizations go through as they become more advanced.

He described the phases of survival, inquiry, and sophistication, also termed the how, why, and where phases. Example: “How can we eat?” Once we go beyond the eating to survive, the question becomes intellectual: “Why do we eat?” With this understanding, we progress to niceties and finesses like “Where shall we have lunch?”

The process is far from uniform. We can pat ourselves on the back that we are pretty sophisticated when it comes to feeding ourselves but consider just how many folks still don’t understand what’s healthy to eat (or abide by such knowledge). Even our scientific types constantly differ about which diets are more effective and flip-flop every few years about things like whether it’s good to have a glass of wine each day.

Health care is no exception. We’re still in the how and why phases for a lot of things, like understanding cancer, various types of dementia, and prion disease. If you’re in academia or research, how and why tend to be your bread and butter.

I consider those of us doing purely clinical radiology, without research, as exclusively in the sophistication phase. We went through how and why during med school and residency, but generally don’t retain or use much of that in our daily lives. (Think, for instance, on the last time you used the knowledge needed to pass the physics component of your board exam.)

Some aspects of our “sophistication” include efficient/fair management of workflows, optimal search patterns and organization of reports to dovetail with them. Other aspects may include strategies for growing/maintaining practices, imaging-protocols or choosing software and hardware.

All of these things are unquestionably important stuff. One can be wrongfully dismissive of “sophistication” as window dressing in comparison to the stuff that is the bedrock of our field. Few would argue that clever tweaking of voice-recognition software is on the same level as the innovation that created magnetic resonance imaging (MRI) or positron emission tomography (PET). Still, if you turn out 10 to 20 percent more work in a given day than someone else because you figured how to get more out of your software, that is not chicken feed.

We take our sophistication seriously because, for our daily purposes, it makes visible differences, and it is something we can control. Well, we should be able to control our sophistication and it vexes us awfully when that doesn’t turn out to be the case.

For example, I have read for a lot of facilities, courtesy of my decade in teleradiology. Multiply that by the number of different technologists in their various imaging suites, and I wind up with an awful lot of ways that imaging studies get performed and organized in PACS. Some make more sense than others but for the most part, the differences are indeed window dressing with no impact on how I read out the studies.

Some wrinkles do, however, make a difference. They force me to click around more, adjust my hanging protocols, and generally waste time getting things so I can interpret the darned images. For instance, making the images scroll from cranial to caudal in some cases whereas others go caudal to cranial, or right to left versus left to right. It is not a lot of fun when you’re comparing against prior studies that went the other way. You’re constantly scrolling the wrong direction on this study because it was the right way on that exam.

Not only is such stuff annoying to deal with, it consumes valuable time. It may result in incrementally delaying a STAT report for the patient in question, and all the other patients on the worklist sit in the queue that much longer too. Plus, I firmly believe that a brain distracted by this aggravation and diverting its resources to extra clicking around is a brain that has less left over for diagnostic purposes.

One of my biggest peeves, if not the absolute #1, is when a tech buries more than one imaging sequence in a single series of pictures. For instance, I had to scroll through a few dozen images of a multiphase contrast-enhanced scan to get to the venous phase. Some techs even bury a venous chest behind an arterial abdomen.

Most places I have worked don’t do that. They appropriately separate out each phase in its own scrollable imaging series. Heck, the techs had to do it anyway to make multiplanar recons for each phase, so it just seems lazy not to separate the phases.

Rads I have seen generally just endure the extra clicking around and scrolling. Some have PACS that allow them to separate out the images themselves. I have not been so fortunate. Even so, I have a hard time understanding why it should be our burden to live with such poor organization. Not only does the interpreting rad have to work around the mess, but any subsequent viewer does, including referring clinicians who want to look at the pix. Indeed, some folks might not even know there is another series of images buried in there and walk away from the monitor never having seen the relevant image(s).

All of this could be avoided if the tech just pressed a few different buttons. To me, that is the lowest common denominator, an efficiency chokepoint that has the most payoff if it is adjusted.

I am not one to silently endure. If I think the sophistication of my profession could be better than it is, I make the effort to fix it. Accordingly, I have reached out to the techs, some of whom have been understanding and willing to adapt. Most, however, do not. There is usually some sort of excuse along the lines of “That’s not our protocol.”

Such answers aren’t sophistication, but sophistry. I’ll get into that next week.