The Double-Edged Sword of Being Dr. Obvious in Radiology

It can be downright embarrassing to tell someone something he or she already knows.

Probably nobody makes it past the first few years of social interaction without having the experience: You thought you had some great intel or insight to share, and one or more peers shut you down by revealing that what you thought was news is, in fact, old hat.

Maybe some folks see this go away with sufficient age and wisdom. For the rest of us, the passing of years just means new flavors of this embarrassment, and new ways in which to experience it.

In diagnostic radiology, we have managed to create a whole new flavor of embarrassment via conveyance of the already known: the “critical results” apparatus.

It is rooted in reasonable concepts. Lest this need saying, certain things we see on imaging are big enough deals that they warrant immediate communication. If I dictate a report and a referrer reads it in hours or even days, that might be fine when I am talking about a “cancer remains in remission” scan or “fracture healing well” X-ray. But if I happen to notice a clot in someone’s lung on the cancer scan, I don’t want those hours, let alone days, to go by.

A one-size-fits-all policy has plenty of potential for absurdity if followed dogmatically, for critical results as much as anything else. A little judicious thought from the radiologist goes a long way.

For instance, I have hung onto a “critical results” mousepad from a previous employer that lists a few dozen abnormalities requiring a doc-to-doc verbal communication. Appropriately, pulmonary embolism (PE) is on that list. Someone following the policy literally would pick up the phone every time they saw a clot, but we not uncommonly receive scans to “follow up PE” after intervals as little as a day. What if I see the clot has shrunken a little bit? Good news, right? It’s the hoped for, if not expected, result of treatment. However, it’s still a PE, and if I’m strictly following the rules I have to call every time they do a scan that shows one.

Potential embarrassment #1: I follow the rules and call the referrer, knowing full well that he or she might be irked at my interruption to tell the referring doc what he or she already knows. Potential embarrassment #2: I elect not to call and then I get in trouble from my bosses wanting to know why I can’t follow the simple rule that PE = verbal communication.

The waters get a lot murkier than that, and most of us err on the side of caution and potential embarrassment. Last week, for instance, I got a head CT on which the tech had noted that there was a known bleed. Sure enough, there’s a subarachnoid hemorrhage, which very much deserves its spot on the critical results list. If it’s “known,” though, should I still be calling it in? Or is the ER doc going to say, “I told the CT tech to write that it was known. Why are you bothering me?”

The problem is, unless they go to the trouble of writing “bleed is known to clinical team; please do NOT alert us when you see it,” I’m kind of obligated, even if the bleed is obvious to anyone who’s ever looked at a head CT. Otherwise, I don’t know who the bleed is “known” to. Is it tech who glanced at the CT monitor and saw it? Is it a patient’s primary care doc who thought there’s a bleed and the patient should go to the ER? Further, what if the bleed they “know” is subarachnoid (without spelling that part out), but I also happen to see that there’s an epidural hematoma?

I have read such head scans more than a few times over the years, and with the exception of postoperative patients from neurosurgery, I don’t think I have ever risked not being Dr. Obvious, calling referrers to tell them what they almost always already know. I have gotten very accustomed to phrasing my communication apologetically, since it helps blunt the embarrassment: “Hey, sorry to trouble you by telling you what you probably already know, but … .”

It also saves clinicians the embarrassment of revealing that they, in fact, were unaware but they could just as easily be embarrassed, even offended, at my implied notion that they wouldn’t have seen the abnormality themselves.

Critical results don’t even need to enter the picture. A couple of weeks ago, I got a chest CT for “persistent cough.” No relevant pathology turned up, so I was going about my business with the various incidental findings, among which was a surgically absent kidney. Why, I wondered, had that been removed? Digging in the patient’s documentation didn’t turn up a reason, but I happened to see a listing of the patient’s medications, including an ACE inhibitor.

God knows for what reason, but my mind helpfully served up info from my med school days. ACE inhibitors are commonly associated with coughing. I wrestled with the notion of commenting on that in my report: Surely, the patient’s referring clinician knew a lot more about coughing and what might cause it than a rad like me. Heck, the scan was a high-res affair so the referrer might be a pulmonologist. Who did I think I was, acting like I might be able to teach them a thing or two about cough-causing meds?

Ultimately, I reverted to Dr. Obvious and put it in. For all I knew, the referrer didn’t know or hadn’t considered the ACE inhibitor’s potential culpability. In saying something about it, I might just spare them further workup in lieu of discontinuing the med and seeing if that might clear up the cough.

In the process, I mentioned the case to a couple of the other rads who were on shift at the time. One commented that he had carefully buried the stressful memories of med school pharmacology in his unconscious and here I was, dredging that nasty muck back up again. I told him that, for my next feat, I would find a way to reference the Krebs cycle in an MR report.