Things You Can’t Say…If You Care About QA

Let’s start out by saying that there are (hopefully) plenty of rads out there who interpret cases purely based on what they think they see, and perhaps a smidge of pertinent clinical history if any is provided. They are not influenced by worries about imperfect QA stats, or med mal opportunists.

Others, I daresay a substantial majority, are not possessed of such nobility, bravery, and/or ironclad dedication to professionalism. Some may have been abused by the medicolegal system. Others might have been sanctioned in one or more jobs for bad QA stats, or are in situations where better stats are rewarded. Even others might have personally had no such experiences, but know of them second- or third-handedly.

Whether or how to improve upon this state of affairs is a subject I’ve touched on in the past. This time, I’m more focused on diagnostic casualties I have noticed as a result. That is, things which a capable rad might otherwise wish to say in his reports…but might think twice about if he wants to avoid being the subject of a QA “gotcha”:

Diagnosing ileus…without mentioning bowel obstruction. Once upon a time, I remember rads would follow dilated bowel, looking for a point of transition if not a visible mechanical impediment. They did this because it was of value to the clinician to offer an opinion as to whether there was an obstruction, since management would obviously differ. If they didn’t see a PoT or mechanical obstruction, they’d call ileus. Well, the QA machine has scolded many of us for daring make such judgments. Not because someone else can point at an obstruction site that the original reader missed…just that “You can’t rule it out.” Repeat this exercise often enough, and presto! No more diagnoses of ileus.

Calling a pediatric chest x-ray “normal.” I used to think it was kind of funny that more than half the CXRs in kids, even read by subspecialty ped rads, included observations of peribronchial thickening. Seemed to me that some overdiagnosis was going on. Were we accomplishing anything by this, other than training clinicians to ignore our crying wolf for small airways disease? And really, if we refrained from calling PBT in a case of genuine pathology, how many clinicians would fail to appropriately treat viral infections or asthma in the absence of our commenting on the matter? Well, if you read kids’ CXRs and have the temerity not to say something about how there might be some thickening…be ready for some dings on your QA, because someone out there will claim you should have.

Denying the existence of a pulmonary embolism…without equivocating. You might have heard the sentiment that, if a patient is well enough to provide a pristine CTA of the chest (can control breathing, stay still, position well, has good venous access and cardiac output for a proper IV bolus, etc.), the chances of their actually having a PE are pretty darned low. For most cases we see, though, the smaller, more peripheral pulmonary arterial branches aren’t reliably visible. Go ahead, stick your neck out and say there’s no thrombus…if you don’t mind occasionally getting zinged because someone thinks they do see one, and the QA judge(s) decide that they can’t totally exclude the possibility. Careful how you hedge, though-because if your verbiage suggests too strongly that there might be a small PE, or you go out on a limb and call one, they might just blame you for that, too.

These are just a few examples on what I’ve come to think of as the endangered diagnoses list (or endangered normals). Rather than going on with the rest, though, I’d be interested to hear some of the readers’ observations. Especially from subspecialists who are arguably the most qualified to offer opinions on their areas of expertise, yet have found themselves having to choose between doing so versus holding back to appease the QA beast.

Have at it! Looking forward to the comments.