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Trick or Treating in Radiology
Is a decent clinical history from referrers as rare as the full-sized candy bar in the Halloween bucket?
This is a fun season in my household. I would personally prefer it if summertime just kept on chugging along, but if the temperatures absolutely have to drop, daylight hours shorten, etc., at least a parade of thematic holidays sweetens the deal. Halloween tops our list.
When it falls on a weekday, in years like this, schedules don’t always allow for much. Like most adults, we easily wind up staying at home and greeting what few trick-or-treaters find their way down our block. At some point, one comes of age and shifts from a role of being indulged (with free candy for instance) to providing the fun (giving candy out or decorating one’s home so it is a good visiting site).
Still, when circumstances permit, we enjoy revisiting yesteryear. This past weekend, we stumbled across a local “haunt” that was running an adult trick-or-treating event. My lady did up her Bride of Frankenstein outfit, I reprised what has turned out to be a very popular rendition of Halloween’s Michael Myers, and off we went. It was a delightfully silly time, in part because the haunt’s apparatus had a few flaws we accidentally exploited. The costumed employees did a great job of redirecting us while staying in character.
The indulged/indulger relationship struck me as reminiscent of the consultation dynamic one sees in health care. There is an implicit give and take. Whoever seeks the consult is supposed to lay certain groundwork: see the patient to get a proper history/physical, address any primary care stuff, and get the ball rolling on basic diagnostics. Based on that, they hopefully determine the appropriate subspecialty to consult, and submit their request with a concise explanation of why they want the help.
That is not unlike the “work” a trick-or-treater does. To get their free candy, they are supposed to come up with a costume and do the legwork to visit whatever homes might be distributing loot. Actually saying “trick or treat,” behaving in character, and generally being a good or entertaining visitor can’t hurt either.
Consultants (including radiologists) play a corresponding role, assimilating the information we have been given and gather more for ourselves if needed. Hopefully, we can fill in the gaps and leave our consultees with a better understanding of their situation, even a plan of action. We sometimes do that very well, for instance with a solid diagnosis analogous to a full-sized candy bar for a grade schooler’s bucket.
Sometimes we have less to contribute via a maybe-this, maybe-that differential, like a fun-size Snickers. Alternately, we may have a completely negative study. Hurrah, we see nothing abnormal, but your patient’s signs/symptoms have yet to be explained. Here, have a weirdo hard candy that nobody likes. Worst, we tell you that the study was horribly limited or not even the right way to investigate your clinical question. That’s the equivalent of a trick-or-treater showing up to a house where nobody is home, or the lights are off and nobody is coming to the door.
Any consultant can tell you that we are not the only ones who come up short. Indeed, if you envisioned an omniscient balance sheet of who fails to hold up their end of the bargain, a lot of us would confidently point at the other camp. In radiology, that comes across as orders for imaging without a proper clinical history or “reason for exam.” Plenty of radiology columns have dwelled on that, including this blog, on more than a couple of occasions.
Some of it is understandable. Referring clinicians can be overwhelmed, without time/energy to provide better. Ancillaries might cut corners and simplify “RLQ pain with rebound tenderness” into “pain.” Software might not let them enter the details they would like when trying to place their orders. Of course, there are also complete messes in which a patient’s clinical scenario is so complex or such an unknown that there is nothing that can be concisely written. Unfortunately, it’s not billable to order with “This pan scan is a fishing expedition. Anything you see might help us.”
Nevertheless, in our own busy days when the worklist seems never-ending and we have a million interruptions, requests for addenda, and technical breakdowns, we are not always able to be paragons of patience and understanding. When we get the umpteenth study for “R/O pain” or “Eval,” to us, it just looks like some sneering teenager showed up to our house without anything resembling a costume and demanded candy.
When the ER abuses their ability to order studies without contrast “because throughput,” it might just seem to us like the same kid came back to our house multiple times in a single evening because they know we are not really able to turn them away.
Take any situation in which rads feel like they aren’t supported in being able to control protocols for appropriate imaging. This could come in the form of overnight non-emergent MSK MR “because my attending wants it,” for instance, or a Lung-RADS scan two days after an acute setting chest CT showed absolutely nothing. The feeling might just resemble that of a household whose inhabitants weren’t going to be around for Halloween afternoon, and instead carefully set up a table of prepped goodie-bags with a “please only take one” sign ... and later finds out the first kid who came by grabbed everything and knocked the table over.
As unpleasant as such encounters might be, they do serve to highlight the good ones. Perhaps it is a kid coming by with a particularly cute costume and nice manners, or a referrer providing a concise but targeted history that directly impacts image interpretation, allowing a precise diagnosis that might otherwise not have occurred.
