Eric Postal, MD, is a diagnostic radiologist with the University of Pittsburgh Medical Center. 

Eric Postal, MD

I am a RVU generator. It is not exactly how I envisioned my career shaping up. Sure, as a diagnostic radiologist, I expected much of my professional value to be expressible in terms of case volume. However, I also thought I would be doing substantial amounts of “on the clock” stuff away from the workstation, whether it was planning strategy, optimizing group efficiency, and even forming policy. In other words, there is an interest in “bigger picture” kinds of stuff.

There are various reasons why that hasn’t happened yet. In the meantime, if I want to philosophize about the greater meaning of my work, it’s going to be in terms of lives I have saved, improved, or at least prevented from getting worse as result of cases I have read.

In the abstract, this is not a hard concept to grasp. Rads can interpret some pretty complex imaging, to say nothing of how we manage when we are given less than ideal tools to work with (technically limited studies, poorly chosen protocols or even modalities for the clinical scenario, irrelevant/wrong/non-existent histories, etc.). Functioning as the “doctor’s doctor,” how could we not be doing important work?

Start trying to quantify it, though, and one rapidly gets brought back to Earth. Muddling through a typical worklist, it is very easy to wind up with a “how much of what I’m doing really makes a difference” feeling. Plow through a few dozen portable ICU chest images, for instance, endlessly describing a bunch of tubes and lines and how one can’t rule out edema on this one or pneumonia on that one. Heck, it seems like they order daily chest films in the ICU without waiting to see what we had to say about the previous films.

Maybe you do a lot of mammos and every so often, somebody publishes a study about how screening doesn’t have a statistical benefit on survival across the population. Perhaps you cover ERs, see trauma pan-scans on patients wrecking their ATVs and realize the same patients trashed their snowmobiles last winter. Did it matter that you identified their rib fractures last year when they just went out and broke some new ones now?

Then there’s the matter of rads not being the only ones looking at imaging studies. There is an assortment of jacks-of-all-trade (ER docs, PAs, NPs) glancing at X-rays, sonographers essentially giving prelims on their scans to whomever asks, and subspecialists like orthopedic surgeons or neurosurgeons proudly boasting that they read their subspecialty images better than we do. It is easy to come away with the sense that even if we didn’t make some key diagnosis (or rule it out), others would.

More than once in a blue moon, I’ve had the notion that, even with all this going on, even with the ever-increasing volume of unnecessary imaging that gets thrown our way to dilute things, there are times where we stand between good and bad outcomes. In our diagnostic rad roles, we have the chance to do what nobody else can or will. As an individual trying to distinguish himself, I may sometimes do what other rads wouldn’t.

Such moments, as rare as they might be in this sea of other factors, are our “delta.” It is the difference that we can make because of how we perform when we’re doing our thing.

Of course, we don’t knowwhen those moments are afoot. If I catch a non-obvious fracture, I don’t know until after the fact whether the ER staff noticed it or sent the patient home to follow up with their primary care doc. If I think I see a suspicious density on a mammo and suggest diagnostic workup or biopsy, I won’t know until afterward if I was sounding the alarm over something benign or malignant. Even if it was bad news, I would have to be omniscient to know whether I made a difference in the quality/quantity of that patient’s life. Maybe the tumor would have been slow growing and instead the patient dies earlier from complications of the chemotherapy that I helped make happen.

It’s only with a very indirect, been doing this for decades, instinctive kind of feel that I have come to sense what my delta might be. I try to underestimate it in order to keep myself humble and my expectations low.

For instance, I think it’s a reasonable hope that as I do my best work, perhaps there will be one case in 10 in which I might say something more helpfully than another rad might have (or refrain from saying something unhelpful). Meanwhile, if you take the population of rads as a whole, it seems safe to say that in at least one out of 10 cases, we produce better outcomes than some other doc would have (ER denizens and surgical subspecialists alike).

Of course, no matter who ultimately looks at a case, let’s keep in mind that an awful lot of imaging doesn’t contain actionable results relevant to the patient who got imaged. Either the imaging was a “fishing expedition,” it was the wrong type of study to order for the clinical interest, or no imaging was warranted in the first place. Assigning that a one in 10 probability might seem cynical to some but not to anybody whose worklists resemble those I have seen.

So, I’m looking at 10 percent for me versus other rads, 10 percent for rads versus other docs, and 10 percent for imaging studies overall. I can reasonably expect my delta to be at least one case in 10,000. My pace of reading cases has varied with the types of infrastructure offered by my last couple of jobs, but that translates to at least twice per year.

Does that seem rare? Of course, I’d like it to be greater, but I did set out intending to underestimate. Even going with two lives per year, that will turn out to be 34 since fellowship. Add another 20 for each decade I keep plugging away before I call it quits (or it gets called quits for me). That’s a few dozen folks who got to live longer and/or better purely because I was involved in their care.

I would consider that a decent accomplishment for my career.

Articles

Amid a glut of unnecessary imaging requests, common worklist frustrations and perceptions from other clinicians that they can interpret medical images just as well, recognizing your role as a humble difference maker may provide the ultimate RVU for patients.

What is Your Radiology Delta?

A decent chunk of my daily radiological workload comes with “prelim” interpretations. Sometimes they come from residents. Some of them come from other health-care personnel. I don’t know that I would be able to identify the source for any particular case. It is not readily apparent. Maybe this is by design but there is a lot to be said for double-blinding in quality assurance (QA). Without knowing, I tend to assume it is coming from a resident rad but that is pure instinct.

After the most important aspect of prelim reads (identifying when there is a difference of opinion and communicating it to the clinicians), it seems to me the second priority is for the prelim reader to get feedback about when he or she has done well, or when the prelim reader has something to learn.

I don’t expect the prelim folks to always be enthusiastic about it. Given the usual structure of QA systems, I wouldn’t be surprised if the majority of participants preferred to opt out of it. One can’t be thrilled with the constant lurking threat of peers or superiors reaching out to say “Hey, you screwed up.”

Still, I perceive the whole prelim/final interplay to be mutually beneficial, a kind of professional handshake. The prelim reader gets to do a cursory read, learn stuff, and potentially have errors caught/corrected by someone else, and the final reader gets an extra set of eyes reviewing things while not having to work 24/7/365.

As a final reader guy, I therefore consider it my part of the bargain to provide whatever value I can, sometimes communicating stuff to the prelim readers beyond the mere (in)accuracy of their reads. This may be in the form of pointers or interesting tidbits. I do concede though that sometimes my days are so hectic that I don’t communicate as much as I would like to.

A recent case in point has prompted me to share my advice with my readers since I never caught up with the prelim reader who inspired it. There was a random emergency room (ER) or urgent care X-ray of an extremity. The prelim reader noted “No obvious fracture.”

I didn’t see one either and moved on. However, something about that prelim stuck in my mind. After a little while, I put my finger on it: Hey, prelim person, is that the limit of your value? You’re only willing to say there is nothing obvious on the images?

The study was good quality. There wasn’t any diagnostic limitation. Indeed, it was a simple three-view X-ray, not advanced imaging of any kind. I know folks can say stuff like “No gross pathology” if they want to underscore that they’re not getting the best view of things.

Could it be that the prelim reader wanted to emphasize that the final read guy has greater skills/experience to the point where there is subsequent appreciation of subtle pathology the prelim reader isn’t equipped to identify? Recognizing one’s own limitations is a good thing, and people like a reasonable dose of humility.

Let’s go with that notion for a moment: I 

 have issues with throwing in that “obvious.” What do you suppose it says to everyone else involved? As the final read guy, it puts the notion in my mind that maybe the prelim readers didn’t look too carefully. Maybe the referring clinician gets the same impression or, if the referrer wrote the prelim him- or herself, everyone else involved in the patient’s care gets that impression about the care that was rendered.

What if the patient got a look at the prelim? If you went to an ER because you thought your leg might be broken and the person responsible for treating you, someone you trusted to be an experienced professional, shrugged, and said you had no “obvious” injury, would that reassure you or would you feel like your case was casually dismissed?

I hear “obvious” applied to a fracture, and I think of something that doesn’t take a radiologist, physician, or other health-care individual to identify it. Google images for “fracture” and most of the pix you see will be things that a grade-schooler could look at and say, “That’s broken.”

I think we can hold ourselves to a higher standard than that—and this includes residents, physician assistants (PAs), and even medical students. If you are in a position to be rendering even preliminary interpretations, you’ve accomplished enough in life that you don’t need to be hedging by saying you’re only liable to find “obvious” stuff. Your opinion is worth more than that.

Alternatively, if you believe you can or should only be on the hook for seeing “obvious” abnormalities, you probably shouldn’t be rendering even preliminary interpretations.

Besides, when you do inevitably miss something, nobody’s going to consider your error any more forgivable because you used hedging terms like “obvious” or “gross.”

One other thought struck me with the “obvious” prelim comment. Some folks get so accustomed to throwing around words like that, it becomes a thoughtless reflex. It stops meaning anything to them, but others still hear it.

Possibly my best preceptor from medical school, a guy I have referenced in this column before, regularly corrected or otherwise commented on the verbiage of his house staff and students. H would tell interesting stories of word origins, and even address grammar and pronunciation. One of his enduring lessons was words matter, if not to you, then at least to your audience.

One of the interns on my rotation with that preceptor routinely used “basically.” Any time he was presenting a patient or giving an update on developments since previous rounds, he would launch with that word. He made it surprisingly far into the first week of that month before the preceptor called him on it. “You use that word a lot,” he observed. “Does it add anything to what you’re saying? It seems more like a nervous habit. You’re not simplifying anything for our benefit, are you?”

Of course, he wasn’t and knocked it off almost immediately. Darned if he did not immediately sound more professional and confident in his presentations.

Is it a thoughtless verbal reflex or a failure to go beyond a surface read of imaging?

Questioning 'Obvious' Notations from Prelim Readers

I have a cast of characters residing in my noggin. They’re all me of course. Regular readers won’t be surprised that I watched Marvel’s 

 series, but I’m not claiming any dissociative identity issues. It’s just that the way I come across can vary substantially with different situations.

We’re not supposed to be like that in medicine. No matter what happens, it is expected that we will always be level-headed, cool, and calm in a crisis, etc. Stress, frustration, and the like shall never mar our consummately professional demeanor. For those familiar with the 

 franchise, we’re about as close a thing to its “mentats” as reality gets: the living equivalent of computers. Give us your data. We will process it and give you results, and our personalities won’t get in the way.

Maybe other docs have perfected this approach. I have not. However mentat-like I might manage to behave, the characters in my mind are regularly in play behind the scenes. I could call them a council to pun on the title of this piece, but with the way they behave, it is really more of a peanut gallery. They are often at their most insistent when I have to get on the phone: Talking to referrers, techs, etc. has a way of rousing my rabble to the point where it is sometimes hard to keep them from taking enough control to verbally express themselves.

Consider the following case in point. A call comes in for a computed tomography (CT) scan I read. As has been the case in most decently organized rad jobs I have had, the initial contact is from a rad support person, to a) make sure I’m available, and b) give me the patient info so I can have the case in front of me before the referrer is talking to me about it.

Organized and efficient as that may be, it doesn’t stop the peanut gallery from squawking at the interruption of my reading cases:

What is it now? Can’t I be left alone in peace?

What about my report was unclear to this individual? Did the clinician bother reading it all that carefully? Is she or he about to try telling me my read was wrong?

Of course, I ride herd on the chatter. Nothing they are saying is worth expressing out loud, especially to my helpful ancillary staff. I say thanks for the case info and that I am ready to be connected. It was a chest CT with a history of “septic emboli” and literally no other clinical info. There was plenty going on in the lungs, even some cavitary lesions. However, they did not look embolic, and I had taken pains to describe why they probably were not embolic

The referring clinician gets connected and semi-accusingly tells me that I “said something about septic emboli” in my report, but that the clinical scenario really doesn’t suggest such pathology. The peanut gallery doesn’t appreciate the tone.

 said something about emboli? That was the only history 

You didn’t really read the report, did you? I spent about half of it explaining why I didn’t think these 

 septic emboli and offered you a differential of more likely possibilities.

This time, I don’t entirely squelch their retorts. It is, after all, being alleged that my report is diagnosing the opposite of what it is, a diagnosis that this individual (or someone else on their team) provided in a clinical history that my caller is now denying. I do phrase it a little better though: “I’m sorry. Was my report unclear? I thought I explained why I didn’t think these were septic emboli. The only reason I mentioned emboli in the first place was because that was the history you provided.”

The caller responds by saying that I “don’t seem to know anything about this patient,” and continues to go on about why he or she didn’t clinically suspect emboli. This does not remotely charm a single member of the peanut gallery:

I don’t seem to know anything about your patient, huh? Whose fault do you suppose that is? The one thing you told me in your “reason for exam” is something you are now claiming you never believed.

I’m glad that neither of us thinks there are septic emboli here. We should be on the same page, since now you’ve read my report and heard me describe it out loud. Can I hang up the phone now, or is there some other way I could express this to your satisfaction? Morse code? Semaphore? Emojis?

I decide to let a quieter member of the gallery sound off. I think of him as the Professor. He likes to share knowledge and educate, even though he sometimes talks over people’s heads or gives them far more info than they wanted.

Thus, instead of trying to force my caller to understand that he or she has done a lousy job of referring and reading my report, and isn’t making up for it in verbal discourse, I lay it on super thick, offering every detail I can think of about septic emboli, what they look like on CT, what this CT shows instead, etc. It is as if I never dictated the case in the first place but instead was doing a “curbside” interpretation for this caller on demand. I made absolutely no effort at brevity.

I do my best to be that bore at a party who buttonholes you and jawbones about something till you wish not only to get away from him, but the entire party.

Mission accomplished. The caller doesn’t have to admit any deficiencies and is being told what she or he wanted to hear in the first place. However, the referring clinician is slowly being punished by wasted time as I babble and is soon climbing over him- or herself to get off the line and away from me.

If I am really lucky, perhaps there will be a lingering recollection that calling me is more of a time/effort investment than carefully reading my reports. Perhaps there will be a little better clinical history in the future with requisition imaging. One can hope.

When remaining cool and collected is a challenge, providing an overload of detail is another way of turning the tide with a frustrating referring clinician. 

Keeping My Own Radiological Counsel

Long-term readers of this blog know I am more than a little fond of the sci-fi and fantasy genres, including superhero comics. It has been gratifying as outfits like Marvel have brought their offerings to screens big and small. I enjoy seeing the rest of society getting in on the good stuff … and feel bad for them when the occasional flop finds its way through whatever quality control should be going on with these endeavors.

In particular, it is nice to see some concepts of near-lifelong familiarity to me gracing the minds of other folks. For instance, if I have occasion to talk about alternate realities or the multiverse, I no longer have to go into a long-winded explanation that leads to peoples’ eyes glazing over, if not rolling back into their heads.

For most people, that may be the case. At least I can reasonably expect that the imminent release of the

 Doctor Strange in the Multiverse of Madness

 movie I referenced in the headline for this week’s blog has folks aware of the concept of a multiverse, right?

Okay, let’s assume not and cover all the bases. If you have seen stuff like 

, you have been introduced to alternate realities. They can differ slightly or drastically from our “real” world. Plotlines usually showcase what would happen if a single key event happened differently (as pithily titled in Marvel’s “What if … ?” series). Sometimes it can be a more radical deviation, like when the 

 crew discovers another universe in which all of the heroes from this reality are villains in that one, and vice versa.

Gather up every single alternate reality you can think of (and recognize that there are infinitely more that you haven’t), and voila! The sum total is a multiverse. A vast collection of realities where anything that could happen did in infinite combinations with all of the other things that could/did happen.

It’s a fun premise for a writer because in an alternate reality, you can make up any storyline you like without consequences. It wasn’t the “real” timeline that future Marvel or 

 writers will have to work in and remain consistent with moving forward. You can kill off key characters, blow up planets, etc.

Again, this is far from a new concept for me. However, having a big-screen flick about to showcase it all probably has this on my mind more than it otherwise would be. While I was working this past weekend, I had the realization that I kind of practice radiology as if I were treating a multiverse’s worth of patients.

I have no idea what case I was reading when this notion hit. Odds are it was an ICU chest X-ray, just because they were the overwhelming majority of my day’s workload. Whatever it was, I was momentarily dwelling on the unreliable nature of the clinical histories, the “reasons for study” that auto-populate into my reports. For the gazillionth time, I mused that I have no way of knowing whether most of the histories I get are relevant or even accurate at all.

For instance, I would hazard a guess that at least 10 percent of the cases I receive are for “sepsis.” This is a very serious pathological entity. Even trying to treat one septic patient would be a huge burden, let alone 10 percent of your census.

The bright spot, however, is that most of the patients I receive imaging for in suspected “sepsis” cases do not actually have it. They might have an infection somewhere, and some mentally lazy or ignorant individual on the health-care team just writes “sepsis” because the clinician may think that is an acceptable usage of the word, and nobody will step in to correct him or her.

Maybe the patient is not infected at all. Perhaps it is an individual from a nursing home who can’t say what is ailing him, and the clinician ordering imaging is just thinking, “Could be sepsis” or “Let’s rule out sepsis.” Worse, it could just be some clerk who was told to get a computed tomography (CT) scan and rubber-stamped the requisition with “sepsis” because nobody would stand in the way of that.

Accordingly, when I get an imaging study for “sepsis,” I have to read it out as if a) the patient is truly septic, b) the patient isn’t frankly septic but might be infected somewhere, or c) there is no relevant clinical history whatsoever. There are surely more options I am not thinking of now.

I must address all of these possibilities. Not only do I want to do my best work for the patient, I also want to avoid a scenario in which some clinician calls me minutes, hours, or even days later to demand an addendum because now he or she now sees fit to provide me with the clinical history that I should have had in the first place. My report will cover the septic versions of this patient in one group of universes, the maybe infected but not septic versions in others, and the no relevant history versions in the remainder of the report.

Sepsis is far from the only nexus of alternate realities for a would-be multiversal radiologist. I routinely get x-rays for history of “fracture,” not knowing if that single word means the referrer 

be a fracture, or wants to make sure there’s 

I see the same thing for tube or line “placement.” More than occasionally when I get a case like that, whatever item the clinician referred to is not there. However, there 

 some other bit of support equipment that was not on the prior study. I have to read it out as if that new item is what the clinician was asking about but 

 as if the clinician placed a different item that has failed to reach the field of view (a central line that did not make it to the chest, for instance).

It’s like trying to diagnose Schrödinger's cat. I might never really know what the patient’s actual story was until after the fact. True, I could pick up the phone and try to track down whoever ordered the study but try doing that for each case you read in a day. I bet your RVU tally won’t be anything to brag about.

Addressing alternate realities may be common practice for radiologists when they are subjected to questionable or negligible patient histories.

A Strange Doctor of Radiology in a Mad Multiverse

Think, for a moment, about someone you know who is completely satisfied career-wise, aside from universal stuff like wanting more money or maybe wanting to work fewer/kinder hours to get it. Perhaps “completely” was a big ask. Let’s aim for whoever’s closest to that 100 percent mark. I apologize if you or other rads you know are not even close to top of the list.

Thinking over who did come in first and others close to it, I have noticed a commonality: Whatever they wanted to be doing in their work, they get to do it most if not all of the time rather than getting diverted with other off-mission tasks. One of my best buds from internship had a blanket term for such things: “Stupid stuff.” (Physicians reading this might recall that they too did more than a little stupid stuff as interns.)

To the working individual, it’s not hard to tell whether one is engaged in stupid stuff or something worthwhile. One can feel it on a gut level. It’s also not too hard to convey the sentiment. If you were talking to someone about what you did for a living and then described some of your stupid stuff, chances are you would see them become puzzled at why you’re doing things irrelevant, even counterproductive, to your job’s actual purpose.

A diagnostic radiologist, for instance, might consider his or her primary function to interpret images and furnish helpful reports about them. Perhaps he or she is tailoring imaging protocols to specific clinical questions. Some radiologists may be taking on certain managerial or leadership roles to help make the rad group function better overall.

Alternatively, a rad might feel like he or she is engaging in stupid stuff when the rad is forced to use reporting templates that don’t match his or personal style or search pattern. Another stupid stuff scenario may occur when the rad regularly receives imaging studies that were done in a way he or she knows to be of less than diagnostic quality, and the rad has no power to fix the situation. For other rads, stupid stuff may involve regular adjustments to one’s reporting verbiage to defend against an overly punitive QA system or being a hypercritical QA reviewer so others will have as many “dings” on their records as the rad feels he or she unjustly receives.

Everybody’s definition of stupid stuff is going to vary based on what they believe their work should ideally be. One person’s mission critical tasks can be another’s complete waste of time.

However, there is a special flavor of stupid stuff that I think is more universally resented, assuming people recognize it. Sometimes, it can be subtle, the sort of thing you only gradually realize is occurring. Alternately, it may remain oblivious to until someone points it out to you one day and suddenly it is as if the person gave you the “red pill” from the 

. You were oblivious but now you see the unpleasant reality.

I am referring to perverse incentives. Perverse incentives in the workplace, from what I’ve seen and heard, seem to be most prevalent in fields with heavy bureaucracy. They seem to be particularly prevalent in governmental and regulatory gigs, but they also occur in academia. You’re dealing with a perverse incentive when you’re rewarded for bad behavior or punished for doing something good. This can be particularly damaging to morale if the punished “good” behavior is simply doing the job you’re supposed to do or if the rewarded “bad” behavior detracts from the mission.

Particularly bureaucratic swamps have entire jobs, even divisions, dedicated to perverse incentives. They may be necessary evils but that does not detract from their perversity. Suppose you are running a health-care system. You’re all about providing health care, right? Except you have folks in risk management who are providing no health care whatsoever but instead are focused on identifying and remediating (or removing) problematic folks in your system. Risk management has the perverse incentive of at least putting the brakes on some of those who could otherwise be providing health care.

Consider a common perverse incentive in radiology. We are all supposed to be productive and do our fair share to clean out the worklists with decent quality reporting. But what happens if there’s no reward for productivity, or even an occasional survey of who’s contributing what to the team effort? Some folks might conclude that all they’re getting for producing more RVUs is extra stress and increased malpractice liability, both of which are perverse 

incentives. They can reduce both by turning down their efforts or taking more breaks for instance.

One example I have seen more than occasionally in those aforementioned bureaucratic places involves certain members of the team noticing impediments to their performance. They could use better tools, more personnel, etc. Leadership is notified and responds by instituting a new protocol. Staff are asked to fill out a new form (or webpage) on the issue every time they feel they are being held back. While it may take a couple of minutes to fill out the form, management can gather data on the situation, which may justify getting new hardware, software, people, etc.

Here is the problem. Workers who might turn to that form are already feeling hamstrung as they try to get their work done. Faced with the latest iteration of trouble, are they going to take the time to fill out and submit a form? Is it more likely they will shake their heads in frustration and use that precious time to get their job done? Plus, there may be a perception that submitting forms like this could get them labeled as troublemakers.

If you really want to get cynical, what is the chance that the leaders making this new policy know full well that this will happen? They can be on the record as having come up with this form idea to gather data for overall improvement of the team. Then, due to insufficient responses, they shrug and don’t have to change anything. They may surmise that it wasn’t that big an issue after all.

The best cure, of course, is prevention. Make sure you have people at the helm who understand the toxic nature of perverse incentives. Let them make it known to the rank and file that they are all about staying on mission. Anybody coming to them with observations or ideas about stupid stuff and perverse incentives will be given a hero’s welcome, fully listened to and invited to help fix whatever problems they have found.

This brings us back to my initial challenge. Thinking about the most satisfied folks you have known, how many of them work for themselves or are in positions of sufficient authority that they can correct most or all the of stupid stuff and perverse incentives that get in their way? Do you think there is a connection there?

Are frivolous time-wasting tasks eating away at the core of what you think your job should be?

Separating Mission-Critical Tasks from 'Stupid Stuff' and Perverse Incentives in Radiology

I was reading out a complex case the other day. It was a cancer-restaging pan scan with a bunch of things to remeasure and compare while keeping an eye out for new lesions, treatment complications and, of course, any unrelated new pathology which might happen to turn up.

Such things can take a while, lest it need saying. While I was slogging along, a couple of other tasks were buzzing around the periphery of my “to-do” radar as I measured this and re-windowed that. After I finally signed off the case, I turned to the waiting tasks. However, I felt a need to pause a moment, regather myself, and recover from the mess I had just navigated.

I have experienced this before, but the past few weeks have brought it front and center for me. The case mix telerads tend to see is not overrun with complex follow-ups of folks with metastatic malignancies and numerous surgeries. We get lots of ER stuff, inpatients with acute issues, etc. Most of it is comparatively simple. Open the case, answer the questions at hand, and move on.

There are no objections from me when it comes to receiving the more detailed stuff. I have a strong respect for the “use them or lose them” nature of my radiology skills. Keeping the complicated cases on my worklists ensures that I will always feel up to their challenge.

Still, receiving more of them than I typically have in my past decade of telerad work has clarified the mental toll they take. Emerging from a case that had a lot going on, I feel like I have just been able to put down a bunch of things I had been carrying around.

It doesn’t have to be a particularly puzzling case, nor one requiring a bunch of measurements, annotations, and comparisons with multiple priors (although those can certainly be contributing factors). Having more than a few of these cases recently, I have come to the conclusion that it can simply be a high number of imaging findings.

By contrast, think of a nice, simple two-view chest X-ray without prior studies. There are no findings whatsoever. Even the clinical history briefly notes “routine preemployment screening.” You look at it, see nothing, report it out—perhaps with your standard negative macro—and move on. Mentally and emotionally speaking, this is as light as a feather.

Now consider the pan scan for a person who has multiple medical problems and a bunch of surgeries with a whole host of details in the known clinical background and prior studies with complex reports. As soon as you open the case, you are swamped in potentially relevant info. Mentally speaking, you are picking up pieces to carry with you on this diagnostic expedition long before you start looking at the actual images. Of course, they are loaded with more stuff for you to pick up and carry.

You might recall the old bit about your short-term memory’s capacity to carry seven items at a time, plus or minus two? These numerous pieces of data far exceed that. Trying to carry them all at once is like going into a supermarket, thinking “I’m just here for a couple of things” and grabbing one of those little handheld baskets rather than a wheeled cart. Then, two to three aisles later, your basket is overflowing while you try to cram even more things into it.

Of course, we don’t do that. These days, courtesy of voice recognition, most of us have a handy monitor displaying our every uttered thought as we look through the images. A lot of dictation software even “captures” clinical info and other things that, once upon a time, we also had to dictate. Even back in pre-voice recognition days, my residency attendings taught us to write down all of our findings on scrap paper so we would have the info ready/organized when it was “TTD” (time to dictate).

However, that doesn’t spare our meager seven +/- two short-term memory. No matter how massive a volume of information we can put on a piece of paper or a screen, it is all still contributing to whatever diagnostic “impression” we are going to put forth in our report. To some degree, we are still holding all that info in mind as we figure out the big questions: Better or worse? Genuine or artifactual?

It is just like the shopping cart you might have gone back to get at the store’s entrance, overloaded with all the stuff you didn’t realize you needed/wanted. You’re not exactly carrying it all. The cart is doing that work. But you’re still aware of it as you wheel it around. You know you’re going to have to put it all on the cashier’s conveyor, get it in bags, bring it to your car, and then transfer it from your car to your kitchen/pantry for stowing away.

It’s only after putting the last item in its place—or hitting sign and closing the case—that you have that diagnostic encumbrance lifted from your metaphorical shoulders. For the cases that had a lot going on—even a messed up chest X-ray with too many tubes and lines, plus differences in positioning from priors and a boatload of abnormalities to describe—it can truly feel like you were bearing a heavy weight that is now gone.

Sometimes, before reaching for the next big burden, it’s a good idea to enjoy being unburdened for a moment. You’ve earned that at the very least.

Does the assessment of complex cases in patients with multiple medical issues carry a certain psychological burden?

Addressing Diagnostic Encumbrance: the Weight of Many Findings

Folks who have read this blog in recent months are probably aware that I had an extended vacation. It was not a vacation I wanted. My rad group got severely hacked in October and that completely derailed telerads like myself. Things could have gone differently, but ultimately the fastest way to get back on my professional feet was finding a new job.

Unfortunately, “fastest” is a very relative term. Most work in health care, radiology included, isn’t the sort of thing where you can go from interviewing to working in a matter of days. Interview processes, due diligence, and negotiating aside, it can take months before licensing and credentialing are complete.

I wound up with about five months between gigs. The last time I had such a gap, it was back in 2011 when I was first moving into the teleradiology world. At the time, I had no serious expenses, and my bank accounts were bloated with down-payment money that had been accumulating during a prolonged hunt for a house nicer than the paid-off shack in which I was living. Taking a sabbatical for a few months that included the summer seemed just fine to me.

This was not quite the case this time around. My unasked-for break spanned winter and the colder part of autumn, and I now make monthly payments for my new mortgage as well as the vehicle I had to get last year. I had enough savings to live without serious worry but that hadn’t been how I planned to use it. I like my net-cash flow to be in black ink, not red ink

Of course, it was nice to be able to fill my days however I saw fit. I could sleep in if I liked, stay up late watching movies or play video games as the mood struck. I had all the time I could want to play with the two pups who had come to live with me just a few months before. I also cranked up my fitness regimen a notch and generally got things done without a full-time work schedule to interfere.

During these months, as during my hiatus in 2011, I thought more than a couple of times that this might be a little taste of retirement. I had never really planned to retire in the traditional sense and neither of these interludes changed my mind.

Part of my rationale is financial as basic as that might seem. I’ve dutifully stashed stuff away in retirement accounts ever since I could, maxing out my annual 401, 403, and SEP contributions for instance. It’s good to know that will all be there in case I ever do have to call it quits, but I just don’t see myself ever comfortably living off those accounts. Again, I like living in black ink. Even if actuaries were 100 percent certain that I would not outlive my reserves, I just know I would feel a need to budget as if I might. Having an income (not to mention benefits) for as long as I possibly can gives me a sense of security that nothing else could other than, maybe, winning a few hundred million from the lottery.

I flatter myself, however, that most of my motivation is above the level of mere dollars and cents. As much as I’ve enjoyed the abundance of free time during these extended breaks, I just don’t need that much. Friends and family tend to only be able to meet up on weekends and holidays, or maybe occasional weekday evenings, times that I would generally be out of work anyway.

Daytime hours from Monday through Friday still constitute plenty of hours to fill. I know I could take on new projects and hobbies to fill that void but, left to my own devices, I won’t. Instead, I’ll find additional mediocre TV to watch, mindless cellphone games to play, etc. Maybe I would take up pleasure reading again. However, I have found that much of my sabbatical time had a certain “waiting for something to happen” feel to it.

To be fair, there is a difference between my temporary breaks from working and a true, long-haul retirement. In my recent circumstances, things were indeed liable to happen at any moment like another round of interviews, more credentialing paperwork to complete, etc. With such a limited horizon, taking on big new projects, let alone hobbies that could persist for years, was not really in the cards. Resuming a full-time work schedule would kill any such new diversions.

An even higher order reason not to retire, one that I have confirmed for myself after returning to work after both extended breaks is that I really like my work as a diagnostic radiologist. It is intellectually satisfying. I am contributing something to society. There is an extra level of mental engagement when I take on administrative/leadership roles like helping to improve a radgroup, even developing a new one. Plus, at least for the time being, non-rads always seem to want to hear about it.

Maybe the day will come when I change my mind about retiring. I could lose my vision or maybe even enough of my marbles that I have no business reading people’s scans. Radiology, or even health care as a whole, could take such a quality-of-life nosedive that I wouldn’t want to remain in the field. I’d certainly “never say never” about the prospect of shutting down a workstation for my last time but I truly hope I never want to.

In addition to recharging one’s batteries, a temporary hiatus from employment may provide time for self-reflection and recognition of what you truly enjoy about your work.

When I Had Extended Breaks Between Radiology Gigs

During the first half of medical school, I wound up with a handful of paperbacks about the firsthand experiences of med students and house staff. Some were true to life whereas others were more fictional in nature. I don’t know if I considered these books serious prep for my imminent future, but it couldn’t hurt. 

However, I think it was in Michael Crichton’s book, 

, where I first encountered the tennis expression “Running around your backhand.” If you’ve played tennis or even similar stuff like ping-pong, you’ve experienced this. Your forehand tends to be better than your backhand. An opponent might do better against you by intentionally sending the ball to your “bad” side, or sometimes the ball just happens to go there.

Faced with that situation, you have a choice. You could use the backhand. Even if it goes poorly, you’re incrementally improving, and eventually it will not be an issue. Alternatively, when you see the ball isn’t coming to your forehand, scramble to get on the other side of it. You literally “run around” your less reliable backhand so you won’t have to use it.

Outside of the situation, the choice seems obvious. You should do the work and develop your backhand since it will make you better in the long run. However, when you’re in the middle of a game, the second choice can be tempting. Using your backhand, right now, will probably cost you points. Why risk the game, not to mention embarrassment, as your opponent watches you goofily backhand the ball over into the next tennis court?

So maybe you never decide to work on it while playing. You promise yourself you will get it to it later. Maybe you imagine you will set aside some time outside of an actual game to practice. Add that to the stack of other things you say you’ll do “sometime” and see if it ever happens. Meanwhile, the deficiency of your backhand skill never gets better and, sometimes, you just can’t run fast enough to avoid having to use it.

Let’s put this another way. You can pay now (with diminished performance while you fix your situation), or you can pay later (with chronically suboptimal performance because you never actually addressed the issue).

“Running around your backhand” has seen enough use that it’s become an expression for any instance of avoiding weaknesses in the name of better performance at the risk of never fixing those weaknesses. It has come to my mind more than a few times, during my daily grind at the radiology workstation, especially when starting a new job.

There is a variety of examples. I encounter something that reasonably should work better. Voice recognition doesn’t transcribe me properly. PACS doesn’t faithfully follow my hanging protocol. Prior studies don’t get identified, uploaded, and/or displayed properly. I should be able to read a certain type of study or exams from a certain facility, but the software won’t let me because it says I don’t have the “permissions” for it.

I could go on and on because I can’t remember the last time I had a flawlessly smooth day in any job let alone life itself. Everything from minor speed bumps to axle-breaking potholes is strewn across the metaphorical highway of my daily grind. Whether it’s getting up to speed on new software, adapting to adjustments in workflow or learning new systems as part of a new job, there will always be challenges.

Whatever the issue is, I can try to fix it, whether it involves retraining the voice recognition software, or messing with the software’s features so some of its persistent errors stop happening. I could also reach out to IT or various other support people regarding the various bugs and glitches bedeviling me. I could inquire with folks in leadership about inefficiencies in protocols that might be improved, potentially for other rads as well as myself.

All of these things, however, would take time away from my reading cases and otherwise doing what is expected of me. While I am trying to get a hold of other folks, explain my situation and let them remote-in to my workstation to watch me demonstrate my issues (if, indeed, they can reliably be reproduced for an audience), I am not generating RVUs.

Maybe my job depends on those RVUs to determine whether I’m meeting expectations, or my tally will impact what I see in paychecks/bonuses. Also, being new at my job, I may want to make a good impression and show that my employer was smart to hire me. This is a key consideration, especially if I have got multiple suboptimal conditions that I’d like to see fixed. Addressing all of them, right now, might decimate my daily numbers. Plus, the last thing I want is to appear needy/demanding to the powers that be by constantly asking them for things.

Accordingly, the pressure is high for me to “run around my backhand,” and find ways to live with all the stuff that I think could/should be better. Just for now, I might tell myself. Let me adjust to everything and I can address these matters down the road.

Instead, as time goes by, I acclimate. I find workarounds for the various issues to the point that I perform well enough to satisfy myself and/or whoever is watching me. Fixing those issues would still improve my situation but I have diminishing interest in expending time/effort on them. After all, taking them on would still mean that I’m going to hit the worklist a little less vigorously today, which remains a disincentive to me.

Also, I might now have less political capital to get the assistance of others. Well-ensconced in my job, I’ve surely asked them for other things or plan to do so. The honeymoon-period from my new hire days has long since expired, and it may be a heavier lift to get anybody to do things for me.

It is unfortunate because the “pay later” aspect of running around my backhand stands to be a drag for my job and likely the work of others. If I am performing at, say, 90 percent efficiency, chances are excellent that other rads are also struggling with this. That is a lot of productivity left on the table.

A proactive rad group would make a point of tapping into this, perhaps by carving out dedicated non-reading time for troubleshooting and optimization. Quarterly or even monthly brainstorming sessions looking into these issues could be beneficial. Perhaps there could even be a handy “I’ve got an issue” button somewhere on the workstation. You would click it and record a brief description of whatever is impeding you. The audio file flies off to a team troubleshooter’s inbox, and you get back to reading your case in a matter of seconds.

Does concern over productivity and RVUs prevent you from taking the time to address weaknesses and workflow inefficiencies?

Are You Running Around Your Backhand in Your Rad Job?

Congratulations, you have arrived! Your professional corner of modern society has made it past the survival and inquiry phases. Your hows and whys are mostly sorted. You now transact at the higher level of sophistication, whether you are optimizing efficiency, mini-maxing costs, and benefits, etc. (See last week’s 

 for more of an explanation. In that regard, I once more doff my hat to the genius of Douglas Adams.)

It’s not utopia just yet though. Things arise to keep your sophistication train from chugging along. At first blush, they may seem decidedly unsophisticated by comparison. After all, you are an educated, highly skilled individual, boasting years, if not decades, of experience … and someone or something is standing in your way.

Consider some examples from our radiological world. A tech does his scanning in some way that might be convenient for him but is lousy for you and maybe a bunch of other physicians who will want to review the images. A referrer insists on the wrong types of exams for his clinical questions rather than modalities you know would yield a better chance of making helpful diagnoses. The folks making the call schedule can ruin a fair amount of your weekends.

If you value your sophistication, not to mention that of the overall team on which you’re working, you might not take this stuff lying down. Things could be better. Why shouldn’t they be better? So you ask the questions: Why are things being done this way? Can we do things differently?

There can, of course, be sophisticated responses to this. You might not like or agree with them, but you’re not the only smarty out there. Perhaps your personal preferences aren’t the same as others. Other rads doing the same work you do have reasons why the protocols that vex you are good for them. Maybe the techs’ hardware and/or software doesn’t give them the options that you think they have. There is always stuff you don’t know about that can impact the situation and once you’re informed, you might grudgingly nod your head and think “Yeah, I guess things weren’t so clear-cut.”

An awful lot of the time, though, the answers you get are less worthy. “That’s our protocol” is one of my favorites to hate. If you ask people why they do something in a less than optimal way and they say it’s their protocol, they might as well have just said, “I do it that way because I do it that way.” It’s a non-answer, right up there with the parental “Because I said so” that satisfies no kids under any circumstances.

It might not be the “It’s protocol” speaker’s fault. If a superior told them to do things in an objectionable way, they might not know the whys and wherefores. Still, I usually try to get them to say whose protocol it is so I can direct my query to the right place. If they don’t even know who I should go to, that’s a medium-sized red flag for me that someone might be hiding behind bureaucracy instead of standing up and owning one’s policies.

Eventually, I can usually find my way to someone who should be capable of explaining the reasoning behind policies and procedures. If he or she persists with answers like “That’s protocol,” “It’s just the way we do things around here,” “Nobody’s ever had a problem with it before,” etc., I know there is a lack of willingness to look at other solutions.

Alternatively, the person might have an idea of the answer, but knows it’s kind of flimsy and wouldn’t be able to explain why we aren’t doing things a better way. He or she might also be put off by actually having to do some legwork to investigate the current rationale and/or making a show of considering my alternatives, if not implementing them.

Hiding behind non-answers can be an easy way to persist in doing nothing. It works great for politicians and similar figureheads but it’s not worthy of folks in the business of providing health care. This is especially the case for those in policy-setting positions as the things they do impact a lot of health-care providers, not to mention vast swaths of the patient population.

Still, ego and inertia are powerful things, and it’s very easy to make an unhelpful adversary out of the only person who could get your sophistication train back on its rails. If he or she can avoid seriously discussing the issue with you, nothing needs to be done and life remains easy. He or she might throw platitudes at you or offer to “look into it” without addressing the matter. But if you’re too insistent, he or she might reflexively dig in the heels and feel like the existing policy is a hill he or she is willing to die on.

One of the niftier tricks of persuasion I’ve learned about in the past couple of years is getting the other person to come to the conclusion I already have. Instead of saying, “This policy needs to change,” and making my cause something that’s external/alien to him or her, I show the building blocks that led me to my current stance. I point out how the status quo is doing patients a disservice by making my team less sophisticated than it could be.

If I lay it all out for the person, he or she can assemble those building blocks and, suddenly, the idea that policies need to change is an idea the status quo person can adopt and own. If that turns out to be the case, he or she is much likelier to accept “his or her” idea without question and might actually do something about it.

The combination of subtle persuasion and allowing a decision-maker to own your idea can be a useful strategy to help remedy workflow inefficiencies. 

Radiological Sophistication Part Two: Converting the Status-Quo Adversary Into an Ally for Change

I have referenced the late, great Douglas Adams (of 

 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.

How advanced are we if we constantly settle for extra clicks, endless scrolling on multiphase contrast-enhanced scans and other pet peeves?