Eric Postal, MD

In my last column, I offered some of my thoughts about the value of an editor—someone other than a writer (whether it be of a column like this, or something else like a radiology report) to serve as an objective set of eyes in the name of fine-tuning.

As I’d mentioned, I can only imagine something so many times in the abstract before I start trying to apply details. The more I can fit in, the more it seems like my pie-in-the-sky ideas might have some legs. I’m not sure I’ve got something actionable here, but even if I never wind up taking it the rest of the way to reality, perhaps some of my notions will inspire a reader.

So, who do we want this editor to be? There might be any number of characteristics on one’s wish list for the position…but let me start with my “do NOT wants” instead:

We don’t want the editor to be a radiologist, or, indeed, any physician who might use the role (or appear to use it) as a peer reviewer. We have mechanisms for QA as it is. A lot of rads would be less than enthused at the notion of yet another person riding herd on them. The idea here is to support, not control, the rads whose reports stand to be edited. Also from a medicolegal standpoint, we’re not looking to introduce a potential witness to conflict with the rad.

Another reason not to have a doc (at least, a practicing one) as the editor -- their hands are full already. And, even if they weren’t, a physician’s time and efforts tend to come at a premium. This editor is potentially going to be producing some cost savings, but not actually generating revenue. Our editor needs to be inexpensive, which also rules out a lot of other experienced and credentialed types that might otherwise be wonderful editors.

We, nevertheless, want our editor to be someone who is attentive, industrious, able, and eager to learn (ideally about healthcare, if not radiology), and, of course, capable at actual editing skills: attentive reading and able to identify and fix errors of spelling and grammar, etc. He or she must also be motivated by something other than dollar signs.

If I wanted a strong pool of candidates for this, I’d be looking for young folks aspiring to be doctors. Pre-med students, even high schoolers planning on being pre-med in the near future. To seriously compete in such regard, they’d already have developed a goodly amount of reading/writing knowhow. Getting experience in the medical field would be a major boost for them (and, thus, they’d probably do it for fewer bucks than they would want from some other job).

Broadening the search a bit, we might consider med students (on clinical-rotation or on an extracurricular basis). Even certain types of residents might find it useful to spend a week or three as a radiology editor. Heck, a radiology resident on a less-than-hectic rotation might be drafted to do some editing. Perhaps some rad techs or department clerks could contribute (when they had nothing else to do, on an extra-hours basis, or even if not actually employed in the practice at the moment).

So, whoever it turned out to be, you’ve got an editor. Maybe even more than one. How does he or she fit into things?

Obviously, one or even a couple of editors aren’t going to be able to take care of all the radiology reports a practice generates—even if the group isn’t covering 24/7/365 facilities. Plus, the more “STAT” a report is, the less room there is for an editor to be inserted into the process.

Depending on how much the editorial workforce can take on, some proportion of the remainder might be chosen: Every 10th report, say, that isn’t urgently due could be put into the editor’s worklist. Maybe some rads don’t like the idea of being edited and are allowed to “opt out” so their reports are never in the mix. Maybe certain referrers are known for being picky, so a greater proportion of the studies they ordered get edited.

Once a rad dictates a to-be-edited exam, the thing goes into a Preliminary Status, where it can be seen by the referrer (or, indeed, anybody with appropriate access to the system). While still a Prelim, the report can be adjusted by the rad as much as he or she likes—since it wasn’t formally signed, he or she has a free hand, rather than being limited to Addenda.

When the editor has gone through the thing, it gets flagged for the rad to review one last time, to make (or ignore) whatever adjustments the editor suggested, and, then, formally sign it as a Final report. If a study is nearing the end of its TAT (turnaround-time) and the editor didn’t get to it, it gets flagged for the rad to sign, with an advisory to the rad that no editing occurred. Perhaps the edited reports even get a tag-line for the practice to show off what it’s doing. (“This report was processed with our premium ExpertEdit workflow!”)

Especially as the editors get more comfortable and experienced with this role, they’ll be able to take on more than just fixing spelling or grammar. Maybe, reading a report, they note that the rad referred to a lesion on the left kidney here, but the right one there. Perhaps, having gained some familiarity with rad-speak, they can see that the report might be confusing to read—for instance, referring to liver lesions in an early paragraph and, then, going back to say something else about them a page later. Or, maybe, the editor sees key findings in the body of the report that didn’t get mentioned in the Impression. Maybe a rad made some snarky remark about a referrer or other staffer involved with a case, or even the patient—the editor might gently suggest that this could cause needless trouble.

A radiology editor might also be of use when a referrer wants something clarified in a report. At least half the time I get requests for addenda or other after-signing clarifications, whatever the caller wants has, in fact, already been addressed in my report. If the report says the patient is post-appendectomy and a nurse wants to know why I didn’t mention the appendix, don’t interrupt me while I’m working on other cases or otherwise doing doctorly things: Let the editor help her with her reading comprehension.

Alternatively, if a caller’s concern does merit some additional action, the editor can take it on by directly fixing verbiage if the report is still in Preliminary status or taking down the details to then convey to the rad for him or her to addend an already-signed/Final report.

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Envisioning the radiology editor – what could that look like?

Your friend, the editor (part 2)

I’ve been writing this column, believe it or not, since 2011. It seems safe to say I have some skills when it comes to putting words together. However good or bad at various facets of it I may be, I feel comfortable in calling myself a writer.

I have also, from time-to-time, taken on a related role: that of an editor, for instance with my med school’s student newspaper. I don’t think anyone would be surprised at the notion that there is considerable overlap between the skill sets of writers and editors.

Even if one assumes no difference in aptitudes between the two, their focuses and goals differ. As a writer, I might want to put forward page after page in the name of sharing my every thought with whichever readers might be interested. As an editor, I might trim someone’s submission to be more digestible.

In last week’s column, for instance, I referenced (humorously, I hope) a number of movie-quotes with relevance to my practice of radiology. One that might have been the funniest was from a Samuel L. Jackson character in 

 I substituted the oft-misused “R/O” in healthcare for the word “what,” in one of his mini-tirades (his first scene, in which he and Travolta are interrupting some young folks’ breakfast).

I make these specifications lest readers want to imagine what would have been in the column…because it wasn’t. That particular quote was edited out of the piece. I guess because the quote had some salty language in it, and even though I liberally replaced letters in the naughty words with asterisks, I’m guessing that was considered insufficient.

Some writers might be disappointed, even outraged, when they see the work they have done being so altered. They can lose sight of the (I cringe to use the trite term) “value added” by an editor other than themselves. Not just in terms of massaging a piece to better appeal to a desired target-audience: There are things that only a different set of eyes (and associated brain) will notice when reviewing a piece.

Self-editing is unavoidably subjective; you need somebody else if you want an objective appraisal. I typically review an entry of my column multiple times before emailing it to my editor for publication. I almost always trim or adjust something on each pass. No matter how many times I go through this, however, if I subsequently see it online, I might still wish I’d said something differently. And, then there are any number of things that might seem fine to me, even with a dozen re-readings, that my editor might recognize at a glance as needing tweaking for better consumption by others.

I’ve had more than a few thoughts along these lines when contemplating the numerous pages’ worth of radiology reports I create in a typical working-day. Far greater volume is generated there, under (partially self-imposed) pressure for better speed and productivity…yet how carefully am I proofreading those reports? Maybe one speedy going-over before hitting “Sign?”

Granted, in that context I’m not trying to be witty or thought-provoking. As long as I’m accurately conveying what an imaging study showed and what it means, my mission is accomplished. Grammar, even spelling, don’t have to be perfect. Indeed, in the name of efficiency and giving the voice-recognition software less to mess with, I have embraced the usage of sentence fragments, as much as it initially offended my sensibilities to do so.

I have nevertheless come to wish that we had some sort of editor other than ourselves, in the radiological workflow. As it stands, the only editing we get tends to be when someone has an issue with reports we already signed, and, then, the best we can do is to make an addendum…which leaves the original content untouched (and highlights it as an imperfection to subsequent readers).

Some places I’ve worked have innovated a layer of software for this purpose. If you’re trying to sign off a report on a right-sided extremity, for instance, and you dictated the word “left,” you get interrupted with a warning. Or, if you’re reading a male patient, and your report mentions the uterus or ovaries. Even if you mention metacarpals in a study of the foot, or metatarsals in the hand.

One problem with such things is that there are always exceptions, and they irritate us would-be productive workers every time they trip us up. For instance, a study was of the right hip, but the left one was also in the field-of-view, and unless I try to fool the software by saying “contralateral” instead of “left,” I’m going to get interrupted when I try to sign off.

Or, it is a female patient, and I dutifully reported on the gynecological viscera. But, the tech erroneously entered the study as being on a male patient, so the software interrupts to alert me to the discrepancy. I also once got hassled by such software when I was reading a scan on a transgender patient.

Even spellcheckers can hinder, as well as help. They can miss a great many medical terms from their dictionaries, and we radiology-drones don’t always have access to an “Add” button to tell the checker that terms like “sphenopalatine” should, henceforth, not prompt a pop-up window. Not to mention the abundance of proper names we might need to include, say when documenting that we spoke to the referrer, Dr. X, or suggesting that a patient might have Lady Windermere syndrome. Also, some dictation software auto-populates certain fields with things the techs or referrers wrote, and anytime they make spelling errors or use unsanctioned abbreviations, we’re the ones who get interrupted by software alerts at signing time.

So, I have come to fantasize about what it might be like to have an honest-to-goodness human editor going over my radiology reports before I officially sign them. And, thinking about it more than once in a blue moon, I’ve moderately fleshed out the idea. I’ll go into how such a thing might practically work next time.

Contemplating an editor for radiology reports.

Your Friend, The Editor (Part 1)

I’ve been known, when I find a movie to my liking, to re-watch it…more than a couple of times. Probably 

, to most. The habit is mine, and I own it. But, I do point an accusing finger at cable TV providers who have made a lot of hay out of showcasing the same couple-dozen flicks, over and over, each month, while they’ve got thousands of options to choose from in their stockpiles.

Unsurprising, then, that I am able to recall more than a few scenes and their dialogue—in detail that some might find disturbing—at the slightest provocation. I’ve learned to curb my “Y’know what this reminds me of?” reflexes in my social interactions, lest that become way too much of a stock-phrase for me. It does not do much, however, to silence my internal dialogue.

Sitting at my home-office workstation, having only imaging studies for company, my mind conjures up things I imagine might be said to anyone involved. And, that is usually the referrers, since the “clinical histories” they’ve theoretically provided are sort of like questions or statements, with my expected response being a dictated report. My internal encyclopedia of movie-spawned quips has been known to offer some alternatives.

For instance, one of my many cases this past week was an abdominopelvic CT with a particularly unhelpful clinical history. It might not even have had one (that sometimes happens when there is literally nothing written on the case documentation. I have no idea how such studies manage to happen. Fortunately, they are rare).

As is not uncommonly the case with such exams, nothing particularly abnormal showed up on the images, and I spent more time puzzling over clues as to what could possibly have prompted the imaging than potential diagnoses of significance. As I reluctantly moved to sign my uninteresting report, this came to mind:

“[Referrer X] has dishonored himself and dishonored [our healthcare system]. I have tried to help [Referrer X]. I have failed. I have failed because [Referrer X] has not given [me a proper clinical history]!” (Apologies to Sergeant Hartman and 

Again, the majority of these imagined quips tend to be directed at the referrer. And, as long-term readers of this column will know, I have had more than an occasional bone to pick with their inability (or disinterest) to provide appropriate clinical information:

“Throw me a frickin’ bone here!” (Dr. Evil, 

“What we’ve got here is failure to communicate.” (

“You can't rely on anyone these days. You gotta do everything yourself. Don’t we?” (Joker, 

). When, having gotten zero clinical info from anyone else, I’ve gone digging in previous imaging-study reports, and come up with some relevant, even vital piece of clinical history.

Then, there are the times I’ve had to speak with a referrer (or one’s underling) about something stupid and timewasting. Like, my report says the study is normal and includes the usual list of pertinent negatives. Now, they want to ask if I looked at the appendix. Of course, while I’m on the line with them I’m entirely courteous and professional. But, it takes everything I have to keep from saying “Bye, Felisha” (

Sometimes, fellow radiologists (or other docs who fancy they can comprehend a scan) come to conclusions about an imaging-study different from my own and want me to support them:

“Yeah, well, you know, that’s just like, your opinion, man.” (

But, it’s not always about casting aspersions on other healthcare personnel. Sometimes, it’s a reaction to the imaging studies themselves. Such as, when I’ve started looking over a study, and begin to see some awful, unexpected pathology that’s going to ruin the referrer’s day (not to mention the patient’s):

“I’ve got a bad feeling about this.” (Multiple characters in the 

When I’ve made a tricky diagnosis, especially if others previously have not:

) Hey, I never said the movies I endlessly re-watched were all priceless classics.

Or, when I’ve opened a new case, and it’s a complete disaster: Patient thrashing around, weirdly positioned to begin with, contrast in wrong phase or absent, developmental-variant anatomy, deformities from surgery, pathology all over the place. Good heavens, where am I going to begin on this one? Why did I even open it?

“Well, here’s another nice mess you’ve gotten me into.” (Oliver Hardy, multiple instances)

And, then there were the days when I’d get called up about whether a 600-lb patient could undergo cross-sectional imaging at our facility:

“You’re gonna need a bigger [scanner].” (

). Happily, not as much of an issue since I left vRad, where an empty worklist meant I was earning absolutely no money for my time.

Rarely, the would-be speaker of the quote isn’t me. For instance, when the PACS, RIS, or some other aspect of my workstation-rig stubbornly won’t do something it should, I can practically hear it telling me:

“I’m sorry, Dave. I’m afraid I can’t do that.” (Hal-9000, 

When imaging studies evoke classic movie sentiments.

To Counterfeit-Coin a Phrase…

I’ve never been good with names. It’s unquestionably a personal flaw. Other people do it just fine, and there are a number of methods out there to improve this ability that I could employ, if I were sufficiently motivated.

Remembering faces is a whole different ball of wax. Even if I haven’t a clue what your name is, I’ll know if I’ve seen you before, and whether or how we interacted. Go figure: I have a “visual memory,” and, thus, wound up in a field like diagnostic radiology, where pattern recognition is everything.

Getting back to names: Unless yours is really unusual, or reminds me of something specific, chances are excellent I won’t know it as of our second encounter, maybe even the third or fourth. I’ll be scanning our interactions and surroundings for anything that can clue me in, so I can gloss over the embarrassing gap in my social skills.

Embarrassing, I say—clearly not enough. If it were, I’d do better. I’ve come to think of such things in the same light as “Fool me once, shame on you; fool me twice, shame on me.” That is, if I’m newly presented with some information that I don’t know, and/or react less than perfectly to it, it’s usually not a serious flaw for me. But, if, the second time around, I forgot or otherwise failed to learn from my initial experience, my learning/adaptation skills could use some work. The more times it takes for me to “get it,” the worse I look (to myself, if not to onlookers).

So here we are, somewhere around five months since COVID-19 was first recognized in the United States, and three months since it was declared a national emergency. Task forces, press briefings, masks, social distancing, shutdowns, stay-at-home orders, etc., ensued. Not everybody was ideologically on the same page, but with such measures there was a degree of forced-compliance to get this thing under control.

All of which was done with the understanding that the genie was out of the lamp, and that we were more about damage-control. We had to get things back to a dull roar, and, then, to minimize, if not prevent, second waves of infections now that we knew more about the situation.

We might consider the initial arrival and spread of the virus as our collective “fool me once” episode. Maybe even pat ourselves on the back for however much our initial reactions to this completely-unexpected pandemic mitigated its impact. Our chance to not be fooled twice would be after we’d gotten past the stage of peak infections, and if not prevent a second spike, at least make sure it was far smaller than the first one.

I can’t speak much for goings-on in other areas of the country, but I had a pretty good idea that we were in for a second mass-fooling around Memorial Day weekend. The weather got nice, and an awful lot of people seemed to throw all of their

cautions right out the window. Crowded beaches, backyard parties, you name it. Then, however much more noble one might consider such causes to be, a bunch of demonstrations and protests across the country, lots of close-quarter activity, with social distancing, masks, and handwashing seemingly forgotten. And, let us not forget that some states were “re-opening” in the process.

It’s not exactly surprising to me, then, that a couple of weeks after, we are seeing multiple new spikes in infections. Arizona grabbed headlines for being the worst, but Florida was in second place, and I think 17 other states were reportedly on a new upswing. And, this isn’t isolated to the United States. China, itself, is now grappling with its own second wave.

So, it seems we have a response to my column’s titular question from a few weeks ago (

): Not enough. At least, not in any effective or functional way. When you’re dealing with population-wide affairs like this, it doesn’t matter all that much if individuals, even a sizable minority, learned their lesson the first time and have done everything right. If a bunch of others sharing the same space as you are able and willing to be fooled again, they’ve got an excellent chance of dragging you down with them.

Heck, anybody who’s seen a couple of movies or TV shows about infectious-disease outbreaks (the aptly-named Outbreak, for instance), even zombie apocalypses, knows that it only takes one idiot to maintain and propagate such a plague.

I’ll be very pleasantly surprised if we don’t wind up spending our summer in much the same way we spent our spring—going back into lockdown-mode and holding our collective breath until the case-count has, once again, gone into a decline. Regardless, I’d say now is a good time to start thinking about how we might avoid being collectively thrice-fooled.

It might not be possible, if enough folks are perpetually willing to be fools. Many might regard this with the same lack of motivation that I have for improving my name-remembering skills: They might know every single thing they’re supposed to be doing to prevent viral spread and just not care enough to follow through. The bulk of the population might never be compliant enough to control this thing—our only hopes in that regard might be herd-immunity, via vaccination or otherwise.

Maybe, in the meantime, it’s possible to safeguard some portions of society. Healthcare leaps to my mind, of course, since it’s my profession and I’ve had a front-row seat to see what’s happened in it during the past few months. Maybe we, at least, have learned enough that we won’t, once again, have to shut down all non-emergent proceedings. As viral-testing has gotten more available, for instance, and we’ve been able to use it as a tool during our controlled reopening, maybe we can leverage it to avoid re-closing.

Will the lessons learned from this next surge of COVID-19 be enough to stop the spread?

Author | Eric Postal, MD

Articles

Your friend, the editor (part 2)

Your Friend, The Editor (Part 1)

To Counterfeit-Coin a Phrase…

Fool Me Twice? Thrice? Or Do We Need to Count Higher?