Eric Postal, MD

Years before I even thought of writing my first blog, I made a series of attempts at fiction-writing. I’m pretty creative, and as a young ‘un I did more than a little reading, so I had seen plenty of examples of others’ successfully-finished products.

I never completed one myself, except for the occasional short story. I would get a great idea and dive into it, churning out page after page while I had time and a good head of steam. Then, life would get in the way, and it might be hours or days before I had another chance to sit at the keyboard…during which my mind would be moving further and further ahead of what I’d written. Eventually, the volume of ideas which awaited transmogrification into actual writing was sufficient to quench my enthusiasm.

The notion occurred to me recently: Never having gotten more than a couple-dozen pages into my would-be novels, I wondered how much blog-volume I’d written by now. Windows readily informed me that there were 459 files in my “blogs” folder. They’ve averaged around 2 pages each…Good Lord, I’ve written enough to fill three respectable volumes.

Of course, this is the result of pacing: Putting together a few hundred words once per week, rather than trying to crank out the Great American Novel before I get bored with it and would rather be doing something else. If you told me, back when I started this column in 2011, that I would be writing close to a thousand pages in the next decade, I might not have believed you. Even now, the thought is rather exhausting.

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There’s a parallel to be drawn between this and one’s body of work as a diagnostic radiologist. If an early-in-career rad is sizing up a prospective job that expresses an expectation of X number of RVUs a year, or Y number of cases per day, that might sound daunting. The young rad might not even know how many cases, let alone RVUs, he’s able to do comfortably/competently. Or how the particulars of a given workplace will help or hinder that.

Learning one’s capabilities doesn’t make this entirely vanish. Knowing in the abstract that I’m capable of X amount of work is one thing. Being told that I can expect to 

 X amount is another, potentially anxiety-provoking matter: Will I continue to perform as I have? What if they give me more than X? What if what they give me turns out to be more complex than I’ve previously seen, and I can only do 80 percent of X? Will they expect me to ramp up and do more than X in the future? How can I increase my capacity?

I’ve probably mentioned at some point that my first job after fellowship was in an outpatient practice that routinely maintained a backlog of cases. You’d walk into whatever reading-room you were assigned for the day, and there would be shelves and stacks of folders waiting for you. Almost every day I was there began with a withering sense of “How on Earth am I going to get through all of this?”

Each case can feel like a drop in the ocean, especially if you’re sizing up everything you’ve got ahead of you all at once. Heck, even in hindsight: there have been times I look back on a busy workday, or some other task, and thought, “How on Earth did I do all of that?”

One way to get through it is to avoid focusing on the individual drops. Back when I ran on my school’s “track and field” and “cross-country” teams, I found out for myself that it was an awful lot easier to run my miles when they weren’t divvied up into countable things like laps. One “away” meet was at a school with an eighth-mile track instead of the usual quarter; having to do twice as many circles, even though it was the same distance, was a killer. I maintain to this day, that gave them an unfair home-field advantage.

In our line of work, however, I try to resist seeing the forest instead of the trees. Each one of these cases is our contribution to someone’s life. Whether it’s checking up on the status of their cancer or screening for it. Evaluating their bone density or carotid arteries to see if anything might be done to avoid hip fractures or strokes. Finding potentially-treatable reasons for symptoms…or evidence for reassurance that nothing bad is going on.

Just as I look back on my 900-plus pages of blog-writing, a rad might think back on however many thousands of lives he’s touched each year. If you’ve been in this game for even a little while, chances are excellent there’s a decent number of people alive today who might not have been without your contribution to their care. Or enjoying better quality of life.

On top of that, there are more than a few clinicians who are now wiser as a result of having interacted with you. You might have taught one how ultrasound is better than CT in a given situation, or why it’s worthwhile to give oral contrast rather than just throw someone on the scanner in the name of “throughput.”

There are surely also other rads who have learned by reviewing cases with you, or seeing your work when it’s a prior study they’re using for comparison against a current case. Indirectly, your impact on them has benefitted the innumerable drops in their oceans, as well.

Follow Diagnostic Imaging Editorial Board Member Eric Postal, M.D. -- @EricPostal_MD

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How many lives have you changed, one scan at a time?

Another Drop in the Ocean

In my relatively new Twitter account, I’ve referenced some intellectual interests that have graced my life in recent months: the skills of persuasion and negotiation, underpinned by cognitive science. My undergrad degree being in psych, it’s not exactly surprising that this stuff would resonate.

I’ve found myself viewing much of daily life through these new-to-me lenses. Even when remembering events of years gone by, I see new angles to them. One episode harks back to my residency…I might have referenced it in a previous column.

Our hospital had given control of its radiology department to a local private-practice group, and while most of our attendings had opted to stay on as its employees, some of the group’s members were new faces in our corridors. Even the group’s leader would occasionally put in an appearance.

His first encounter with one of the junior residents was in the non-interventional fluoro area. The leader-guy marched into the room, eyeballed the day’s schedule (which never had more than half a dozen assorted barium exams, spread out over the morning and early afternoon), and told the resident, “I want all of these studies done by ten o’clock.”

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The resident was a good, likeable guy, easy to get along with but not afraid to be blunt. Surprised and irked by the demand, his bluntness was on full display as he informed the leader that there was no way the edict could be fulfilled. The leader, perhaps unaccustomed to being challenged by a subordinate, seemed somewhat horrified and left the scene. Fluoro cases proceeded with no more alacrity than they ever had, that day or any subsequent.

Until now, I’ve regarded the exchange in the same way I did as a resident, and, indeed, the way the junior did that day: the leader was being imperious and demanding. His first day in the place, he struts around, and tells folks who have been working there that they’re going to abruptly do everything differently on his say-so? Whether or not logistically possible?

I have no way of knowing what the leader’s goal was in that exchange. Maybe he genuinely did want the fluoro service to run more efficiently…or maybe he just wanted to impress the resident and nearby rad-techs that he was a take-change, watch-me-improve-everything kind of guy.

Whatever his motives, he could have gone about them more effectively. Rather than barking out demands and, then, retreating when they were not well-received, he would have been far better served by gathering information and recruiting the resident and techs to his cause.

For instance, instead of “I want all of these cases done by ten o’clock,” he might have taken a thoughtful look at the schedule and, then, started asking questions about it:

“Is this a typical daily case-load?” “How frequently do cases get added on?” “How long do these cases tend to take? Are they difficult?” “What else do you have to do, that doesn’t show up on the schedule?”

He would have done well to not only listen to the verbal responses, but also note tone of voice, posture, gestures, etc., accompanying them. The techs and the resident might have had valuable information or insights that could, then, be teased out with follow-up questions.

For instance, had the leader invited the staff to help him understand the situation, any one of them might have pointed out that the limiting reagent was not their desire or ability to get cases done…but, rather, the incredibly balky and inefficient system that got patients down from their rooms to the radiology department. Nurses on the wards and patient-transporters had plenty of other demands on their time, and/or weren’t particularly motivated to maximize throughput for imaging studies. You could go ahead and schedule two or three times as many fluoro studies each day, but all that would happen would be patients showing up hours after they were supposed to be there, and, then, sitting around even longer waiting to be brought back to their rooms.

Armed with such information, the leader might have understood that the problem he needed to attack was not his own staff in the rad department. He might have taken things up with hospital administration. Perhaps gotten a patient-transporter or three specifically assigned to radiology. Gotten dispensation for one or more rad-techs to go and fetch patients themselves, when feasible.

And, in his first interaction with the resident and rad-techs, he would have come off not as a haughty Grand Poobah, doing a drive-by on his high horse…but, a down-to-earth new guy, wanting to learn the ins-and-outs of the place just like anybody else. Except with the clout to maybe make some things better.

I did say, however, he only “mostly” botched this. What did he get right -- aside maybe from establishing that he was in charge and comfortable making demands?

One item is that he expressed what he wanted. Not everybody does that, and at some point in every negotiation you need to plainly communicate what you want to the people who can give it to you.

And, maybe he didn’t really want all of the cases done by 10:00 a.m. Maybe all he was after was moving the needle, getting cases done sooner in the day. In a negotiation, your first “ask” shouldn’t be the same thing as what you’re ultimately willing to settle for. So, if fluoro cases ordinarily got done by mid-afternoon, maybe an initial demand for 10 a.m. would ultimately lead to having things done by lunchtime. Turning fluoro from a full-day schedule into a half-day, after which your personnel can be allocated elsewhere? That’s a “win” for efficiency.

Believe it or not, this is just the tip of the iceberg. Tempted as I was to make this a marathon column delving into the various other ways this rad-group leader could have done better, let’s give your eyes a rest, shall we? Come on by my Twitter page and we can discuss the rest!

Taking time to ask questions – instead of announcing mandates – can be far more effective.

A Mostly Botched Attempt at Leadership

One of the biggest logistical wastes I have seen in the world of radiology has been in the setting of follow-up studies. I’ve poked some fun in the past at the referring clinicians who are involved (imagine, you spend as much as a decade between med school and post-grad training so you can be qualified to write orders like “F/U nodule” multiple times per day). But, today, my focus is on our end of the process.

“Process,” really, is a rather generous term for how most rad groups approach it, because things rather seem defined by a 

 of process. A rad who said something should be followed almost never knows if follow-up happened, outside of some structured setting like a research project or mammo practice. The technologist whose schedule includes the follow-up imaging study doesn’t necessarily know what is being followed or whether there are particular ways the study should be done to make this follow-up effective or conclusive.

The rad receiving the study, who’s expected to render a decision as to whether the thing being followed is improved, stable, worsened, or better characterized, is the one in the “hot seat” and, thus, seems to me the variable that’s most appropriately (and effectively) adjusted to fix matters.

I’m sure this isn’t a problem in some practices—perhaps academic or otherwise heavily-sub-specialized groups. I can only say that I have yet to work in such a non-problematic environment – or know anyone who is. It seems the majority of radiology groups are simply too hectic (one might also say over-burdened, even over-extended) to make this a priority.

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One remedy I’d suggest, if at all feasible, would be to make it a policy that any follow-up study gets earmarked to be protocoled and read by the rad who recommended the follow-up. That rad knows better than anyone else what was going on in his or her mind when he or she made the recommendation, and this eliminates the chance for disagreements between original and following rads. It will also cut down on the time it takes to interpret the follow-up study, since a rad following himself or herself will recognize or remember his or her own work…as opposed to some other rad having to review the prior case.

Of course, that’s not always feasible. Even if the follow-up study is routine or non-emergent, sometimes the original rad will be unavailable, or the follow-up study will be at some facility other than the one the original rad covers. (Though, I would suggest that part of this effort could include making sure the patient got scheduled at one of the rad’s facilities, at a time when he or she would be around.)

The next-best thing would be to earmark an interpreting rad when the follow-up study is scheduled, so he or she can protocol it to whatever specifications he or she feels will be necessary to do the follow-up properly. Again, this might not be an issue in some groups where rads routinely get to protocol their own studies, but I’ve yet to see that outside of my residency or fellowship institutions.

 study explicitly performed for follow-up gets done with all relevant priors ready for comparison and review by the interpreting rad. Priors done at another facility? Have them requested/delivered/fetched before the current scan gets done. The whole “Priors not available, referrer insists on a read now and will expect a detailed addendum later” is a duplication of work that should be avoidable the vast majority of the time.

So, for instance, I get an alert that there’s a pending “follow-up” case that will be mine to read, and here’s my chance to protocol it. I can now look over the prior study and see what I think is needed. Is it a nodule in the dependent portion of lung, where incomplete inspiration might obscure it? Maybe I want the CT tech to position the patient prone and urge him to make sure the patient does a maximum inspiration for the scan.

Maybe the original study was a dynamic-contrast liver MR, but I can see that the follow-up has been scheduled non-contrast. Now I have a chance to get the study modified to include IV enhancement. Or, maybe I think another imaging modality would provide more answers than just re-doing the last type of scan.

Maybe I don’t think the study should be done right now—the prior recommended follow-up in six months, and it’s been a couple of weeks. I, now, have the chance to get the referrer on the phone and see if this was an error, or if he or she has another reason to re-scan early.

Maybe I don’t think the study should be done at all—the original rad didn’t suggest follow-up, but some referrer is doing it anyway—again, a chance for me to get on the horn with the referrer and possibly spare the patient some radiation. Or, the original rad recommended follow-up contrary to guidelines of the Fleischner Society or Lung-RADS. Perhaps I don’t even see the lesion he or she is referring to, and I’d like him or her to point it out.

All of this amounts to more work on our part, in exchange for zero extra reimbursement. Heck, it might even result in a little net-loss if we canceled or delayed a few studies—although that could possibly be counterbalanced by more efficient reading of the follow-up studies when they do happen. I can also imagine a reduction of medmal-exposure with this approach.

Most importantly, I have a hard time seeing how it could fail to improve patient-care, and referrers might just come away with the impression that, when we recommended “follow-up,” we’re actively managing it as a plan, rather than some knee-jerk CYA maneuver.

Double-check behind those follow-up orders – is now the time, is it the right study, are prior studies needed?

Not Following Blindly

In recent columns, I’ve mentioned gradually wading into deeper waters of social media, and how this has led to greater communications with other professionals, radiological and otherwise. It feels a little more profound than sharing dank memes with Facebook “friends” I’ve never actually met.

Last weekend, one of my new LinkedIn contacts—in radiology fellowship, but far more accomplished than most budding rads are at that stage—suggested that I get in the game on Twitter. He had kind things to say about this little blog of mine, but thought I’d do well to have a larger social media profile.

I haven’t been an early adopter when it comes to this stuff. I never even considered getting into MySpace, and while I think I started using FB before it peaked, it probably wasn’t all 

 long before. I only started using LinkedIn this year and haven’t touched any of the others except for when I hear of an interesting post, and I can go snoop without creating an account.

It never occurred to me to create an account so I could “follow” anyone. I know the meaning of the word “follower” has morphed, but in my mind it still conjures up notions of subservient, sheep-like minions, if not cult-members. The wrong end of a leader-follower dichotomy. If someone called me a “follower,” I might feel insulted.

That said, I also don’t think of myself as someone who’s got enough material to attract and retain followers on Twitter. Heck, sometimes I have difficulty coming up with material for this column, and I only do that once per week…what on Earth could I have to offer on a daily (or even more frequent) basis that would make someone want to follow me?

Underscoring that: I wouldn’t consider most of my thoughts to be fodder for such a public forum. The permanent nature of the Internet (go ahead and delete whatever you said, but it’ll still be out there somewhere), offensitarianism, and troll-culture being what they are, I think anybody with something to lose—including professional reputation as a physician—is tapdancing in a minefield by going on social media at all…

 if saying word one about matters sociopolitical.

Even if it’s something that a doc should reasonably know more about than the general population—for instance, a proposed change to national healthcare policy—pretty much no matter what stance the doc takes, about half his audience is going to disagree. Probably strongly, if not angrily and vindictively. Why risk alienating so many people? What’s to be gained?

Let’s say a rad nevertheless wants to give tweeting a go and plans to avoid such things. What’s left to post? I’ve seen people share interesting cases, advertise their practices, discuss new academic discoveries, etc. Not so coincidentally, things I’ve pretty much never done in the 9.5 years I’ve been doing this column. If I did try to focus on such “safe,” professionally respectable topics in tweets on a daily basis, my lack of such material—or interest in same—would be on full display.

If I blundered on ahead—pretending to know/care about such things while surely being seen through by any savvy onlookers, or risking my future reputation by delving into more divisive, emotionally-charged stuff—I think I might just stand revealed as more of a twit than a tweeter.

And yet—that rad-fellow mentioned above sure seemed to know what he was talking about. If another rad with far more social-media experience tells me I should get into it, might I be more of a twit if I 

After all, I have no real idea of how many folks actually read this column, or how tweet-hungry they are. Maybe, since they usually see one column from me per week, they’d be fine with an occasional extra line or two? Not unfollow me for the sin of failing to post on some days? Perhaps they’d just like a forum where they could comment on each of my weekly blogs. Responding to comments might just be hectic enough to keep me looking engaged.

What the heck, let’s give it a try. If nothing else, I’ll find out how many folks make a point of regularly reading this column. I created a Twitter account, calling myself EricPostal_MD. I might already have been a twit and done that wrongly, because a quick Google-search for that name turned up diddly-squat. I guess I’ll know soon enough if followers start to appear.

My first act with that account shall be to “follow” the rad-fellow who inspired me to create it; come on by and discover who he is! (I won’t follow anyone else for a few days, to make it easy for you.)

Follow Eric, a member of the Diagnostic Imaging Editorial Board, on Twitter --

Follow Diagnostic Imaging Editorial Board member and regular columnist Eric Postal on Twitter.

Author | Eric Postal, MD

Articles

Another Drop in the Ocean

A Mostly Botched Attempt at Leadership

Not Following Blindly

Twit, MD…Might That Be Me?