Eric Postal, MD

At some point during my more-hectic-than-usual Thanksgiving work week, I got messaged from our telerad support-staff: A patient whose spinal MR I had read wanted to talk to me.

Your mileage may vary, but in my practice it’s vanishingly rare for a patient to speak directly to a rad who interpreted their stuff. Excepting things with a personal touch, such as interventional or other fluoro, diagnostic mammo, etc.

I could go into all sorts of reasons for this, but a lot of them can be summed up: prior to the referral for imaging, there’s been an interaction between a patient and his physician. When that physician decides that it’s time for imaging, s/he’s creating a new interaction with a radiologist.

The referrer is the only one in the mix with a full understanding of the circumstances necessitating imaging (think of the difference between a patient’s chart in the referrer’s files and the typical “reason for imaging” that the rad receives). Thus, he or she is the best person to explain or discuss results of that imaging with the patient. Creating a new interaction between patient and rad, excluding the referrer, opens wide the door to potential misinformation—not only for the patient, but also for the rad to potentially enter into the medical record. More than a few referrers would be perturbed, if not downright angry, to learn that this had happened.

So, when I received this message, it got me on high alert. Something potentially unkosher was afoot, and I’d best tread carefully. I had our support-staff advise the patient that he should speak with his physician, who had all of the relevant info, and if, then, needed, his doc could speak with me.

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Support-staff successfully did this, mentioning to me along the way that it seemed like the patient wanted me to amend my report, which had described his spondylosis as being mild, to say it was “moderate.” Regarding getting his insurance to pay for something, perhaps surgery. (By the way, I had another look at the images, just in case, and there was nothing on them to justify such a change from me.)

Fast-forward a couple of hours, and his physician was on the line. I took a deep breath, ready to be pressured to alter my interpretation in order to get the insurer to play ball. Happily, the physician was not after this—indeed, had no idea why the patient had contacted her office to get her to speak with me until I told her. She was mildly horrified at her patient’s request, and reassured me that there was no way she would ask such a thing of a rad. A few pleasantries later, we returned to our respective workdays.

Aside from my internal fretting, I can’t think of an easier/better way this episode could have gone, thanks to the telerad support-staff who ran interference for me. If, instead, there were no buffer at all to people ringing me up at my workstation, the patient would have easily gotten ahold of m, and caught me flat-footed. And, depending on how insistent he was, no amount of diplomacy might have enabled me to stand my ground without him going away mad.

He wouldn’t be the only one able to directly contact me. It could be any random patient (or referrer), whose studies might have been read by other rads. Family members of patients. Insurance companies. Recruiters. Political pollsters. Nigerian princes, you name it.

Pretty much anybody reading this has had the unpleasant experience of trying to phone someone—their own doc’s office, maybe, or some other business (banks and airlines leap to mind)—and being in that patient’s position of not being able to get through to the person who seems most suited to solve a problem. There’s an entire industry built around running interference.

The big difference there, however, is that most of that is about wearing down the caller to the point that s/he hangs up, or maybe doesn’t even try in the first place, thus diminishing the business’ overall burden of incoming calls. This often happens with the assistance of a touchtone-maze and recordings that steer the caller to dead-ends, if not an on-hold purgatory.

Legit instances of running interference do exist, however, and I’ve happily been shielded by them for the past 9-plus years of my radiological career. It was such a seismic shift in work environment from my previous jobs that I am increasingly amazed when I hear of other rad groups that haven’t instituted similar measures. So much efficiency is needlessly lost, and so many avoidable problems allowed to occur.

Screening out telemarketers and other outright fluff is a good start, but that’s amateur-hour. It doesn’t take much more training and effort to have phone-answerers direct calls so that rads are only interrupted by queries pertinent to them (cases they personally have read, or are capable of reading/protocoling, for instance).

It can get even more efficient than that. Suppose a referrer wants to talk to a rad about a specific case. If the support-staff can get the relevant information (medical record number, for instance), and shoot that in an instant message to the rad, he can get the case on his screen and message back that he’s ready to talk. If the instant message can be embedded with a hotlink to the case in question: rad clicks on it, and the case (including report) comes right up on his screen, ready for review/discussion.

Coordinate this process with support-staff in the referrer’s office, and neither doc has to get on the phone till they are both prepared to discuss the matter at hand. Referrer tells his staff he wants to talk with the rad about patient’s X’s scan. Staff contacts rad group staff with the request, and rad group instant messages the details to the relevant rad. Rad indicates that s/he got the instant message and has the case open, staff connect her/him with the referrer, and the game is afoot. Just about every second the docs spend on the phone is with each other, discussing the case…no wastage of doctorly time.

 hearing a referrer breathing in their ear as they fumble around to get the case on their screen, including spelling out the patient’s name in a search function, and, then, trying to re-familiarize themselves with the case on the fly. To each his own.

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Articles

When support staff step in to control communications and keep the workday running smoothly.

Running Interference

I’ve mentioned, here and on my Twitter page, some recently discovered interests during these months of living under COVID quasi-house-arrest: persuasion, influence, and negotiation, approached from a perspective of cognitive science and real-world practical applications.

One of the more valuable points I’ve been learning to apply is a healthy skepticism of “yes” when it comes from someone on the other side of the negotiation-table…and that includes when there’s no actual table, or, indeed, formal negotiating going on.

The problem is that an awful lot of the people who tell you “yes,” or its equivalent, don’t really mean it…at least not in the way you think/hope they do. They said it because they feared what you might do if they didn’t. Or, maybe you were just very convincing in the heat of the moment, and they subsequently realized they felt otherwise. Possibly they are just very uncomfortable saying “no.”

However you wound up with such a “yes,” it might not turn out to be something you can count on. Whoever said it to you might subsequently drag their feet or even walk it back. That is, they said “yes,” but their actions are a “no.” Maybe they even resent you for having gotten the “yes” out of them, and they blame you for putting them in this awkward position.

A neat thing about learning such things is, courtesy of a fairly robust memory, I can look back on any number of events in years gone by and see how they applied before I knew about them. And contemplate how, if I knew then what I know now, I might have acted differently to arrive at better results.

Case in point: my last pre-teleradiology job. I’ve written about it in this column before, a pair of outpatient imaging centers. I signed up with a four-year partnership track, knowing that the region was decidedly 

 job-seeker friendly, and any promises of partnership should be taken with more than a few grains of salt.

Still, I knew I was bringing a lot to the table—not just my radiological skills, but a pretty darned good work ethic and a few other virtues that don’t necessarily get taught in med school. I expected that, in four years, I would more than demonstrate to the guy who ran the place that it was in his best interest to retain me by offering something genuine, even if it hadn’t initially been his plan to do so.

Interrupting the narrative just a sec: Note that I was aware his “yes, you can be partner in four years” was liable to be a falsehood -- a no-in-yes-clothing. Yet, I proceeded with the idea that I could turn that “no” into a “yes.”

Just about four years later, I gently reminded him that we were just about due. There was no chance that he’d forgotten; I had simply learned that he feigned forgetfulness when it came to things he wanted to avoid or delay. With my reminder, he wouldn’t be able to do that.

Thus began a campaign of months to get him to live up to the “yes” he’d given me. Almost any time the subject came up, it would be by my prompting, and he’d apologetically talk about his accountant or lawyer needing to do this or that. A reasonable enough response, at least initially…although it could be said that a good-faith partnership track would have details and documents ready to go pretty shortly after my four-year anniversary, if not the day of.

My inquiries were initially respectfully spaced a few weeks apart, but as time moved on – and it became clearer that some serious foot-dragging was happening – I gradually shortened the interval to turn up the heat. Not quite halfway into my fifth year, he finally coughed up his “partnership” terms, which I’ve detailed in one or more previous columns: a bad joke, if not an insult. Absolutely nothing of value, other than being able to say I was a partner. I’d own non-voting shares of stock in one of his money-losing corporate entities. I would not have the right to sell those shares, and they could be reclaimed at any time without compensation to me.

In other words, he had said “yes” to the notion of my eventually attaining partnership (he even used the term “equity”) when I interviewed, reiterated the “yes,” as the four-year track went along, again at its terminus, and, then, repeatedly over the course of the subsequent half-year. Then, finally having to follow through, his action was about as close to a “no” as he could get without actually saying the word. (Hence, I left.)

Whether he was lying from the very first “yes,” or he was initially genuine but came to realize he didn’t want to live up to his promises, his “yes” was counterfeit. Just a few years out of training, it was easy for me to be dazzled by the notion that, “yes,” I would be a partner in a successful radiology practice, and, thus, I was ready to be taken in.

Encountering the same situation today, I would be far-better armed with the awareness that, as my negotiation-guru on Twitter has aptly phrased, “Yes is nothing without How.” Have I really worked through the underlying issues with the person telling me “yes,” so I know it’s supported by a plan of action? If not, the negotiation isn’t over. Similarly, I know not to doggedly pursue a “yes,” especially in the face of resistance. Some people will tell you want they think you want to hear just to get a confrontation over with.

Most radiologists have, at some point, heard of satisfaction of search, AKA “happy eyes.” You’re looking over an imaging study and see an abnormality, especially one that relates to the reason for exam. Hurrah, mission accomplished…and, you are now psychologically at risk for missing other findings as you finish your interpretation.

Missing More Than the Gorilla in the Reading Room

The same self-discipline that helps a good rad avoid falling victim to satisfaction of search can apply to following through after receiving a “yes.” “Happy ears” can be just as misleading as “happy eyes.”

An agreement or a promise does not mean much if it is not clear how you can or will reach the goal.

The Poison Pill of “Yes”

I wrote last week about a feature of some rads’ workstations: a button that can, with a click or two, send a case from the worklist into a “needs something done” pipeline. More images/recons, priors uploaded, better clinical history, etc.

Even when that button is superbly programmed and supported by conscientious, capable personnel, it’s not a panacea. There are any number of circumstances where a case can be read as-is…although it could have been done better, and it’s not worth everyone’s time and trouble to do anything more for it. Or, nothing is wrong with the case, per se, but the situation surrounding it is, shall we say, suboptimal.

Example, conveyed to me by a rad who saw last week’s column and could have used a button—or something else—to punch during a frustrating bit of time-wastage at his station. It started innocently enough with a chest X-ray, no priors, for the brilliant clinical history of “Abnormal finding of lung field.” Normal case, he moved on.

A day or three later, he got an addendum-request: The referrer wanted it compared against an abdominal X-ray. For whatever reason, the AXR was not uploaded on the same system as the CXR had been, so the rad had to go back and forth between two programs. Also, while the abdomen’s pics had been uploaded, its report had not, so there was no hint as to what might have been seen that needed comparison (if anything; addendum-requests don’t always make sense).

Interrupted in his hectic day and annoyed, the rad had no idea what was supposed to be compared. The AXR and CXR barely had any overlapping anatomy. He reviewed what little there was, saw nothing of note, and said so in his addendum. Also commented to the staffer who had brought him the addendum-request that the prior wasn’t uploaded to the regular PACS; please make sure to do that in the future.

Fast-forward another day or three: Rad gets another addendum-request for the same case, from the same staffer. Only 

 is it specified that the addendum is supposed to regard the AXR’s questioning of a nodule in the lung base, and indeed, now the report for the AXR has been provided, commenting on the possible lesion. Even so, the AXR has still not been loaded to the regular PACS, so the rad has to go back and forth again.

None of this should have happened; the original CXR clinical history should have mentioned that the CXR was for a possible nodule seen on a prior study, the prior study should have been uploaded as a comparison in the first place, its report should have been there for review, and if, by some mistake, any of this failed to happen at first blush, it should 

 have been corrected when the first addendum-request indicated that something was missing.

Looking for the third time, the rad was relieved that there was no real nodule there. But, he could vividly imagine the embarrassing scenario of having to say in a second addendum that, yes, it was there and he’d missed it 

. Further, he’d now spent at least thrice the amount of time he should have on the case, and was pretty ticked off…in part because he had no reliable way to prevent the exact same thing from happening again.

He could have gone on a mission to find someone of authority to tell his tale. But, would it be worth his time and effort? Would they be able to do anything meaningful? Would they be motivated to try? Or would they just write this off as another overworked rad complaining about the imperfect world he lived in?

So, instead, the rad vented to me. As I’ve said more than once in this column, I find it highly flattering that I’ve gotten to a point where complete strangers find it helpful to unburden themselves to me – and gratifying when I can be of assistance to them. Plus, sometimes it gives me fodder for this column.

The rad’s story is far from the first I’ve heard of its type. Pressured to get an obscene amount of stuff done in limited time, with high quality despite suboptimal resources and infrastructure, one is going to encounter all kinds of stumbling blocks. Some have clear-cut fixes, others are murkier, and yet others have no visible solution. But, that doesn’t diminish the frustravation (like that? I combined “frustration” and “aggravation” into my own little sniglet, many years ago) they cause.

I, thus, conceive a new button on a rad’s workstation: Feedback/Venting (F/V for short). Simple enough to implement: The user clicks on the thing, and, immediately, it starts recording him via his voice-recognition microphone as he verbally relates whatever issue he’s experienced. No typing necessary, just click a “done” button when finished speaking. The rad doesn’t have to schedule a meeting with anyone or even get ahold of somebody (in person, or on the phone). It’s immediately available, whenever he needs it.

One or more folks up the chain-of-command in the group periodically reviews these recorded messages. The “efficiency officer” I once described in this column would be an ideal person for this because at least 

 of the recorded messages are going to showcase aspects of the workflow that could use improvement. Or, “never events” that are warning signs of disasters waiting to happen, which might get shared with the “risk management” people.

Others won’t be, which is why the button is clearly labeled as a vehicle for venting instead of exclusively for constructive feedback. Whoever listens to the messages will know that, and, thus, take everything he hears with a grain of salt. Heck, he might find some of it entertaining. Meanwhile, the frustravated, even angry rad vented into a digital recording—instead of at some undeserving tech, referrer, or (God forbid) patient.

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Venting into the ether when you are "frustravated" can be cathartic.

The Feedback/Venting Button

One of the neatest things about having an online presence as a known teleradiologist is getting to hear from far more radiologists than I otherwise would have. Whether or not they initially contact me to pick my brain—which, as I’ve said before, I find extremely flattering—invariably they share their own experiences. I wind up with a vicarious peek at the innards of many hospitals and rad groups that I’d personally never see.

A very common theme: Group/facility X could go about something in a simple, easy way. But, instead it opts for something complex, inefficient, and/or more taxing to those working in their systems -- even when it’s pointed out how things could be improved and the folks who could make such changes have no reasonable explanation for why they’re maintaining the status quo.

For instance: One of the things that vRad got right (and, indeed, one of the few things I miss about working in their system) was that there was a quick-n-easy way to deal with imaging studies that could/should not be read as-is. A clickable button on the RIS screen would bring up a short menu of the most common issues: sonographer didn’t attach a worksheet, multiplanar reconstructions were missing, prior studies weren’t uploaded, etc. There was, of course, an option to choose “other,” and type in your own issue.

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When a telerad did this, the case would vanish from his screen and not return till the folks behind the scenes addressed the issue, at which time the case would return to the rad if he was still working.

Another doc who worked alongside me in the virtual trenches of vRad, recently shared with me his frustrating scenario. Having also moved on to another telerad-type gig, he had a similar setup on his RIS. Not quite as robust, but still a clickable button for use whenever a case could not be read “as-is.” The resulting menu options weren’t as good, and he more frequently had to choose the “other” option, which necessitated typing out whatever was wrong with the case.

Whether or not resulting from this less robust mechanism, the issues with defective cases were resolved less frequently. It felt like as much as half of the time he used the button, cases came back to him without anything changed. If he wanted to press the issue, he’d have to click the button and re-type his complaint, hoping for a better outcome.

Unsatisfying as that was, the real frustration he shared with me was from a new development. He’d gotten a message from one of the high-ranking, behind-the-scenes (non-physician) people in his group, ordering him not to use that button anymore. If he has issues with a case, he should now forget the button exists and instant-message or call one of the Operations people. To date, the reason for this change has not been explained. He doesn’t even know if this directive is exclusive to him.

Let’s contrast these workplaces’ solutions to the common issue of a case not being readable when a rad opens it:

1: Give the rad a two-click solution to flag the problem so others can deal with it, while the rad moves on to other cases that are ready for him to read. At most, perhaps, he has to do a little typing to explain the case’s issue.

2: Give the rad a clickable recourse that almost always requires him to type. It only works about half the time. Now, take that away from him, and tell him that he has to type out his issues 100 percent of the time or find someone who will answer their phone and explain everything to them, including spelling out patient names, medical record numbers, etc.

One hopes that the rad will eventually find out that there was a good reason for taking this tool away from him. In the meantime, his group has moved from a quick, simple solution to a more time-consuming, complex one. It has chosen to make reading these problem cases into more of a hassle for him, perhaps to ease the burden on the non-rads behinds the scenes who had been receiving the alerts generated by the rad’s usage of the button.

What do people do when they are confronted by recurrent, problematic circumstances that they can’t fix? Do they cheerily take it in stride or grumble a bit, but muscle on through? Maybe some do. At least, for a while.

Human nature, however, develops other behaviors that avoid hassles and obstacles. We like simplicity, and we tend towards the path of least resistance.

So, in scenario No. 2, might we have an increased frequency of rads, confronted by yet another problematic case, just heave a heavy sigh and risk reading an ultrasound without the sonographer’s worksheet? The images 

 straightforward, after all. Risk reading a CT for unspecified “follow-up” without a provided prior study? The study 

 pretty negative, so maybe it’s not really worth the hassle of getting someone on the phone to ask whether they forgot to upload the prior.

Every time a rad convinces himself that this simpler path of least resistance is reasonable, there’s a chance of patient care suffering. Maybe a referring clinician will be unimpressed. Maybe a med-mal lawyer will get a nice payday.

Or, perhaps, the rad gets a little more comfortable with the idea of opening a case, seeing it’s got issues, and, then, quietly putting it back for someone else to deal with because it’s late in the day and his RVU-tally is less than it should be. Easier to grab another case that he can read out as-is.

Rads are the one thing that a radiology practice cannot do without. They bring in the revenue that keeps the place afloat, and, indeed, pays everyone else. If you’re giving anybody the infrastructure they need to do the best job they can, with the fewest headaches along the way, it seems they should be the primary focus.

Follow Diagnostic Imaging Editorial Board member Eric Postal, M.D., on Twitter: @EricPostal_MD

What options do you have when presented with cases that cannot be read “as-is?”

Eric Postal, MD

Articles

Running Interference

The Poison Pill of “Yes”

The Feedback/Venting Button

The Simplest Path of Least Resistance