‘I’m Telling You for the Last Time’ (Said No Radiologist Who Was Ever Taken Seriously)

A self-proclaimed pet peeve of one of my grade school classmates was repeating herself. In hindsight, she told people about the peeve often enough that the peeve, itself, surely qualified. One hopes that someone eventually advised her that more enunciation and less mumbling might have resulted in less need for repetition.

However, it is not an unusual peeve. I wouldn’t go so far as to say that nobody likes repeating themselves. Most of us know a person or three who can be counted on to tell the same jokes, anecdotes, etc., multiple times per year. Stand-up comics make a living doing that. Indeed, the title of this week’s blog was taken from a Seinfeld HBO special wherein he showcased a bunch of his old material before retiring it for good.

If you don’t like repeating yourself, your best career option is to find work that requires speaking (or writing) as little as possible. There is only so much language to use, and most types of work involve repetitive usage of a limited skill set. Doing the same sort of stuff all day, every day, isn’t likely to result in much jamais vu.

Meanwhile, as more than a few in our profession have observed, radiology entails a lot of “pattern recognition.” In other words, we see the same things over and over. Efficiency being what it is, we gravitate toward a certain routine of words and phrases, rather than racking our brains to come up with new verbiage every time. There are only so many ways a body rad can indicate that he or she sees a hemangioma, whether by describing progressive centripetal enhancement or “macro hemang.”

It might not be the most intellectually stimulating thing in the world to engage in such repetition, but it is not particularly vexing. Nobody is forcing you to repeat yourself. You’re doing it because you believe it to be necessary, or a sufficiently small burden that beats whatever risks you imagine you would incur by not doing it.

Take, for instance, CTs for “R/O pancreatitis.” When I was a resident, at least two of my highly capable attendings would routinely state in their normal pancreas reports something to the effect of “Please note that a normal imaging appearance does not preclude a clinical diagnosis of pancreatitis.” It seemed very reasonable to follow their lead, and I never stopped, especially because I subsequently saw other good rads in the field who did the same.

Still, every time I put that statement in, a little part of my mind rebels. Do we really have to keep on saying this? Don’t the referrers know it already? Aren’t the same clinicians seeing me say this over and over, such that they know it now even if they didn’t before?

As long as I am told to “R/O pancreatitis,” I have got to imagine that whoever wrote that really thinks that I can rule it out based on my images. It is no longer a given that people ordering imaging or indeed reviewing my reports are actually physicians; I can’t assume any medical competency on their part. The disclaimer, along with many others like it, thus remains in my repertoire.

I do remain on constant lookout for stuff I can prune. Another habit I picked up from a mentor or two was the repetition of such disclaimers more than once per report, most memorably the limitation of non-contrast scans. It might be said three different times: once in the technique section, another time in the body of the report, and a final reminder in the impression. I am happy to say I kicked the habit long enough ago that I can’t remember the last time I was in its clutches.

Maybe some did it because you never really know how much of your report is actually being read. Folks who should be aware of the consequences of their no-contrast insistence have a better chance of seeing your warning if you say it more than once. I can imagine some of it was from rads who were just really fed up with having to read studies that were done the wrong way, and venting three times in a report is extra purging for your spleen.

While the self-inflicted repetition isn’t usually irksome, things change when you have to do it because someone else wasn’t paying sufficient attention to your statements. Nagging referrers about the limitations of non-contrast studies can feel like that, but unless you are keeping tabs, you don’t really know how many times any particular referrer has seen your contrast advisory.

You might get a little more annoyed when the same people keep sending you “follow-up” studies on things that you (or other rads) have explicitly stated do not need following, such as pancreatic lesions according to ACR guidelines or 1 mm lung nodules as per the Fleischner Society. Sure, it might be an easy read for you, but it is unnecessary utilization (and dosage for the patient).

There can be something of an existential crisis. If I said, “This needs no follow-up,” and you disregarded my judgment to order a follow-up anyway, why would you now trust me to read the follow-up study? Is anything I say going to matter? What is my purpose here?

The absolute worst, for me, is when I have already said something in my report and I am asked/commanded to make an addendum that repeats my statement. One flavor of that comes from the billing people that I wrote about last week. I am told that I “need” to addend that my previously dictated technique section was accurate. It is the radiological equivalent of “I said what I said.”

Repetitions to appease billing can, at least, be somewhat forgiven since they aren’t docs, and can’t be expected to understand all medical complexities. I throw that forgiveness right out the window when rads are interrupted with demands that they make an addenda to address things that are already in their report. It screams out that the addendum requester didn’t bother reading the thing before accusing the rad of doing an incomplete job.

The classic is “Please comment on the appendix.” Meanwhile, the report already said that it was normal, surgically absent, or not identified. I don’t even consider it a reasonable thing when we say the GI tract is normal and they insist on an addendum for the normal appendix (yes, genius, that’s part of the normal GI tract).