Dammit Jim, I’m a Doctor, Not a Ventriloquist’s Dummy

October 28, 2016
Eric Postal, MD

Putting someone else’s words in the radiology report.

Sometime earlier in my career, a colleague in outpatient imaging reminisced to me about a frustrating communication from a referring clinician. Specifically, a chiropractor wanted an addendum to a spinal X-ray that the rad had interpreted as being normal.

The chiro didn’t believe the rad had missed an abnormality, but wanted some additional verbiage that presumably made sense in the chiropractic world. However, to the rad (and me, as well as I daresay the vast majority of practicing physicians), the requested words were utter gobbledygook. Perhaps the chiro wanted this to jibe with his physical exam or treatment of the patient, or simply his billing documentation.

In any event, it came across in much the same way it might if a psychiatrist phoned me up about a normal head CT I had read, insisting that I render an addendum stating that the scan showed no evidence of cyclothymia.

The rad (properly, I thought) told the chiro that he thought his report was proper, and would not add things to it simply because someone told him to. Consequence: The chiro’s referrals, if they even continued coming to the practice at all (hardly a loss if they didn’t, as they were all money-losing XR), were shunted to other rads.

I get more than occasional requests for addenda to my reports, of similarly flimsy merit, often demanding that I say something I already said, or that I say something I believe I should not:[[{"type":"media","view_mode":"media_crop","fid":"53352","attributes":{"alt":"Radiology ventriloquist","class":"media-image media-image-right","id":"media_crop_1406499451772","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6656","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 248px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Lorelyn Medina/Shutterstock.com","typeof":"foaf:Image"}}]]

I report normal vasculature on a CT, but they want an additional comment on the aorta.

I am told to state that a patient is cleared for surgery (for instance, based on an AP portable CXR).

I say the bowel is unremarkable, and an additional statement is requested about whether or not there is obstruction.

I state, level by level, that the spine contains no stenosis of canal or foramina, and they want another reassuring negative comment about some foramen in particular.

(I’ve long since given up the ghost on getting clinicians to understand that, when I say the bowel is normal, that includes the appendix, so now my reports have a completely separate section for this structure. The best way to fight battles is often to prevent them.)

It’s one thing for a referrer to believe (perhaps after having looked at the images themselves) that I might have missed something, and ask me to maybe have another look at it. It’s entirely another to consider me a parrot or ventriloquist dummy rather than a physician, and expect me to put someone else’s words into my reports on demand.

These are, of course, also physicians, or at least noctors with equal access to the patient record. By all means, let them make their own addenda, or write a note in their patient’s chart saying what they think of the scans I have already reported in plain English (admittedly with smatterings of Latin and Greek, courtesy of medicine’s deep historical roots).

They are not, sadly, the only ones who seem to consider radiologists as Howdy Doody, MD. Also entirely comfortable with putting words in our mouths is an increasing horde of folks who have zero contact with the patients we are diagnosing. An armada of regulators and unaccountable rule writers who make unilateral, blanket decisions about words, phrases, and even paragraphs our reports have to contain. Failure to be a good little parrot means you might not get paid for the work you have done-or even more harmful consequences.

Tangentially related is the not uncommon phenomenon of addendum requests from referrers who habitually don’t bother giving a proper patient history (“Pain” or “R/O path”). Then, upon receiving a rad report which fails to answer some clinical question they never asked in the first place, they grudgingly supply some info about the patient.

In other words, referrer can’t be bothered to spend a few seconds of his time while ordering a study, but is more than fine wasting minutes of ours when we have to go back and essentially re-read the exam. At least, in this circumstance, there’s a realistic chance that patient care is being improved in the process-if only because the referrer hamstrung it in the first place.

Lest someone else feel the need to say it: Yes, we are in a service industry, and customers’ requests are generally better met with helpful responses than fits of pique. There is nevertheless a difference between accommodation and groveling.

We are professionals, physicians whose opinions are to be trusted regarding the interpretation of diagnostic imaging-but not if we willingly become clerks who simply write what we’re told.

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