How to Address Superfluous and Outrageous Radiology Addendum Requests
Is there a proverbial line in the sand for reasonable pushback against seemingly extraneous addendum requests?
Suppose you retain a lawyer to update your will. He does his thing, and you look over the document he produces. You then tell the lawyer to rewrite it in Victorian English.
The lawyer might be a little taken aback, and/or ask why on Earth you need such a thing. He might advise you that it won’t make the will any better, or even that it could impact the functional value of the thing.
If you insist, however, chances are excellent that the attorney will go ahead and do it (probably via ChatGPT). Of course, it will cost you more, however much extra time it takes him times his hourly rate. The same sort of thing might happen if you go to any other professional and demand that he or she skew their services to your particular interests.
I say “any other” professional. Well, not quite. Most physicians don’t have such autonomy.
This line of thought was prompted by a radiology social media post from last week. The question was how folks would respond to a urologist who wants all reports to provide measurements and locations of every stone on each study. The uro demands addenda on any reports he encounters that do not live up to his standards.
Last I checked, the social media thread had over 40 responses, and only one rad unequivocally said he would do what the uro wanted. Others were, shall we say, variably emphatic in their denials. For the rest of you, imagine having an arborist come to check out your trees and then insisting that he or she give a detailed appraisal of every individual branch and leaf.
If we were like the other non-health-care professionals I mentioned above, determining for ourselves what our time is worth and charging for our services, we might go ahead with it. Sure, Dr. Uro, I can make an addendum for the numerous stones on this CT. A quarter of my hourly rate is $X. To whom should I send the bill?
As I have written in more than a few blogs in the past, however, we have long since been captured by third-party payors and regulators. Each imaging study we read is worth a flat rate, over which most of us have zero negotiating power. A completely normal scan pays the same as one with a gazillion findings. Supposedly, it all balances out to a reasonable average. (For any non-rads reading this, I get about $66 for a stone CT.) Addenda earn us not a penny extra.
We do them anyway of course. Sometimes it is for better reasons than others. If, for instance, voice recognition quietly removed the word “no” from my “No signs of appendicitis,” and I didn’t notice before signing off my report, the only way I am allowed to fix it is with an addendum.
Other addenda make us grind our teeth a little bit. We receive a non-emergent MR with no relevant clinical history. We read it and then a week later, we are told, oh, by the way, this patient had a background of cancer and prior scans from another facility have just arrived for comparison. Nobody wants to hear your thoughts about how this time-wasting exercise could have been prevented. Hust do the addendum doc.
Having worked in a few different environments over the years, in job markets both wonderful and awful, I have noticed a fluctuation in our ability to move the addendum request needle. At times, we have been subject to browbeating, if not flogging, for showing any resistance at all. “This is a service industry,” folks will tell us as if we somehow didn’t know. “Never say no. Your attitude should be ‘Do you want fries with that?’”
At other times, such as now, we are in high demand. Everybody needs rads to hustle on to the next case in the weeks-long backlog, or daily onslaught of STAT cases. (“Rad, please get on the trauma scans from the 12-car pileup and stop measuring those non-obstructive stones.”) We are allowed to have a little more backbone. One of the comments on the urologist-related social media posting was “’No’ is a complete sentence.”
It might feel good to imagine just saying “no” to someone who’s trying to order you about, but it can spawn strife. I find it less stressful and trouble-provoking to be more oblique in my refusals to make addenda that I know are unnecessary.
I remain adamantly against requests that I reiterate things already in my original report. If I say that the GI tract is unremarkable in the body of my report and my impression is “normal exam” or the like, don’t expect me to dictate anything else if you ring me up to ask for an addendum about the appendix. The best you are likely to get from me is a verbal confirmation that, yes, the appendix is a part of the GI tract that I already told you was normal.
When I get someone like the urologist asking me for details I have never known any rad to give, I might be a little more flexible, even curious: Hey, is there something to be learned here? Long ago, I recall hearing from other uro folks that it helped them to get a comment about whether an obstructing stone could be seen on the CT scout image, and thus whether KUB films could be used for follow-up. That sounded reasonable to me, and I incorporated it into my routine.
Giving a demanding referrer a chance to explain his or her requests isn’t always so illuminating. A resident might just say “My attending wants it” without knowing why. In these cases, I think it is reasonable for the attending to account for him- or herself. An attending who says things like “that’s just our protocol,” or refuses to give a reason at all is going to push me away from his or her line of thinking rather than draw me into it.
Fortunately, technology has moved forward to provide a solution to a lot of these situations. Most health-care systems now allow referrers to view the images themselves and draw all the measurements they like. This has the bonus effect of letting them use measurement technique to their satisfaction rather than wonder whether the rad who interpreted their studies measured things properly.
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