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Keeping My Own Radiological Counsel


When remaining cool and collected is a challenge, providing an overload of detail is another way of turning the tide with a frustrating referring clinician.

I have a cast of characters residing in my noggin. They’re all me of course. Regular readers won’t be surprised that I watched Marvel’s Moon Knight series, but I’m not claiming any dissociative identity issues. It’s just that the way I come across can vary substantially with different situations.

We’re not supposed to be like that in medicine. No matter what happens, it is expected that we will always be level-headed, cool, and calm in a crisis, etc. Stress, frustration, and the like shall never mar our consummately professional demeanor. For those familiar with the Dune franchise, we’re about as close a thing to its “mentats” as reality gets: the living equivalent of computers. Give us your data. We will process it and give you results, and our personalities won’t get in the way.

Maybe other docs have perfected this approach. I have not. However mentat-like I might manage to behave, the characters in my mind are regularly in play behind the scenes. I could call them a council to pun on the title of this piece, but with the way they behave, it is really more of a peanut gallery. They are often at their most insistent when I have to get on the phone: Talking to referrers, techs, etc. has a way of rousing my rabble to the point where it is sometimes hard to keep them from taking enough control to verbally express themselves.

Consider the following case in point. A call comes in for a computed tomography (CT) scan I read. As has been the case in most decently organized rad jobs I have had, the initial contact is from a rad support person, to a) make sure I’m available, and b) give me the patient info so I can have the case in front of me before the referrer is talking to me about it.

Organized and efficient as that may be, it doesn’t stop the peanut gallery from squawking at the interruption of my reading cases:

What is it now? Can’t I be left alone in peace?

What about my report was unclear to this individual? Did the clinician bother reading it all that carefully? Is she or he about to try telling me my read was wrong?

Of course, I ride herd on the chatter. Nothing they are saying is worth expressing out loud, especially to my helpful ancillary staff. I say thanks for the case info and that I am ready to be connected. It was a chest CT with a history of “septic emboli” and literally no other clinical info. There was plenty going on in the lungs, even some cavitary lesions. However, they did not look embolic, and I had taken pains to describe why they probably were not embolic

The referring clinician gets connected and semi-accusingly tells me that I “said something about septic emboli” in my report, but that the clinical scenario really doesn’t suggest such pathology. The peanut gallery doesn’t appreciate the tone.

I said something about emboli? That was the only history you gave me!

You didn’t really read the report, did you? I spent about half of it explaining why I didn’t think these were septic emboli and offered you a differential of more likely possibilities.

This time, I don’t entirely squelch their retorts. It is, after all, being alleged that my report is diagnosing the opposite of what it is, a diagnosis that this individual (or someone else on their team) provided in a clinical history that my caller is now denying. I do phrase it a little better though: “I’m sorry. Was my report unclear? I thought I explained why I didn’t think these were septic emboli. The only reason I mentioned emboli in the first place was because that was the history you provided.”

The caller responds by saying that I “don’t seem to know anything about this patient,” and continues to go on about why he or she didn’t clinically suspect emboli. This does not remotely charm a single member of the peanut gallery:

I don’t seem to know anything about your patient, huh? Whose fault do you suppose that is? The one thing you told me in your “reason for exam” is something you are now claiming you never believed.

I’m glad that neither of us thinks there are septic emboli here. We should be on the same page, since now you’ve read my report and heard me describe it out loud. Can I hang up the phone now, or is there some other way I could express this to your satisfaction? Morse code? Semaphore? Emojis?

I decide to let a quieter member of the gallery sound off. I think of him as the Professor. He likes to share knowledge and educate, even though he sometimes talks over people’s heads or gives them far more info than they wanted.

Thus, instead of trying to force my caller to understand that he or she has done a lousy job of referring and reading my report, and isn’t making up for it in verbal discourse, I lay it on super thick, offering every detail I can think of about septic emboli, what they look like on CT, what this CT shows instead, etc. It is as if I never dictated the case in the first place but instead was doing a “curbside” interpretation for this caller on demand. I made absolutely no effort at brevity.

I do my best to be that bore at a party who buttonholes you and jawbones about something till you wish not only to get away from him, but the entire party.

Mission accomplished. The caller doesn’t have to admit any deficiencies and is being told what she or he wanted to hear in the first place. However, the referring clinician is slowly being punished by wasted time as I babble and is soon climbing over him- or herself to get off the line and away from me.

If I am really lucky, perhaps there will be a lingering recollection that calling me is more of a time/effort investment than carefully reading my reports. Perhaps there will be a little better clinical history in the future with requisition imaging. One can hope.

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