Minding the Whys and Wherefores

November 2, 2020
Eric Postal, MD
Eric Postal, MD

Knowing the reasons behind your decisions – especially ones that affect patients – can be as important as the decision itself.

I mentioned in a recent column that I’ve been experiencing some slow days in my telerad work. At least some of that has been due to technical issues regarding the transmission of cases from systems in the onsite facilities to the remote apparatus. For all I know, the actual case-volume might have dipped, too.

However, it happened, this resulted in more opportunity than usual to chat with other telerads via instant message apps. Normally, a vehicle for queries, such as “Hey, mind having a look at this case,” or “Are you having difficulty loading studies, too,” the app also lends itself to commiserating about the antics of techs, patients, even other physicians.

Details escape me now, but a colleague was sharing his frustration over some study he’d received which served no logical purpose. That is, short of some entirely-unexpected incidental finding, his report would have no impact on patient care – not an unheard-of circumstance for most of us. I rather imagine a typical rad would be blessed to go through a workday without at least one “Why did they even do this study” moment.

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It put me in mind of a recurrent scenario from my residency, which I shared with the other telerad. Back then, my institution’s sonographers would typically stay in-house for part of each evening, after which there was no routinely available ultrasound. If some clinician insisted that a late-night or wee-hour sono had to emergently happen, the sonographer would have to be called in.

The exception was ultrasounds for trauma patients in search of free fluid (“FAST” scans). Such studies couldn’t wait for a sonographer to come in and were considered simple enough that the rad resident on call should be able to wield the transducer.

This was more than a little bit of a production. The resident would have to head down to the other end of the floor to fetch the designated sono machine, wheel it back to the ER, and do the scan, during which he or she would be unable to read other studies, do contrast injections, etc. The resident would also have to bring the unit back to the rad department and upload the scan so the next morning’s attending could review the case. We’re not even going to pretend that the resident might have been all caught up with work and getting some sleep when the trauma team demanded a sono.

Meanwhile, we residents noticed that our scanning never seemed to make a difference. That is, whether or not we saw free fluid, the patients always went on to be pan-scanned via CT (which, of course, would also show fluid if any was there).

Some of us would try reasoning with the trauma team: What’s the point of the sono? To look for free fluid. If we see free fluid, we go straight to the OR.

So, the vast majority of the time, we’d see no fluid, and a routine whole-body CT would ensue. But, once in a blue moon, we’d see fluid, and think, aha! Time to stand back while they whisk the patient away to the OR…here’s one pan-scan I won’t be reading tonight.

Then, we’d watch, incredulously, as they proceeded to request the CT anyway. Wait a second, we’d protest. You have your free fluid. What happened to the OR? Oh, well, now we have to see where the fluid is coming from.

The question, “If you’re going to get the CT no matter what the ultrasound shows, what’s the point of the sono?” never got a straight answer from members of the trauma team.

Now, maybe there was a valid explanation for doing things this way. Perhaps some academician could lay it out for me in a comment on my Twitter page. Meanwhile, we were left to conclude that none of the local clinicians at our level-1 trauma center really understood the whys and wherefores of what they were doing.

I think a lot of healthcare, and indeed other work done by folks who supposedly know what they’re doing, suffers a similar lack of “why are we doing this” self-scrutiny. To a certain extent, that’s probably unavoidable when you’re in a field of ever-increasing complexity like healthcare. People can only comprehend so much, let alone explain it to someone else. “Cookbook” medicine (following protocols, flowcharts, etc.) helps to compensate for this.

For instance, I might not remember every little bit of detail and supporting evidence for all the wrinkles of the latest iteration of Lung-RADS…but, I know that when I refer to it, I’m following a well-trodden trail that was blazed by many folks wiser than I.

Nevertheless, it does seem a reasonable expectation that a trained professional should, at some point, have fully understood the rationale underpinning his doings. If questioned (or taking a moment for self-reflection), and realizing that he can’t explain himself, he should be able to come up with the answers with a little sifting through what an erstwhile med school prof of mine liked to call the “cobweb section” of his mind. Where stuff that was once learned but is not consciously remembered still resides and can be dredged up with a bit of effort, perhaps aided by a quick glance through some reference materials.

Trusted as I am for my diagnostic/radiological expertise, if I find myself at a loss to explain why I’m doing what I’m doing, and I can’t come up with an answer even after referring to some trusted references, I consider it a high priority to fill in the hole in my knowledge-base. I’d recommend fighting against any urges to dodge the question in the hope it doesn’t come up again—it makes for the look of a charlatan.

Follow Diagnostic Imaging Editorial Board member Eric Postal on Twitter: @EricPostal_MD