No, I Won’t Tell You What’s Wrong

August 19, 2014

Are our clinical colleagues intentionally holding back relevant case history? I’d like to see what would happen if there were consequences for such information hoarding.

It’s practically become a part of residency training in radiology to accept a routine lack of clinical history when patients are referred to us. As a med student, one learns that the vast majority of diagnoses can be made from history, even without physical examination or laboratory testing - something like 80 to 90 percent of cases, as I recall.

Later, the med student is taught about the great importance of supplying good information to consultants, even those shadowy denizens of radiology and pathology.

And then, it gets forgotten. Or consigned to the same mental bin of unused memories as one’s History of Medicine elective and the finer points of amino acid metabolism. The only ones who seem to remain mindful of the value of supplying clinical history to consultants are the consultants themselves.

At least, that’s what I thought was going on as I saw the vast majority of imaging studies coming my way bearing little or no appropriate clinical history from the referrer. You know what I’m talking about: “Pain,” “R/O path,” even “R/O pain.” Details like where the pain was, whether there was trauma (let alone the mechanism of injury!), if there was recent surgery, etc., were being left out because the clinicians were overly busy. Or the computerized order entry software was clunky. Or the clerks were being careless. Surely, our clinical colleagues weren’t intentionally holding back relevant information.

But from time to time, I find out that this is precisely what some of them are doing. Most recently, in commentary to a blog entitled “Who is the better radiologist?” one of the respondents, a hospitalist, unabashedly expresses a view I have heard from more than a couple of clinicians: They don’t think interpreting radiologists should be “biased” by having all of the clinical information known to the clinicians, themselves. (This particular hospitalist, to be fair, did give lip service to supplying at least a “clinical question,” which is more than the non-histories I am supplied 90 percent of the time.)

Contacted regarding an individual study for a given patient, most clinicians will agree that, of course, history is relevant, and they will tell you whatever you want. Others, like the hospitalist above, seriously think it’s reasonable to insist that the radiologist generate a formal dictation, and only after this is on the record will they grudgingly share additional relevant clinical details so the rad can then re-read the study and generate a report addendum. Encouraging, is it not, to see how little respect fellow professionals have for your time? Their little “I have a secret” game show reenactment is not only at the expense of your time and productivity, but also a liability that could come back to haunt you as your pre-addendum report is an etched-in-stone part of the medical record.

I wonder how gracefully such clinicians handle it when, after having seen a patient for 30 minutes and ready to conclude the encounter, are derailed by the patient’s mentioning, perhaps on the way out the door, “Oh, and another thing, doc…” followed by a major bombshell that, in terms of medical importance, should have been the very first issue addressed. To say nothing of how they would squawk if their patients flatly refused to answer their history-taking questions, saying, “I wouldn’t want to bias you regarding my case, doc.”

I also wonder if these clinicians are in the habit of, when bringing their cars in for servicing, telling their auto mechanics only a fraction of what they think needs doing, rather than offering as much detail as possible in the name of getting the job done properly and efficiently.

Confronted with their own shoddy job of communicating relevant information to their consultants (radiological and otherwise), some clinical types, perhaps partially out of embarrassment, choose to go on the attack. Implying that we rads could get all the history we wanted by picking up the phone and calling them, or leaving our reading rooms to go peruse patients’ charts or interview patients ourselves.

Yes, we could do these things - but then, those same clinicians would be the first to complain that their 20 “STAT” CTs on other patients were sitting unread in our absence. (Perhaps that’s why we ask for a “reason for exam” in the first place? Because it’s a more efficient usage of everyone’s time?)

Another little wrinkle: Most of the clinicians who are willing to proclaim what clinical information we should or shouldn’t receive have themselves never actually interpreted diagnostic imaging. Who, then, is the better judge of what historical details are relevant, let alone crucial, to the diagnostic imaging process - them, or the rads reading the cases, with years if not decades of experience doing so?

It might be interesting to see how things changed if some responsibility, even consequences, for such unilateral information hoarding were to be established. For instance, if a diagnostic “miss” on imaging can reasonably be attributed to insufficient history, rather than pure radiologist error, let the peer-review process focus not just on the rad who received the case but the clinician who made it unnecessarily difficult (or impossible) to interpret correctly.

Or, if reimbursement for a scan is declined (or substantially delayed) as the study was deemed medically unnecessary when a more thorough history would have resulted in proper payment, let the red ink show up on the clinician’s spreadsheet rather than the radiologist’s. The clinician could then explain his theories of bias prone consultants to the insurers or CMS. I’m sure it would be a deeply satisfying experience for all involved.