Not Quite Striving for Perfection

April 11, 2018

Spelling-and anatomy-count when it comes to quality medicine.

A reminiscence to my medschool class from one of its erstwhile profs: Once upon a time, if a med student (or intern, resident, fellow) failed to know the correct answer to a preceptor or other attending doc’s query, the proper response was, “Sir, I don’t know. But I’ll know it for you tomorrow.” After which the trainee would make darned sure to research the information so as to be able to thoroughly discuss it during rounds the next day.

Even then, some of us joked about how that would not save the trainee from a serious chewing-out or other embarrassment, depending on who the overseeing doc was and what mood he might have been in. Regardless, none of us doubted that it was a good practice, upon discovering a hole in one’s knowledge, to mend it as soon and as thoroughly as possible.

Having lived on that side of the coin for long enough, one can become predisposed to identifying such holes in others, and providing guidance in filling them. Even if one did not remain in an academic setting. Maybe it’s just force of habit. Maybe we want to help others improve themselves. Or maybe we prefer, in our chosen profession, to surround ourselves with as many capable people as we can, and help ourselves when we boost their capability.

This can be a formula for frustration when the healthcare personnel around us, perhaps in a systemic effort to “do more with less,” exhibit a steady declining trend in credentials, education, and (unfortunately far too often) interest in excelling.

I’d wager a strong majority of practicing rads have noticed, for instance, that a rising proportion of imaging-studies are not being ordered…and sometimes not followed up…by our fellow physicians. Some of these non-doc “referrers” are acting on behalf of docs who are just too overburdened to do this stuff themselves. Others are practicing independently.

Even if you don’t make it your business to see who’s ordering the studies you read, the “clinical history” often includes clues that the referrer might not have attended medical school (or, indeed, paid particularly close attention while training to be a nurse or PA).

My favorite is the blatant misspellings. I think I wrote a blog in the past couple of years where I proposed a new rule: If you can’t spell it, you probably shouldn’t be allowed to order a study for it. I’m not talking about a single errant letter (although even that gets my suspicion up)-these “words” look like a subpar spelling-bee contestant tried sounding them out…and failed miserably. Sometimes I can’t even figure out what they were trying to convey, although it can be fun to puzzle at if I’m not particularly busy.

Next is the anatomic goof-ups. Granted, some of these are nitpickier than others, but none of them would probably be committed by someone who managed a passing grade in a Gross Anatomy class, let alone a subsequent exam like USMLE. Some examples from recent cases I’ve read: A reference to the PIP joint of the thumb (and no, the patient did NOT have a supernumerary phalanx). Not knowing the difference between the leg and the thigh. Calling up confused about what it means when a central line is reported to be at the cavoatrial junction. Mixing up lateral and medial with regards to the hand, wrist, or forearm. These aren’t just academic points-if someone ordering a study is suspecting injury to the fifth metacarpal but calls it the “lateral hand,” they’re conveying the wrong information.

Then, there’s the higher-order stuff, which could possibly result from an overworked or otherwise distracted doc not really paying attention when the exam was ordered…but, dollars to donuts, the referrer wasn’t a doc who knew and/or was familiar with the patient. Imaging studies for “r/o chole” or “appy” when the patient had the relevant structure surgically removed, and clearly says so to the radiology tech. Or gender-incompatible details, like asking after prostate cancer in a female.

It’s not just when ordering studies that these items pop up-at least then, face can be saved with anonymity. The more embarrassing (but potentially entertaining) times are when a phone call, or even an in-person interaction is involved. “I wrote that the study was to rule out X, why didn’t you mention it in your report?” “Because that is nowhere near how you spell X, and I had no idea what you were talking about.”