Outside, Looking In

September 27, 2013

Whether hospitals take external advice about improving their radiology departments could depend upon the type of outside source.

Slowly working my way into my backlog of old journals, I encountered a piece from maybe a year ago. The author, reflecting on his time in teleradiology, recognized that he was in a unique position to compare and contrast the various facilities he covered. It was a nicely written, well-considered piece that addressed important issues of imaging protocols and the like…plenty of potential academic fodder, or at least sufficient material to inspire several follow-up research studies.

Meanwhile, having been at the teleradiology game for a couple of years, I had experienced similar thoughts. Being neither academically capable nor inclined, I daresay anything I might have written on the subject would not quite have been fitting for the AJR. Perhaps the National Enquirer.

You see, when I am covering my dozens of hospitals on a typical night, I tend not to remember which places give me 3mm CT slices rather than 5mm cuts. I don’t keep tabs on who makes good use of ultrasound to look for appendicitis or which facilities are more likely to have rigorous radiation dose-reduction initiatives in place.

But there are things that I do notice as the outsider looking in. It’s abundantly clear to me that some hospitals (radiology departments and otherwise) have their act together to a much greater degree than others.

There are places which consistently send me patients with good clinical histories, with well-chosen imaging protocols for the indication at hand, and quality technique. Prior studies (and their reports) are routinely supplied for comparison/correlation. If I have issues that need addressing, and ring up the radiology tech or the ordering clinician, they’re on the phone promptly, ready for anything.

Then there are other places, where every study sent to me has a history of “pain.” CT performed because there’s no sonography tech or because the clinician didn’t know that ultrasound was a better study for the clinical question. Protocols seemingly chosen at random, patients all poorly positioned and moving during imaging. Priors and/or reports not provided, even when the study was specifically ordered to compare for interval changes. I groan when I realize I have to call these facilities to speak with their staff because it can take half an hour to get anyone relevant on the phone (everyone’s off-shift, on break, unfamiliar with the patient, unwilling to take responsibility, etc).

There are motivations to provide feedback to these various facilities. Maybe out of a sense of professional pride and a desire to improve the field…or at least a hope for improved efficiency from Trainwreck Hospital since the reader is tired of routinely sorting out a dozen problems from that facility each night he’s covering.

Most often, the reward for such feedback is stony silence. Being the outsider, one may have no idea if one’s communications were even received by the right people. If they were, the onsite folks may feel no obligation to reply. They might actually resent the effrontery of these interlopers who dare to have an opinion about how the place is run-just shut up and read the scans!  It’s even possible that the onsite folks agree with the teleradiologist 100 percent...but have fought battles over the issue in question time and again and know it’s a lost cause because of hospital politics or the like.

It’s occurred to me that there’s a thriving field of related business out there…not begging clients to listen to free advice, but instead sought out and given big bucks for it: Business consulting. Companies, large and small, pay small fortunes to have outsiders stroll in for a few days or weeks to size things up and tell management what’s wrong and how to fix it. It doesn’t matter that 90 percent of the companies’ employees could have told management exactly the same stuff; the consultants, as outsiders, are deemed more capable as they are impartial observers…in part because they’ve seen how other companies dealt with the same issues.

So I think maybe I’ll stop begging and pleading the staff of the hospitals I cover to consider my recommendations. Instead, I’ll send their CEOs a flashy-looking CV and cover letter making vague promises about all the wonderful things I can do for them. If retained, I’ll deliver a nice PowerPoint presentation of the feedback I’ve, thus far, been freely offering…and they can pay for it by giving me a slightly higher percentage of the professional fee they collect while I read their imaging studies.