Radiology: A Common Pathway for Feet of Clay

One of the podcasts in my daily diet comes from a fellow you might have heard of: Adam Carolla. He brings a lot to the table, on account of not being a one-trick showbiz pony. Yes, his podcast is fun, he does plenty of stand-up, and his IMDB is nothing to sneeze at. Before all that, however, he did a bunch of blue-collar stuff (landscaping, carpentry/contracting, even boxing instruction).

That adds up to a hefty “talent stack,” to borrow a term from another fave podcaster of mine who has sadly gone to grass. It refers to an accumulation of different abilities that don’t typically develop together, but synergize in valuable, often surprising ways.

One of its effects on his show is a recurring theme of rants about people and societal systems that, simply put, can’t get things done well. That doesn’t fly in the world of hands-on work in his background. If you do things poorly, unreliably or not at all, you don’t build a successful business as a contractor or anything else. People look at what you have done or hear from your former clients and avoid dealing with you.

Capable contractors and others who put in the work usually want others around them to do the same and get vexed when that fails to happen, even confused at the notion that those others don’t seem to care about doing better. Don’t they want to get ahead in life? Don’t they want to have a sense of pride in what they do, or at least an absence of shame about it?

Few would have the insight or gumption to reply “No, I don’t.” In one of his recent episodes, Carolla exclaimed how satisfying it would be to occasionally hear someone say “Wow, I screwed this up. Okay, I will never do that again.” Far more frequently, folks offer lame excuses of why they once again failed to do this, that or the other thing. It’s never quite their fault.

Carolla told of another common response, a step below even that, which I will share before getting on to the radiological connection in all of this. People will look you dead in the eye and insist that they did do what you both can clearly see they did not.

It is easier for them to spout such bald-faced lies than admit their incompetence or lack of caring. On some instinctive level, they know you probably won’t call them out on lying. First, because you are unlikely to throw more energy at something that is giving you nothing back and second, because they might just use that as an excuse to get angry. A shouting match moves away from the actual issue and gives them a better shot at something resembling a “win” or at least a draw.

Another factor, at least in health care, is that we usually have zero authority to do anything about their failures. If we do want to hold someone accountable, it has to go to some superior who doesn’t really give a darn. The superior will ultimately make some sort of parenting maneuver: “Okay, kids, let’s just understand that both sides have a point, and try to get along better next time. Now get out of my office.”

One might think this isn’t a particularly big deal for radiologists. How many other people’s failures really come home to roost in our reading rooms?

Unfortunately, for most of us, the answer is “quite a lot.” Diagnostic imaging is a common pathway for much of the health-care system, and a single radiologist is the final common pathway for the work of multiple techs in different modalities.

So we see numerous instances of crummy clinical histories from all over the place. We put comments about this in our reports to advise that we would be giving better interpretations if we had better info, hoping that once in a while, a referrer will notice and mend his or her ways. We might even have our ancillary staff reach out to the referrers or pick up the phone ourselves but that doesn’t seem to stem the tide.

It is the same thing when clinicians order the wrong protocol or even modality for their diagnostic scenario: We will keep on reporting that you should have used oral contrast, or that MRI was better than CT for whatever you wanted to know about. You might not admit that you chose lesser options on account of ER “throughput” or your own ignorance, but maybe, just maybe, 1 percent of the time our guidance will move the needle a bit for a referrer. We can hope.

I can only guess at how many times I have picked studies up from worklists and seen no priors for comparison, but the exam is for “F/U lymphoma” or the like, and I know there is a comparison somewhere. My gazillionth attempt to get techs, even schedulers, to get such relevant priors uploaded without my having to ask might eventually hit home for some ancillary staff. However, thus far, I can’t say these episodes have gotten any rarer.

We rads aren’t immune to such behavior. At least once per week, I read a study following an older scan where the rad reported “no comparisons available” yet I plainly see half a dozen relevant priors on the list. Of course, I can see every item he recommended follow-up for on the older exams from 2014 (stable of course).

What would happen if we all ranted like Carolla does, when his employees fail for the umpteenth time to turn off the compressor overnight or get the time difference wrong for a transcontinental phone interview? By and large, I suspect we would get reputations for being grumpy, short-tempered prima donnas who want everything done in our particular ways.

If we did it with humor, not that most of us have comedic chops anywhere near Carolla’s league, it would go over better. Unfortunately, an awful lot of people aren’t as funny as they think they are (and a few diamonds in the rough underestimate their capabilities, thus don’t show them off), so just counting on rads to self-select for ranting because it’s funny clearance isn’t a winning strategy.

The alternatives, of course, are to stop caring that, as one former colleague of mine lamented, “We have to do everyone’s job including our own,” or to bottle everything up inside in a psychologically unhealthy way. It is a rare individual who can just keep on fighting the good fight without having some method of dealing with its frustration.

Like Carolla, however, we less than happy warriors accept that we will keep on doing it because nobody else will.