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Recognizing the Connection Between Simplicity and Compliance in Radiology


The success of compliance initiatives is often preceded by an easily understood rationale and simply stated benefits.

This blog serves a sort of magnet for rads all over the place to tell me about the quirks of their professional situations. They don’t need me for the usual stuff. Folks readily chatter with other rads in-person or online about gripes with insurance companies or the government, enduring frailties of voice-recognition, the never-ending struggle to get decent clinical histories, etc.

Lower-order things, more specific to one’s particular job, don’t really lend themselves to that. Nobody outside of your workplace is going to know all the peculiarities of your situation to understand why a certain sequence of events that happened to you last Thursday were very maddening and soul-crushing. You would have to give them such a long preamble to set up the story that you would never retain your audience long enough to get anywhere near your punchlines.

I guess I touch on such things often enough in this blog that I seem more receptive to such material (and I am). Case in point: A rad recently unburdened his frustrations over getting stuck at work over half an hour after he was supposed to be done for the day. It wasn’t due to anything worthwhile, like helping clearing worklists or puzzling out a challenging case to make a meaningful contribution to patient care.

Instead, it was a stupid cascade of logistical log rolling, dithering with nonsense about workflows and protocols. It involved complex rules that nobody could really figure out had to be disentangled so folks in different departments could be satisfied, or at least not overtly vexed.

Part of what made the situation so incredibly frustrating was a keen awareness, shared by just about everyone involved, that it could all have been prevented. The policies in question had been an issue time and time again over a course of many months. They had been repeatedly pointed out as a confusing mess that nobody understood. Every time they caused problems, everyone agreed that they could be better but, somehow, they never got fixed. Episodes like this current one would just keep on happening.

Such things remind me of one of the more salient lessons from my early med school days, courtesy of a pharmacology professor. As we dutifully learned dosage schedules for a gazillion different meds and their various clinical scenarios, she advised us to remember the human element of trying to adhere to such regimens.

In other words, the books might say that medication A should be given twice daily, med B every 12 hours (not the same as “twice daily,” lest non-doc readers wonder), med C every 8 hours, med D every 6 hours, etc. All of that might make perfect sense on a biochemical level. However, if you give them all to a patient and expect him or her to properly comply with the regimen for any length of time, you’ve got another thing coming.

Move forward a year or three in the education/training of med students, and they’re immersed in a world where patient noncompliance is a big obstacle to achieving the best outcomes. There is a lot of talk about how to improve compliance, but I think a lot of people mentally lose track of its connection to simplicity.

It doesn’t matter if there are a dozen ironclad reasons why doing something in a complex/convoluted way will produce better results than doing it in a simpler way. If the people who have to actually do it can’t understand the intricacies of the plan and remember how to execute it correctly, it’s not going to get done. Moreover, the less they’re actively aware of the benefits of the complex approach, the less motivated they will be to adhere to it, especially if they don’t think they are the ones who will benefit from it.

I think the intelligence and training that are standard for most physicians works against us here. Maybe we are more capable of keeping track of complex things, and just assume that everyone else can/should. There are also a bunch of circumstances in which we accept without question that the complexity yields benefits that would not be achieved with a simpler approach.

In radiology, for instance, nobody would dismiss the value of a multiphasic CT (or MR) if you are investigating hepatocellular carcinoma. It is a more complex exam to perform and interpret than a single-phase scan to be sure and that complexity results in greater opportunity for error. A routine abdominal scan may not be done correctly because the referrer wrote an incorrect order, or the tech screwed up and followed the wrong protocol. Perhaps the rad who gets the case might not really know the intricacies of reading arterial versus delayed phases. None of those are valid reasons to do the simpler wrong scan.

We are willing to sacrifice simplicity if it means better outcomes. We might lose a little compliance in the process, but in the grand scheme of things, there will be a net gain unless, of course, we make things so insanely complex that nobody can actually get to the endpoint of the good outcome.

What happens if the outcome isn’t so grand? Suppose we are no longer talking about patient care, or even the efficiency of the health-care system (affecting patients en masse). Now we are talking about things like managing workflow, sharing coverage equitably, or other administrative/housekeeping stuff.

These things aren’t irrelevant. They have to happen. But at this level, it’s more valuable to have nice, simple rules that everyone can understand and follow without being walked through them on a daily basis. For this sort of stuff, removing barriers to compliance is probably more valuable in getting the mission accomplished.

There is one guideline that I have found works well: The longer it takes to explain a rule to personnel and the more frequently you have to remind them of it, the greater the chance it needs simplification if you want them to reliably follow it.

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