The Shifting Power Dynamic in Radiology: Respect and Equal Footing with Referring Clinicians

There is a lot to be happy about in diagnostic imaging. Doom-and-gloom rads can be found, especially online. However, I would wager that most of them are predisposed to focus on clouds rather than silver linings, and not just in their professional lives.

For the rest of us, we have all the work we could want with pretty favorable conditions. One has to look increasingly far in the rearview mirror to see when this wasn’t the case and even back then, I recall there being much more good than bad.

When you are in the middle of the negative stuff, it can be hard to imagine how things can ever change. Even afterward, you might only be able to guess at when things took a turn for the better. From my experience, most of it is simply supply and demand. The combination of more rad work to be done and a lack of sufficient increase in the number of radiologists results in rads being treated better as they do it.

For instance, I recall a source of discontent in the increasingly way back when of my residency training. We did a fraction of the work rads do nowadays but often felt pretty busy and even overtaxed. Some of that was because we did not have today’s efficiencies: We used dictaphones and transcriptionists instead of voice recognition, hanging films and decorating them with china markers pre-PACS.

Getting just another couple of scans to read from the ER or other “stat” sources could therefore be a significant stressor. This was especially the case if you were the on-call rad, singlehandedly reading everything. Add to that an impression that some of this imaging was unnecessary and occurring as result of others’ laziness or carelessness, and your blood might boil a little bit.

We had all been taught and trained that there was a proper order to medical evaluation and management. First, health-care personnel were supposed to see patients, get a history and do a physical exam. That could be abbreviated. One might not ask a demented trauma patient in the ER about extended family history for instance. Still, one should try to find out where they were hurting, look at wounds, etc. Bloodwork, imaging and consults would then be reasonable.

Increasingly, that wasn’t happening. Patients were practically being rolled from the ambulance bay into the scanners before anybody really evaluated them. Our radiology attendings described the process by saying that CT was being used as a triage tool, and it wasn’t really a joke.

Part of the excuse was that the ER staff (and other docs ordering STAT cases all over the hospital) weren’t just shirking their responsibilities. They were overburdened in having to attend to too many patients. If they knew that the 78^th patient of the day would probably need a CT, but they were still occupied with patient #71, they might see getting the scan before they even saw the 78^th patient as a time saver.

Reading these scans as they occurred, we were in a perfect spot to see how, as events unfolded, many imaging studies turned out to be wasteful or entirely irrelevant. I have delved into numerous reasons why in other blogs, so I won’t rehash them here. Meanwhile, part of our radiology training was a steady drumbeat of imaging “wisely” and appropriate utilization, and this routine rubbed our noses in the fact that we had no control over any of that.

What was the cherry on top? Our phones and pagers were constantly going off as the folks who had ordered all of these studies hassled us for faster readings. Many of these clinicians seemed to have the impression that, while their being overburdened allowed less-than-judicious ordering patterns, we rads were somehow just kicking back and were not similarly overburdened with running to stand still.

Fast-forward to the current day: As imaging volume has continued to explode and the radiologist population has not, many institutions have developed a perpetual backlog of unread studies. Many more referrers have come to understand that rads often just can’t keep up. Even the referrers have to face the consequences of their overutilization. Flogging the rads to work faster is no longer a simple one-step solution.

Your workplace may vary but from what I have seen, the days are pretty much gone when a referrer can throw around terms like STAT (or “super-STAT”) and expect us to jump on whatever they want because we have got a dozen other STATs that they and their colleagues already laid at our doorstep.

They can’t ring many of us up directly to demand that we drop whatever else we were doing to “just have a look” at some complex post-surgical nightmare. We have long since gotten ancillary staff (God bless them) that referrers have to go through. While the ancillaries take requests and assure the referrers that the next available rad will be on the case, we have a precious few extra seconds, if not minutes, to continue drinking from whatever other firehose we were dealing with at the time.

In other words, the power dynamic has shifted. Back in the day, there was a certain sense that, even though we were all physicians, rads were somehow subordinate to any clinician with a demand. We have become recognized as a more precious commodity. In other words, we are viewed as professionals on equal footing. Our time and efforts are regarded with greater respect.

Whether or not this impacts the quality of patient care is something I am sure many would eagerly argue about. There is plenty that could be done in that regard by targeting overutilization itself, but I don’t think too many of us expect that kind of corrective action.