Whether it’s attempting to get appropriate clinical histories from referring physicians or getting a tech to split up a multiphasic contrast study into separate image series, consistently striving to fight the good fight for optimal image interpretation is worth the effort.
I have written about more than a couple of dysfunctional workplaces in this column, radiological and otherwise. In addition to good story fodder, they have been great opportunities to “learn by bad example” as I wrote a couple of weeks ago.
The denizens of such workplaces commonly find themselves faced with a choice of doing things the easy way or a tougher way, and this isn’t just a matter of working smarter instead of harder.
A key part of the dysfunction is that the harder way is the right way, or a better way but employees are pushed towards the easier way because it is the path of least resistance for the employer.
That resistance can take many forms. The simplest is one’s own resistance to expend more time or trouble than one has to. We’re energy-efficient creatures under most circumstances. If we can get something done by physically or mentally exerting ourselves but can accomplish the same thing (or nearly the same) by sitting in a chair and operating on mental autopilot, we are predisposed to do the latter.
For example, a rad could make a point of scrolling through all of the images on a CT, including every multiplanar recon and maximum intensity projection (MIP), but he or she just reviews the regular thickness slices and glances at the recons only if the rad feels they are necessary to answer questions. A tech doing a multiphasic contrast study could split the arterial, venous, and delayed sequences into separate image series to make the study easier for others to review, but he or she just uploads them all in a single block.
One step up on the resistance scale is the notion that doing X might bring unwelcome consequences, but Y is more of a risk-free option. A rad receiving unsplit scans from that aforementioned tech might think, “This is inefficient for the way I read studies, and I am not the only one. Plus, what if a non-rad reviews one of these scans, and doesn’t even realize there are multiple contrast phases buried in there?” The rad might want to reach out to have the tech split the study into its component sequences (and do so for all similar exams in the future).
Now there are two layers of resistance working against the rad’s pursuit of better imaging. First, there is the extra effort in reaching out to the tech (and persuading or pressuring him or her to actually do it). Second, there’s the risk that the tech is going to push back. Now the rad has to decide whether to exert his or her authority, and maybe contact someone higher up the food chain. There is the potential embarrassment of discovering that he or she hasno such authority: The tech just refuses, and the upper ups don’t support the rad. Maybe the rad looks like a demanding troublemaker in the process. The path of least resistance is simpler: Read out the case and move on, accepting that future cases will be presented the same cumbersome way.
(Editor’s note: For related content, see “Clinical Histories in Radiology: Could They Get Worse?,” “Could Controlled Imaging Rein in Suboptimal Use of MRI, CT and Ultrasound Exams?” and “Learning from Bad Speakers in Radiology: Three Things to Avoid in a Lecture.”)
Consider another example of risk-related resistance. Suppose you have no real productivity incentive at your job. Yes, you’ll hear about it if you don’t produce enough but you know that you will get nothing more for reading 110 cases today than if you read 100. You have 10 minutes left in your day, and you just signed off case #101. There are still things on the worklist.
Taking one of those cases has risk. What if that case turns out to be a mess? It might be complex and keep you later than you wanted. It might evolve into multiple calls back and forth with clinicians. It might even turn into a malpractice nightmare that haunts you for years. The path of least resistance might just be doing something else for the next 10 minutes until you can leave.
I alluded to another level of resistance. Suppose mediocre X and superior Y are both options, but for you, they offer equal (or absent) resistance. There is no reason you should ever choose X, but what if other people are involved, and they perceive that Y would mean more effort or risk for them?
Now you’ve got to motivate these other parties. Before, it was just a matter of deciding for yourself that the superiority of Y was worth your while. Once you decided, that resistance was resolved but now you have got the resistance of convincing others.
For example, suppose you are trying to staunch the constant flow of ordered imaging without proper clinical histories. Anybody with a lick of medical experience appreciates the value of a diagnostic rad knowing why a patient is being imaged yet that constantly fails to happen. We do everything from demanding to begging that our referrers cooperate a bit (or that administrators force them to) but that would require action on their part. Their inertia is a powerful resistance.
Do you know what is an even greater level of resistance? Suppose you’re not just fighting against these other folks’ reluctance to doing more work or sticking their necks out for you. On top of that, suppose their interests and yours are in conflict. You are no longer simply fighting against your inertia (or theirs). Now there is an opposing force actively working against your goals.
For instance, suppose you hear about a patient being referred from the ER for a CT. You get the relevant history, and determine the appropriate protocol includes oral contrast. The ER decides against it. Maybe they have a good reason they didn’t tell you about or maybe they value throughput over getting the best possible imaging for the patient. Whatever the case, you and the ER want different things.
You can fight the good fight. Maybe you will prevail sometimes. However, if it keeps coming up (in other words, the ER never quite seems to accept that you know how to practice radiology, and pushes back whenever you try), sooner or later you’re going to at least be tempted to take the path of least resistance and let them order whatever the heck they want. Maybe that happens after you appeal to your own department’s leadership and find out that they fought the good fight and chose the path of least resistance years ago.
It seems like a no-brainer. If there’s resistance to doing things in a more efficient, higher quality way, that resistance should be removed. The ability to remove it, however, is almost never possessed by the folks facing that resistance. It tends to come from further up the hierarchy. Upper ranks have the ability to make the mediocre path of least resistance a road less traveled. It’s just a matter of whether they seize the opportunity to do so.