The Simplest Path of Least Resistance

November 9, 2020
Eric Postal, MD

What options do you have when presented with cases that cannot be read “as-is?”

One of the neatest things about having an online presence as a known teleradiologist is getting to hear from far more radiologists than I otherwise would have. Whether or not they initially contact me to pick my brain—which, as I’ve said before, I find extremely flattering—invariably they share their own experiences. I wind up with a vicarious peek at the innards of many hospitals and rad groups that I’d personally never see.

A very common theme: Group/facility X could go about something in a simple, easy way. But, instead it opts for something complex, inefficient, and/or more taxing to those working in their systems -- even when it’s pointed out how things could be improved and the folks who could make such changes have no reasonable explanation for why they’re maintaining the status quo.

For instance: One of the things that vRad got right (and, indeed, one of the few things I miss about working in their system) was that there was a quick-n-easy way to deal with imaging studies that could/should not be read as-is. A clickable button on the RIS screen would bring up a short menu of the most common issues: sonographer didn’t attach a worksheet, multiplanar reconstructions were missing, prior studies weren’t uploaded, etc. There was, of course, an option to choose “other,” and type in your own issue.

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When a telerad did this, the case would vanish from his screen and not return till the folks behind the scenes addressed the issue, at which time the case would return to the rad if he was still working.

Another doc who worked alongside me in the virtual trenches of vRad, recently shared with me his frustrating scenario. Having also moved on to another telerad-type gig, he had a similar setup on his RIS. Not quite as robust, but still a clickable button for use whenever a case could not be read “as-is.” The resulting menu options weren’t as good, and he more frequently had to choose the “other” option, which necessitated typing out whatever was wrong with the case.

Whether or not resulting from this less robust mechanism, the issues with defective cases were resolved less frequently. It felt like as much as half of the time he used the button, cases came back to him without anything changed. If he wanted to press the issue, he’d have to click the button and re-type his complaint, hoping for a better outcome.

Unsatisfying as that was, the real frustration he shared with me was from a new development. He’d gotten a message from one of the high-ranking, behind-the-scenes (non-physician) people in his group, ordering him not to use that button anymore. If he has issues with a case, he should now forget the button exists and instant-message or call one of the Operations people. To date, the reason for this change has not been explained. He doesn’t even know if this directive is exclusive to him.

Let’s contrast these workplaces’ solutions to the common issue of a case not being readable when a rad opens it:

1: Give the rad a two-click solution to flag the problem so others can deal with it, while the rad moves on to other cases that are ready for him to read. At most, perhaps, he has to do a little typing to explain the case’s issue.

2: Give the rad a clickable recourse that almost always requires him to type. It only works about half the time. Now, take that away from him, and tell him that he has to type out his issues 100 percent of the time or find someone who will answer their phone and explain everything to them, including spelling out patient names, medical record numbers, etc.

One hopes that the rad will eventually find out that there was a good reason for taking this tool away from him. In the meantime, his group has moved from a quick, simple solution to a more time-consuming, complex one. It has chosen to make reading these problem cases into more of a hassle for him, perhaps to ease the burden on the non-rads behinds the scenes who had been receiving the alerts generated by the rad’s usage of the button.

What do people do when they are confronted by recurrent, problematic circumstances that they can’t fix? Do they cheerily take it in stride or grumble a bit, but muscle on through? Maybe some do. At least, for a while.

Human nature, however, develops other behaviors that avoid hassles and obstacles. We like simplicity, and we tend towards the path of least resistance.

So, in scenario No. 2, might we have an increased frequency of rads, confronted by yet another problematic case, just heave a heavy sigh and risk reading an ultrasound without the sonographer’s worksheet? The images look straightforward, after all. Risk reading a CT for unspecified “follow-up” without a provided prior study? The study looks pretty negative, so maybe it’s not really worth the hassle of getting someone on the phone to ask whether they forgot to upload the prior.

Every time a rad convinces himself that this simpler path of least resistance is reasonable, there’s a chance of patient care suffering. Maybe a referring clinician will be unimpressed. Maybe a med-mal lawyer will get a nice payday.

Or, perhaps, the rad gets a little more comfortable with the idea of opening a case, seeing it’s got issues, and, then, quietly putting it back for someone else to deal with because it’s late in the day and his RVU-tally is less than it should be. Easier to grab another case that he can read out as-is.

Rads are the one thing that a radiology practice cannot do without. They bring in the revenue that keeps the place afloat, and, indeed, pays everyone else. If you’re giving anybody the infrastructure they need to do the best job they can, with the fewest headaches along the way, it seems they should be the primary focus.

Follow Diagnostic Imaging Editorial Board member Eric Postal, M.D., on Twitter: @EricPostal_MD

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