Tilting At Windmills

October 14, 2013

Practice Quality Improvement is an excellent ideal, but it can be difficult in practice.

I observed one of my former partners preparing for his recertification in diagnostic radiology under the Maintenance of Certification requirement. I confess that I am one of the dinosaurs that is spared that ordeal and glad of it. One of the requirements I found interesting was the Practice Quality Improvement (PQI) project. It seems a bit odd to me to have to require someone to improve their medical practice. On closer reflection, I began to question, based on my own experiences, whether this was even possible.

To me PQI is no more than practicing good, ethical radiology. One thing that always bothered me was having a two-view extremity image submitted but billed as a three-view study. For example, three-view studies of the ankle and foot were requested, but only one lateral view was submitted, resulting in only five films.

In the old film days, I would tell the tech to hold the films for the ankle in one hand and the foot in the other. If they didn’t have three films in each hand, the charge for one of the studies was incorrect. In the digital age, this has become problematic.

Likewise, proper film collimation, especially on pediatric studies, became a crusade. Convincing techs that a single film of the chest that included the abdomen should not be charged as a separate chest and abdomen films proved frustrating. Similarly the proper placement of skin markers for palpable lesions on mammography has never met with anything but a glazed look.

My guiding principle in these “practice improvement” efforts has always been a corollary of the Golden Rule – do what is right for the patient. Sometimes this has caused me grief, like the time I was working for a large group and was the radiology director at one of its small hospitals. One day, I read knee films that showed an acute fracture. The problem was that I knew the requesting physician was out of town on a ski trip.

I called the office and asked for the person who had actually ordered the study and got the doctor’s nurse. I gave her the report and wasn’t sure what she should do next. I decided to mention this to the chief of the medical staff because, as an idealist, I felt that this was not a good medical practice. When the physician returned, he got a letter from the chief of staff, and he was furious with me. As a result, my group, which was hoping to joint-venture with said physician, took the department directorship from me. No good deed goes unpunished.

My most recent crusade involved pre-op chest X-rays. In our area, these are done without regard to national standards or common sense. Patients of all ages, regardless of symptoms or lack thereof, are required to have this study. Even a chest X-ray performed just hours or days before, but not reflecting the reason “pre-op,” will not protect the patient from having it repeated. I asked a number of anesthesiologists at our hospitals about this and was told “the surgeons want them.” When I asked the surgeons, I was told “the anesthesiologists want them.” Some people thought they were required by hospital by-laws or possibly a standing order was found on the back of Moses’ stone tablets. Most did not think them necessary, but it proved impossible to change.

Therein lies the problem. Whenever, I have identified an opportunity for “practice quality improvement,” I have found that I did not have the authority or leverage to affect the improvement. As a radiologist, I work in departments with people who receive their paychecks from someone else. I feel a bit like Don Quixote. Sancho Panza! My lance and my shield! I see a PQI spinning on the horizon.