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What the Heck are the Rules in Radiology?


A singular database of current rules, guidelines and best practices in radiology would be a welcome advance to ensure ease of access, consistency, and proactive prevention of frivolous malpractice cases.

I have mentioned in recent blogs that I began a new job not long ago. I have always tried to keep my skills honed in as many types of imaging as my working situation allows. Sometimes, I can go for months or years without doing something of which I was capable. Then — poof! — jobs or workloads change, and those old friends return to my worklist.

When the first breast ultrasound showed up in my new digs, I almost did a double take. Those haven’t come my way in a few years. I had missed them a little, but it made perfect sense to me that they should go to whomever was reading the mammos and breast MR.

Indeed, I thought it might be required for that to happen. I had been pushed into being the breast guy during my last on-site job, and that included staying up-to-date on all sorts of regulatory requirements. When I left that job, I wasn’t too sorry to leave those administrative hassles behind me, nor my Mammography Quality Standards Act (MQSA) credentials, since my subsequent telerad gig sent me zero mammos and I had no way to maintain the required case volume.

Occasionally, though, even the telerad worklist contained breast sonos, usually “R/O abscess” cases from ERs hither and yon. I initially hesitated. Was I even allowed to read those anymore? I must have punted the question to leadership because I subsequently read those cases without worry.

Fast forward to the current gig, and now I wasn’t so sure. Had those telerad leadership guys been correct to give me a green light? Had the rules changed since then? I figured I had better look them up, which proved to be easier said than done.

Google led me to a formal-looking American College of Radiology (ACR) page, which laid out rules not only for rads, but other potential imaging interpreters such as surgeons. The page said very clearly that a rad doing breast sonos must be “qualified to interpret mammograms under MQSA.” There was no verbiage about any exceptions for emergency cases.

Prior to finding that page, I decided to pose the question on one of the radiology social media forums I frequent. Surely, wise colleagues there would know what’s what. Multiple helpful people came out of the woodwork. Others, like me, had no idea what the rules were, and also wanted to know.

The folks with the answers spoke confidently but some contradicted each other. I ultimately chose the answer that seemed most reasonable (and provided references). The FDA was the ultimate authority, and the FDA page did not require MQSA certification for emergency sono reading.

I found myself wondering, if I had absolutely nothing else to do with my time, whether I would accomplish anything by reaching out to the ACR so they could adjust their web page. If they responded to me at all, might they dig in their heels and insist that they had it right? What do you do when you have more than one authority, and they give you conflicting rules?

Taking a giant step back, it seems obvious. If rules are considered important in any venue, and it’s desirable for folks to follow them, those rules should be as easy to understand and as simple to find as possible. Any unnecessary layers of complexity, let alone secrecy, work against your system unless the system is being designed with intent to create “gotcha” pitfalls.

That may sound cynical to some readers, but it will ring unfortunately true to others. Over the years, I have seen more than one write-up about how government and the law have become so multilayered and complex that it is increasingly impossible for an individual to behave within bounds all of the time. “Show me the man, and I will show you the crime” becomes all too easy, Stalin regime or no.

Adding to the ever-increasing probability that one will at least accidentally transgress, there is a “punishment by process” mechanism. That is, if people in positions of authority decide to target you for scrutiny, proving your innocence can be a burden in its own right. Just being named in a garbage med mal suit, for instance, can cost you countless hours (and dollars!), while giving you an item you must list on applications for licensure, credentialing, etc. for the rest of your career. You can even commit punishable transgressions in the process of vindicating yourself.

Suppose we don’t want a system that makes it difficult or impossible to comply with the rules. How might we go about creating and maintaining it?

The simplest approach would be one I have advocated in this blog from time to time: prevention.

I won’t rehash the whys and wherefores behind that, in part because it is too late for that approach. Regulators and third-party payors have already established that there’s no real limit to their authority over us. Undoing that, if at all possible, will probably only happen with major upheaval.

The next best option would be a mechanism whereby all rads could be on the same page. To a certain extent, we start out that way at the end of residency. Presumably, at that point we have been properly trained, or at least been shown the ropes to the extent that we know the hard-and-fast rules, “best practices,” etc.

After that, we kind of drift. Folks who remain in rigorous academic environments probably keep current, at least in their own subspecialties. For others, it’s just kind of hoped/expected that they will keep current by reading the right journals and doing the right CME. However, aside from “nuisance” CME for special interests in this state or that, all that matters to a lot of us is getting our required quota of credits.

I would value a radiological database that maintained an up-to-date listing of all current rules, guidelines, etc. It could be maintained by ACR, but a separate entity might be better. The site itself would be free to access (again, what’s the point in hiding the rules?), but it could easily offer paid CME credits for folks who used it.

A robust internal search engine would be key. For instance, in my scenario, I might select breast imaging and ultrasound. I would probably also enter the state where I was working, since it surely has its own peculiarities. I would like it if my screen further broke things down into actual rules/laws versus guidelines, each with specification as to who was issuing said guidelines. If there were widely accepted “best practices,” let that be a third section.

Down the line, I could see such a source interfacing with radiology workstation software. It could be an option to have pop-up windows (minimized as a default rather than annoyingly covering my dictation window) targeted to whatever imaging study just opened. Is it a thyroid ultrasound? Remind me where we stand as to whether TI-RADS is mandatory or just preferred. Is it a carotid study? Alert me as to whether I will be dinged for not mentioning North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria.

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