Why are we doing this, again?

December 7, 2018

Sometimes it’s good to look up and ask why things are the way they are.

Longer-term readers will know that I’m not a big fan of outside interference in our field. Specifically, by those without medical, let alone radiological, experience reaching in and meddling in how we practice our specialty.

In such pieces I’ve expressed the opinion that the best means of counteracting this is prevention. That is, don’t even let the meddlers get a foot in our metaphorical door.

Related article: Radiologists Have Too Much to Do

Still, they find their way in, and once they do we tend to follow the path of least resistance: Learn to live with these barnacles on our collective hull, no matter how much they drag on our morale and professional efficacy. I think because the effort of scouring them away is far greater than the effort of appeasing them at any given juncture.

A good thing gone bad

For instance, suppose a healthcare facility for which a rad-group is providing coverage institutes a policy: Certain types of imaging study must have their results phoned in and communicated verbally, doctor to doctor. No matter how positive or negative.

Under some circumstances such a policy makes sense. One prime example being “stroke protocol” CTs, where “time is brain.” A rad calling in to say that there is no bleed, and thus thrombolysis can ensue, saves time as compared with the rad just signing off his report, followed by some interval before a member of the clinical team happens to check and see that the report is there.

Another reasonable example is an x-ray for a surgical-instrument miscount; a rad calling in to say there are no unexpected foreign items immediately allows the folks standing around in the OR to get on with things, rather than having a member of their team repeatedly checking the computer to see if a report has been generated.

As so often happens with such policies that sound perfectly reasonable in the committees which decide to enact them, these things have a tendency toward “mission drift.” Next thing you know, a bunch of head CTs are getting treated as such “stroke protocol” cases when they are anything but, and no thrombolysis is being considered. For instance, a scan for generic “altered mental status” on demented patients who have had a dozen such studies in the preceding months, none of which were done with a view towards thrombolysis.

Or a patient for whom a head CT and a CTA of the head and neck were ordered rapid-fire…such that, even with the negative head CT having been phoned in, it’s now required that the results of the head CTA and the neck CTA get phoned in, too. Whether or not the ordering clinician wanted it that way, she’s getting three separate calls.

Indeed, commonly the referring doc did not, and the repeated phone-calls with negative or otherwise non-urgent results pose annoying interruptions to him-not to mention the rad who has to be on the other end of the line (and whatever ancillary personnel are involved in arranging the call and tracking down the relevant docs to get on the line if they are fortunate enough to not have to hold the phone themselves while connections are established).

Efficiency drain

Beyond the “gosh, this is annoying” factor, there’s a real impact on the efficiency of each of the docs/personnel. The rads are getting pulled away from reading other cases (ones which might be truly abnormal and deserving of urgent calls), the clinicians are getting distracted from other patients they’re trying to treat, and the ancillary personnel have yet another item added to the never-diminishing mountain of tasks expected of them. All detractors from the healthcare machine functioning as a well-oiled one.

Related article: Dealing With Stress in Radiology

The negative impact of such poorly-executed (or, sometimes, conceived) policies is multiplied across the healthcare system by the number of impacted healthcare workers, and not only the number of patients but however many times a given patient’s care might be impacted during a given clinical course (for instance, someone who gets 3-4 head CTs during his hospitalization). In short, these things add up.

What seems to be missing awfully frequently is a mechanism for periodically reevaluating whether these policies are, in fact, accomplishing what they were supposed to. And an appraisal of how much “collateral damage” is being done in the process.

I find this rather darkly amusing, since many of these policies are hatched by the same committee-dwellers who have passed off other bits of clinically-unhelpful fluff on us doctorly types-such as CME on the PDSA (Plan-Do-Study-Act) cycle. That cycle would dictate that someone should be monitoring things like the “call all results” policy.

Related article: Five Steps Away from Paradise…and Misery

Make no mistake; I’m sure some monitoring is occurring-but I’d place a large wager that most if not all of the monitoring is aimed at making sure there is compliance. That is, 100% of such imaging-studies are being called in, and if only 99.5% are, what’s being done to remediate and/or punish the remaining 0.5%? In other words, all the monitoring is biased in favor of the policy. Better enforcement may be needed, but perish the thought that some aspects of the policy might appropriately be trimmed back.

I’d suggest that, as long as one or more folks living under such a policy feels that it places burdens on some aspect of your system, it’s foolish not to have a periodic review as to ways in which the policy is negatively impacting the place. Corrective action for those negative aspects should be at least as much of an ongoing goal as compliance itself-and, if it becomes evident that the policy’s negatives outweigh its positives (for instance, a “Waste, fraud, and abuse” campaign that costs ten times as much as it ultimately saves), it shouldn’t be a Herculean labor to nix the policy itself.