Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, December 01, 2006

Rad Rage

Flea is to Emergency Department as #1 Dinosaur is to Radiology.

It should be so simple. A patient with fever, productive cough, chest pain and rales on exam. I order a chest x-ray. I write a note that says, "CXR; r/o pneumonia." The patient goes to the hospital and gets the chest x-ray. So far, so good.

As it happens, this patient has been through a lot in his life (including throat cancer and asbestos exposure) that has left its mark -- lots of marks -- on his chest x-ray. The report comes back:
We do not have any previous studies for comparison. It is very important that we compare the current study with the previous study to determine any changes. This patient has extensive asbestos-related pleural changes and calcifications in both lower pleural surfaces. There is also nodularity in the left mid lung fields which needs to be compared with previous chest x-ray to ensure stability. If this is new, then a CT of the chest would be indicated. There does appear to be subtle infiltrate in the right lower lobe, which may represent an early right lower lobe pneumonia.
As it happens, I have reports on this patient's chest x-rays going back to the early 1990s at the same hospital. Therefore the films described in those reports are all -- say it with me -- at the hospital. With a choice of a CT of the chest or comparison with old films, guess which one has no radiation or contrast exposure, is completely independent of patient compliance and doesn't cost nearly as much? I'll just get them to do a comparison with the old films.

I call the film room. I give the patient's name, date of birth and medical record number. I tell the clerk that I would like the radiologists to please compare the current chest x-ray to the old films that they (should) have in their files. The clerk asks for the patient's date of birth (again.) I give it (again.) I am told that I need to put my request for comparison with old films in writing. I am given a fax number to fax it to. I write the following (after writing the patient's name, date of birth and medical record number):
Please compare CXR of 10/6 to previous films. I include dates of 3 most recent previous films going back to 2001. Previous reports attached.
I fax not just this note but the report from the most recent previous CXR. Hey, I'm trying to be helpful. Maybe there's some secret code number somewhere on the report that will help them find the film more easily.

I wait.

A week later I call the file room back. They never got the fax. I send it again. This time I call to confirm that they got it. They did. I ask when I can expect to see the comparison. They tell me they have to find the patient's old film envelope; then the radiologist can dictate an addendum to the report.

I wait.

Another week later I call back. Monica, the film room clerk, and I are now on a first name basis. She lets me know that the films are in the radiologist's pile and I should see the addendum in 2-3 days.

I wait.

The following week I call my friend Monica, who promises it will be faxed to my office by the end of the day.

The next day, the addendum reads (essentially) "No change from previous films." Time elapsed: 1 month to determine that my patient has all kinds of nasty-looking pleural shit that is stable, and a new superimposed RLL pneumonia (for which I treated him) and from which he is now clinically recovered.

Just in time for the followup chest x-ray to make sure that infiltrate cleared. Keep in mind this is a guy with asbestos damaged lungs who stopped smoking for about 5 minutes after he was diagnosed with his throat cancer (ok, it was maybe about 2 years) so there's always the possiblity that the new infiltrate dscribed last month wasn't actually pneumonia but something bad like a lung cancer.

(Deep sigh.) Ah, but this time I have learned my lesson. My note for the CXR reads:
CXR; please compare to study of 10/6 to determine resolution of RLL infiltrate in patient with known abnormalities on CXR.
Six days ago he had the film done. Three days ago it was read. Yesterday it was dictated. Today I saw the report:
PA and lateral views of the chest were performed and compared to a previous study done on 10/6. Again noted is extensive asbestos related pleural changes with calcified pleural plaques as well as increased density in both lower lung fields especially in the left perihilar region. While this has not significantly changed since October, I would like to compare these findings with older chest x-rays which we will attempt to obtain. Once the previous chest x-rays are available, additional recommendations will be made.
AS YOU CAN SEE, NOT ONE WORD ABOUT THE RIGHT FUCKING LOWER LOBE!

Fay Wray is to King Kong as Monica the film room clerk is to #1 Dinosaur.

I call the film room. I tell Monica what the problem is. She is so good at her job that I actually keep a civil tongue in my head. She is also a fucking miracle worker: about two hours later, the radiologist -- the VERY SAME RADIOLOGIST THAT ACTUALLY READ THE FILM even (after supposedly having read my note) -- calls me back! I surprise myself at the civility of my tone (after listening to her tell me why they can't find the older films anymore and these two are so abnormal she really wants to compare them to the older ones) as I ask, "What about the RLL infiltrate? Is it still there?"

Finally finally finally it turns out that the two films are identical. The likelihood is that it wasn't really an infiltrate from 10/6 at all but rather all pleural based stuff, as he has very extensive bibasilar changes. But the bottom line is that now what he needs is a CT of his chest. (Very. Deep. Sigh.)

20 Comments:

At Sat Dec 02, 06:35:00 AM, Blogger Flea said...

No analogy is perfect. Has the chairman of your department ever sent you a letter recommending anger management for impaired physicians?

best,

Flea

p.s. Some shit you can't make up!

 
At Sat Dec 02, 01:22:00 PM, Blogger Sid Schwab said...

Oh man, the memories this post evokes. It's hard to be civil on the phone when you're literally trembling with rage....

 
At Sat Dec 02, 05:31:00 PM, Blogger Allen said...

I'm surprised he didn't wind up in the ER.

GruntDoc

 
At Sat Dec 02, 10:57:00 PM, Blogger MedStudentGod said...

This is why medical students were invented. My job has often been to go and resolve these "disparities" by going to Radiology and hunting down the Radbats, stroking their egos, and obtaining a perfunctory read for what was needed.

You need some medical students, Dino. We're annoying, incompetent, and utterly lost, but damn cheap :)

 
At Sun Dec 03, 07:11:00 AM, Blogger Long Island Nurse said...

i dunno if anyone clicked it, but the right link is http://www.drflea.blogspot.com/.

 
At Sun Dec 03, 09:04:00 AM, Blogger #1 Dinosaur said...

LI Nurse: Your link is to "An Internist in the Western USA." Mine is to a pediatrician in the northeast. Different docs; different blogs; and the one I'm talking about (with the correct link) is the peds guy who goes ballistic (appropriately) at the way his patients go the ED instead of calling him and the way they're handled by the ED (not calling him.) I don't know if Western Internist has the same issues, becuase I haven't read his blog at all. On the other hand, now I will.

 
At Sun Dec 03, 09:07:00 AM, Blogger #1 Dinosaur said...

Then again, Western Internist hasn't posted since 8/11/05.

 
At Sun Dec 03, 10:33:00 AM, Anonymous Anonymous said...

One way to help this frustrating situation is to tell the patient to get copies of his X-rays, and to wait for them while at the original appt. at the hospital. I try to do this, though sometimes the clerks there look at me like I'm an idiot for asking. Or it takes me 4 requests to get copies.

I've run into a similar situtation as well. When making an appt at a radiology lab, the clerk doesn't bother to tell me to bring any prior films. Then the radiologist writes in his report that he had no prior films to look at. All the while, the lab has the report of the former film stored on their computer system.

I know two people who work as clerks in the radiology dept. at a local hospital. One told me that they lose films. Or they put a new film in the 'discard' bin when it should have gone in the 'file' bin. The other clerk has told me that if a patient or doctor calls and asks for a report to be faxed, that often enough the request is lost, or the clerk who took the call simply forgets to fax the report. Either way, no one knows that the fax request was never filled. And no one is held accountable for the lack of faxing.

This must drive doctors nuts.

 
At Sun Dec 03, 03:53:00 PM, Blogger Gasman said...

All too common. The radiologist uses one of their pat excuses 'poor technique', 'corelate with clinical exam', 'films unavailable for comparison', and then you want to push them to actually do the work for which they are trained and handsomely paid. By pointing out that they own and are personally responsible for the old films they so wish to remain permanantly lost you have stolen one of their security blankets. Now they will have to come up with new ways to cover their ass using hedge words and phrases.

 
At Thu Dec 14, 09:20:00 AM, Blogger universal health said...

Er...digital, anyone?

As a former nursing supervisor, who did EVEYONE'S scut work in the wee hours, I can't tell you the difference having a filmless read system makes - the missing film problem disappears, the comparison reads are a breeze, and many programs allow scanning films into the system, so very old films can still be accessed via the digital system. And there's no time delay!

I haven't heard squawking by the rads, either, but I'm sure they'll correct me if I'm wrong.

Your story rings, oh-so-lamentably-true.

 
At Thu Dec 14, 11:24:00 AM, Blogger Jo said...

I've decided that our radiology department will do anything they possibly can to not see our patients.

I get calls all the time asking if the Patient was NPO for a procedure they don't need to be NPO for, like a CXR. ("Well...if he had some Jello this morning then it will have to wait until tomorrow")

If they patient is in isolation or on Oxygen ("well...we can only do a portable then....god forbid should WE take precautions or carry an oxygen tank")

or my favorite...actually forgetting to come get the patient even after confirmation of the order. ("well...I can't find the order in the computer...are you sure you ordered it?"

Got here via Change of Shift.
Sorry for the rant...great post!

 
At Thu Dec 14, 12:42:00 PM, Anonymous Kim said...

Wow - I need Norvasc just reading the post! LOL!

We went to a digital x-ray system a few months ago where the ER docs can call up new and old films right at their desk.

Many bells and whistles.

The best being that the patient can have a CD of their x-rays instead of carrying around big old films (and the primary doc can get them, too!). The trouble is the official radiologist report doesn't go on the CT, but one would hope that would be easier to find than an old film.

I'm wondering if I should start asking for copies of any x-rays I might need...

 
At Mon Dec 18, 06:05:00 PM, Blogger Long Island Nurse said...

My apologies. First time I clicked the link, it didn't work. Now (2 weeks later), it does. I was just attempting to be helpful. But you're right. Two different fleas. lol.

 
At Tue Dec 26, 06:23:00 PM, Anonymous ddrad said...

As a radiologist, it really hurts to see my speciality performing so poorly, and it hurts even more to read your story and conclude that you are right, the radiology department is not performing adequately. A few comments:
The way the file room works is out of the control of the radiologists, don't blame them, its not their fault, blame the hospital administration.
Get a PACS system, with all the images stored digitally, most of these problems go away (but not all of them)
Radiologists don't "own" the films, the hospital does, they collect the techinical fees and in exhange are supposed to maintain the films and provide them for follow up comparisons.

 
At Mon Jan 01, 06:56:00 AM, Anonymous Sinky said...

and as another radiologist, I need to echo the above. Remember though, we are also victims of dysfunctional SYSTEMS, and they thwart us too, in our ability to read the imaging well, to help you look after our patients.
- and remember, these sentences of 'radiologyspeak', like 'suggest compare with old films', and 'allowing for the technical reservations', or 'correlate with clinical exam', are not just defensive disclaimers, borne of a reluctance to take responsibility, but genuine valid recommendations, which actually do make sense in helping care for our patients.
- the best thing you can do to help the process, is to empower your radiologist with a good history......by this, I mean, TELL HER that your patient has asbestos exposure and a history of throat cancer. These were critical omissions in the original referral. We are all battling dysfunctional systems in big hospitals and practices, but this is a simple do-able measure, which will make all the difference.

That said, gee your hospital is slow, in its turnaround time in getting just simple CXR reports out. Youre gonna love PACS, when you guys get it.

 
At Sun Jan 21, 09:04:00 AM, Anonymous Anonymous said...

Wow
Those dudes need to get on PACS pronto.

 
At Wed Feb 28, 08:13:00 AM, Anonymous plainoldacademicsurgeon said...

This is why I try to always discuss radiology films in person with the radiologist. Granted I have that luxury as I work in a teaching hospital with a digital radiology system - but you see me in that darkened room many call nights sitting next to my radiology colleagues each filling in blanks left by the other; it is a most salutory way of clarifying your thinking.
God help us if we ever go to outsourcing our reads to India!!!

 
At Sat Dec 22, 09:39:00 PM, Anonymous Anonymous said...

The systems always seem to be at fault, but no one will change them. I instruct my patients to SAY nothing, and give the Radiology department my request. My request says "smoker with LLL rales" or similar, but always is changed to "cough" on the report. The reason seems to have to do with billing, in which r/o cannot be used, so they get in the habit of substituting a billable reason for the film. Whenever I have complained, the radiology manager says that the "radiologists are free to look at your request." So why don't they dictate it?!

After several years, I just stopped caring, and try to send my patients to other locations. You think they might listen. After all, I trained at that hospital, been affiliated for 16 years, and my father is a radiologist there.

 
At Sun Dec 23, 10:42:00 PM, Blogger MadMT said...

As a medical transcriptionist, let me also say that I believe those stinkin' normals so popular in rad dictation factor in, too. Normals are great for our line counts, but gad, they scare the heck out of me!!!

 
At Tue Mar 25, 07:00:00 PM, Anonymous Anonymous said...

As a hospital based radiologist, I feel your pain. But, I do say that quality comes critique. Keep complaining, complain high... Chairman, Radiology Head administrator (not the same). Find a radiologist or group you like and insist on sending your business to them. You control our income. PACS is great, but doesn't solve the problems of non-
clinically based radiologists.

 

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