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.

Thursday, April 03, 2008

Rad Rage Reciprocated

Do not piss off a radiologist.

I learned this the hard way today.

Earlier this week I had another case of a radiologist ordering a breast biopsy: a call came asking me to fax over a note for a patient already sitting there. I had seen the abnormal mammogram, but apparently the report for the extra views and the ultrasound never made it to me. They faxed it over; I made the patient come over for an exam and then sent her back for the biopsy. Actually, she had more than one lesion: a cluster of little cysts that were aspirated uneventfully, and a "worrisome" lesion that they tried to needle but said that if the pathology came back negative, I should assume it was because of faulty sampling, because they really thought it looked like cancer on both mammogram and ultrasound. (So why needle it? Because they can.)

Anyway, the next day I had called the radiologist back and threw a major hissy fit; really chewed him a new one. All he agreed to was that I should have gotten a phone call instead of just the report (that never came.) And he made certain I got the report of the aspiration/biopsy. Along with a later addendum with the path results (which I had gotten under separate cover anyway.)

Actually, I got the report twice: the original, then the addendum faxed under separate cover after a call from the Breast Center Liaison confirming my fax number (because they wanted to be *sure* I got it.) Then I got the whole thing sent over again, labeled "Superceded Report." Actually, it came over twice.

Then today it came over again. And again. And again. And again. And again. And again. And again. And again. And again. And again. That's right: 10 more times. Four pages each.

After the eighth time, I called over to the hospital and promised never to yell at them again; just please, make it stop! They claimed it was an IS gremlin, but I found it a bit too coincidental that it just *happened* to be the same patient I'd chewed them out over. They had the IS guy call me; he asked me to fax the first page back over to him. I asked why. So they could tell where it was coming from. Good luck; there was NO indication of what phone number was sending the runaway faxes. By then, though, I thought it had stopped.

No such luck. About half an hour later it came over again; and then again. Another call to radiology and another transfer to IS; more groveling on my part; promises never to complain to any radiologist ever again; happy to write notes allowing them to do ultrasound guided mastectomies if they would please please please stop faxing me the same goddamnable report over and over and over. Eventually it stopped.

Ever feel someone sneering at you from two miles away?

Uncle.

13 Comments:

At Thu Apr 03, 10:07:00 PM, Anonymous Anonymous said...

Uncle, schmuncle. That's what trash cans and shredders or for. Or you could just box up the lot and deliver 'em to the IS guy. Your were right and these people were wrong and are being juvenile.

 
At Thu Apr 03, 10:31:00 PM, Anonymous Anonymous said...

Have you thought of anger management?

 
At Fri Apr 04, 06:08:00 AM, Blogger Bardiac said...

Why make the patient come over to your office for an exam only to send her back when she's already there?

I'm sure there's a really good reason, but I'm not seeing it.

 
At Fri Apr 04, 10:33:00 AM, Blogger Stark Raving Med said...

Amusing anecdote, though I doubt the repeated faxing, if it was malicious at all, had anything to do with the radiologist. It's unfortunate that clinicians and radiologists are the Montagues and Capulets of the medical profession, though I doubt that's going to change anytime soon. The conflict, I imagine, stems from a profound lack of understand of what each other does and why they do it. Case in point:

"...a 'worrisome'lesion that they tried to needle but said that if the pathology came back negative, I should assume it was because of faulty sampling, because they really thought it looked like cancer on both mammogram and ultrasound. (So why needle it? Because they can.)"

Cynical, yes. Accurate, no. Radiologists biopsy (at the request of referring primary care physicians and surgeons) lesions that are almost certianly malignant as the tissue diagnosis is useful to the surgeon prior to definitive surgeory and helps avoid multiple surgeries.

It's a shame you have such an adversarial relationship with your radiologists - that's the radiologist's fault. Direct and frequent communication should be the rule - and not just to avoid lawsuits.

 
At Fri Apr 04, 10:55:00 AM, Anonymous Anonymous said...

I wouldn't assume the repeat faxing was deliberate and malicious. It might have been a glitch with the auto-dial or the fax memory.

I'm sure it was annoying but sometimes coincidences really are just coincidences.

 
At Fri Apr 04, 11:38:00 AM, Blogger KELLY said...

Interesting. What would be frustrating is with all the "same report" over and over again - it would make it really easy to miss a "new report" that might have gotten lost in all the craziness.

And if this radiologist was behind this craziness - how unprofessional and immature! I would think his time would be better spent making sure that he was as thorough in all the duties he was supposed to be doing! ha!

 
At Fri Apr 04, 11:47:00 AM, Blogger Stark Raving Med said...

"Why make the patient come over to your office for an exam only to send her back when she's already there?"

Because they can bill for another office visit. You're not the only one who can play the cynical card!

Seriously, Bardiac, the answer to your inquiry is no - there is no "good" reason. It is competely irrelevant whether the lesion can be palpated or not. An ultrasound-guided core biopsy is a far more effective diagnostic tool than a fine needle aspiration of a lesion you think you can palpate. How do you know you were in the correct lesion when you get a negative result? I have had countless referrals for ultrasound guided biopsy of lesions which could be palpated.

And furthermore, (anticipating another possible explanation for calling the patient back) radiologists are in a far better position to advise patients on breast health than a family practice physician - not to insult your fragile ego. Unlike with other disease processes, radiologists are an integral part of the patien's clinical experience, even, in many circumstances, delivering the pathology result to the patient's themselves and ensuring appropriate follow-up. This an important part of the training of all radiology residents and only medical and surgical oncologists surpass a radiologist's knowledge of breast health.

 
At Fri Apr 04, 03:50:00 PM, Blogger #1 Dinosaur said...

My heavens, folks; of course it was nothing more than a computer glitch. It was just too much fun to pretend to harbor dark thoughts. Also, it made it funnier.

Regarding the visit: keep in mind that no one up to this point had actually done a clinical breast exam on this lady (including the radiologist, Stark Raving, despite their supposed "far better position to advise patients on breast health.") Not all palpable masses show up on mammography. They only ultrasounded the breast with the mammographic abnormalities. What if there was a palpable mass in the other breast that didn't show up on the mammo? Everyone would have been digging around on one side and ignoring another potential tumor in the other breast.

Also, keep in mind that I didn't actually have the U/S report until after the patient was in my office. Before I saw that report, I didn't know if I was going to send her back to have it needled or directly to the surgeon for a more definitive procedure. As it happened, they were still able to take her back and do the procedure, but at the time I was not certain that was how I was going to proceed.

I was just trying to be thorough.

 
At Fri Apr 04, 04:24:00 PM, Blogger Stark Raving Med said...

"I received a mammogram report the other day that described a new nodule in a breast. The conclusion read, "Biopsy recommended." I called the patient and asked her to come in for a breast exam to see if the abnormality could be felt, to which she readily agreed."

This was the comment I was mainly responding to - from Rad Rage Part 2 as you didn't specifically state your reason for wanting to do the breast exam in the current post. Also, your current post is a little misleading:

"the report for the extra views and the ultrasound never made it to me. They faxed it over; I made the patient come over for an exam and then sent her back for the biopsy."

This implies that you did have the ultrasound first. No problem though, just a misunderstanding.

Though, it seems to me that the clinical breast exam would best be done BEFORE the patient comes for yearly mammogram, to best direct her into a screening or diagnostic category (if a lump was felt). The need for a clinical breast exam to evaluate the other breast after a suspicious finding, while important, should not delay diagnosis of the lesion in question. In fact, the standard of care is fast becomming bilateral MRI following a cancer diagnosis to detect those very mammographically occult lesions you were looking for - as we know all too well, clinical breast exam isn't the most sensitive diagnostic tool in the world.

 
At Fri Apr 04, 06:08:00 PM, Anonymous GingerB said...

You saw the woman for a check-up, referred her for a mammogram, but didn't do a breast exam at the check-up, even though she was being sent for a mammogram? If her imaging had been good then she'd never have had a breast exam.

When I have a mammogram it's always hooked up with an appointment -before or after- that includes a breast exam.

I believe the current wisdom is that self-exams aren't worth doing, but professional ones are still recommended.

 
At Tue Apr 08, 05:10:00 AM, Blogger Bla said...

Your blog makes me feel hypochondriac.

 
At Tue Apr 08, 04:22:00 PM, Blogger Sid Schwab said...

"only medical and surgical oncologists surpass a radiologist's knowledge of breast health."

Wow. Rarely have I seen a statement with which I disagree more (except, of course, in the political arena.) It's true that radiologists believe it. Which is exactly the problem.

I don't disagree that they are an integral part of the approach to the management of breast problems, and that communication between them and the people actually taking ongoing care of the patient is essential. But, as a general surgeon whose 25+ year practice consisted of more breast care patients than any other category, I can't count how many times I was placed in a bind by radiologists either recommending what sort of intervention ought to take place, or doing it without consulting. I realize that's not the point of our estimable host's post, so I'll not belabor it further. But there's a HUGE difference between what radiologists learn about the breast and what ANY decent general surgeon does; likewise, being responsible for the entirely of the care, as opposed to putting words on a page, makes one much more attuned to all the ramifications. Not, I'm sure, that any radiologist would agree.

 
At Sun Apr 13, 10:38:00 AM, Anonymous Anonymous said...

Well said Sid. I must say that jokers statement was one of the most ignorant, uninformed ones I have ever read.

 

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