Just say "yes!".
Article Type: Editorial
Subject: Ultrasonics in medicine (Usage)
Ultrasonics in medicine (Analysis)
Pelvis (Medical examination)
Pelvis (Methods)
Author: Mirvis, Stuart E.
Pub Date: 10/01/2009
Publication: Name: Applied Radiology Publisher: Anderson Publishing Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Anderson Publishing Ltd. ISSN: 0160-9963
Issue: Date: Oct, 2009 Source Volume: 38 Source Issue: 10
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 231313766
Full Text: The following story will probably sound familiar to most radiologists. While on call one night, we received a request for pelvic sonography. At night the Radiology Department is responsible for emergency pelvic sonography, instead of the OB/GYN department. The Emergency Medicine (EM) resident described the clinical symptoms, which did not sound like anything remotely emergent, and the radiology resident suggested that the patient be scheduled for a complete routine pelvic sonography the next day. There are a lot of real emergency imaging procedure requests at night, and given staffing and the need for rapid interpretation, we try not to do studies that are clearly, in our opinion, nonemergent.

After making this suggestion, the clinical history changed from mild lower-abdominal pain to severe abdominal pain and now an ectopic pregnancy needed to be excluded. Of course, the resident and I were somewhat surprised and miffed at the sudden change in the history. The EM resident then insisted that her "attending" wanted the sonography performed--the "ace-in-the-hole" approach. I strongly encouraged the EM resident to ask the EM attending to stop by the reading room when an opportunity arose so we could talk. The EM resident was a bit surprised as the new academic year had recently begun and she did not realize an attending radiologist was always covering emergency imaging studies.

About an hour later, the EM attending stopped by the reading room. He is a great guy, friendly, respectful and knowledgeable. He apologized for the resident's style in requesting the study and admitted that the clinical picture was somewhat murky and that the presentation was nonurgent. I carefully explained our point of view and that we were covering many really sick patients. Our technologists were not available to perform the nonemergent study, so the resident who would have had to perform the study would have spent an hour away from his other multiple and varied responsibilities. This would create delays in many other activities required for other patients who were indeed quite ill or emergent. I am personally willing to "become" the resident while they do sonograms, but I am not as efficient nor fast enough on my own to cover everything (as hard as that may be to believe).

The EM attending seemed to understand and agree. I found out the next day that the study was requested and performed after another radiology attending and resident took over coverage.

There are many reasons why we would recommend against a study. Some studies are technically or medically inappropriate, whether the wrong modality is chosen to answer the clinical question or if it would lead to a study that is medically contraindicated. Other reasons for recommending against imaging are cases when an exam would add no further information to what has already been established, or when an exam may be indicated but is done so electively. In several countries I have visited, when the radiology resident or attending says that a study is not indicated, the decision is typically respected by the requesting physician. These are countries that are not limited with respect to equipment or availability.

It has been my experience that when a nonradiology department consultant makes a recommendation, either for or against a study or procedure, usually that advice is followed. Why is it that so often when the responsible radiologists says "no" it is often dismissed and, not atypically, leads to quite a battle? Is the radiologist's opinion generally faulty? Is it that he is just being lazy? Is it that they do not have the best interests of the patient at heart? Is it that they did not examine the patient? Is it that they are not "real doctors?"

I find it odd that our clinical referrers are generally all too happy to accept our final opinions about what studies demonstrate diagnostically, just not about an opinion that a certain imaging study is perhaps not indicated. I believe most radiologists would be fine with putting a note in the chart concerning their recommendations, but for some reason, this is seldom sought. There are some referring physicians that I always say "yes" to. It is too painful a process to proceed in any other fashion. In most cases, attending-to-attending, I start by saying the study will be performed if it is their wish, but that I would like to discuss the circumstances of the decision first. Most will agree to this, but still want the study. I will not allow any study where the patient is at reasonable risk for a major complication, but usually such issues can be resolved to mitigate such risk.

I know the story above resonates with most academic radiologists, but I do not know how such matters play out in the private setting. I assume the answer is usually "yes," except when a given study would put the patient at unacceptable risk.

I wonder how much the issue of medical malpractice concern influences the aggressiveness with which some imaging studies are pursued. Many a resident and attending have given the indication of just "CMA" (covering my assets) as the actual indication. When looking at the medical literature I was amazed at how little there was in the way of research that addresses this issue. Asking the physicians themselves is worth relatively little as they often will not admit this behavior. However, when asked about other physicians' observed behavior they will indicate that malpractice concern has a definite influence.1 A survey asked physicians if, based on their experience, the fear of malpractice liability causes physicians to order more tests than they would normally order just based on their medical judgment alone. On this survey, 91% answered "yes" and 11% "no."1 Certainly, from the perspective of an emergency radiologist, this response would be expected.

I do not know how the health care debate will come out, that is, who will benefit and who will not. There are so many disparate interests pulling in different directions that it will be a wonder if anything that is both comprehensive and solves real problems can result. All I know is that when tort reform was "taken off the table" at the very start, the ultimate sincerity of the entire effort was suspect.

We will all see how things go. In the meantime I guess it's better to just say "yes."

Reference

(1.) Common Good Fear of Litigation Study: The Impact on Medicine. April 11, 2002. Available at: http://commongood.org/assets/attachments/68.pdf. Accessed September 8, 2009.

Stuart E. Mirvis, MD, FACR

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.