Radiology Call Backs

[Groove]

Do you guys get call backs for all PEs and/or expect them from your radiologists? I'm including sub segmental/tertiary PEs.

I've been having a real issue with our radiologists over the past few months. I've had them miss all types of findings and they are reading from home giving us prelim reads overnight. I even had them read a CT as neg and when I reviewed... had a massive blowout L2 fx with retropulsion and when I called him, he really didn't have much to say. Needless to say, I've been dogging them over the past few months with study after study where something was missed or they didn't call back for acute findings. They've missed spinal Ca mets (On my overnight STAT MRI no less), PEs, Fxs, Masses, etc..

I'm trying to decided if my recent sub segmental PE is worth getting on my bandwagon again. From my point of view, I'd like a call back on any acute PE. Period. I don't care where it is. How do you guys feel? Am I being unreasonable?

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[Birdstrike]

Do you guys get call backs for all PEs and/or expect them from your radiologists? I'm including sub segmental/tertiary PEs.

I've been having a real issue with our radiologists over the past few months. I've had them miss all types of findings and they are reading from home giving us prelim reads overnight. I even had them read a CT as neg and when I reviewed... had a massive blowout L2 fx with retropulsion and when I called him, he really didn't have much to say. Needless to say, I've been dogging them over the past few months with study after study where something was missed or they didn't call back for acute findings. They've missed spinal Ca mets (On my overnight STAT MRI no less), PEs, Fxs, Masses, etc..

I'm trying to decided if my recent sub segmental PE is worth getting on my bandwagon again. From my point of view, I'd like a call back on any acute PE. Period. I don't care where it is. How do you guys feel? Am I being unreasonable?

I agree. You're being totally reasonable. Take up a case with hospital admin, to have these guys fired and bring a higher quality group in. It sounds like they're providing s very poor service.

 

[WilcoWorld]

I thought missed findings were bad enough, but you're saying that the radiologists will amend their preliminary read to include a PE or a spinal met and not even call you about it? That's unacceptable and definitely worth raising a fuss over.

 

[Gadofosveset]

PEs and mets should probably be called in. Report changes should usually be called in.
A few things to consider

- some radiologists have advocated that subsegmental PEs are not even worth mentioning. Risk vs. benefit. Same idea behind not sounding the alarm over thyroid nodules. At least a few radiologists probably feel they're trying to help out by cutting down the incidentals.
- radiologists often feel like they're bothering the clinical team with calls in general
- there's some variability with subsegmental PEs in terms of reader sensitivity. If an overcaller overreads an undercaller then suddenly a new subsegmental PE may appear out of thin air. Still should get a call (but see the previous point)
Spinal mets should be called in, unless there's a good reason not (e.g. the patient already has multiple known spinal mets)

 

[scootad.]

I'd suggest talking to hospital admin. Part of the problem is your hospital is covered remotely by teleradiologists. Telerads are much less likely to take the time to get on the phone and call in results. It's because they get paid by the # of cases they read. If your hospital had radiologists in house, reading their MRIs and CTs right down the hall from you, they would feel more responsibility to call you with results, because they could attach a name to a face, and there is more accountability.

Band together with the other Emergency docs and demand boots on the ground radiologists and try to get rid of the telerad coverage.

 

[SoCuteMD]

PEs and mets should probably be called in. Report changes should usually be called in.
A few things to consider

- some radiologists have advocated that subsegmental PEs are not even worth mentioning. Risk vs. benefit. Same idea behind not sounding the alarm over thyroid nodules. At least a few radiologists probably feel they're trying to help out by cutting down the incidentals.
- radiologists often feel like they're bothering the clinical team with calls in general
- there's some variability with subsegmental PEs in terms of reader sensitivity. If an overcaller overreads an undercaller then suddenly a new subsegmental PE may appear out of thin air. Still should get a call (but see the previous point)
Spinal mets should be called in, unless there's a good reason not (e.g. the patient already has multiple known spinal mets)

I totally understand the idea that sub segmental PEs may not be worth mentioning, but it seems that it should be somewhat consistent across an institution. And really, is a radiologist the RIGHT one to make the determination that a sub segmental PE is or is not significant? At all of the institutions I've worked at, radiologists do not access or read the patient chart, so they know only a brief clinical history.

Groove - I don't know the answer to your question. I, too, have struggled with radiology callbacks (we get prelim reads sometimes from our own attendings and we use teleradiology). I have found no solutions, but I anxiously await an update from you as to whether you make any progress.

 

[Gadofosveset]

I totally understand the idea that sub segmental PEs may not be worth mentioning, but it seems that it should be somewhat consistent across an institution. And really, is a radiologist the RIGHT one to make the determination that a sub segmental PE is or is not significant? At all of the institutions I've worked at, radiologists do not access or read the patient chart, so they know only a brief clinical history.

Groove - I don't know the answer to your question. I, too, have struggled with radiology callbacks (we get prelim reads sometimes from our own attendings and we use teleradiology). I have found no solutions, but I anxiously await an update from you as to whether you make any progress.

The point is well taken.

I think it would be uncommon that a radiologist would see a definite subsegmental PE and then choose not to report it.
What would be more likely would be
1) they would put it in the report, but not call about it, because it's likely not significant
2) they would be debating over three pixels, whether it is or not a subsegmental PE, and then err on the side of not to avoid anticoagulating the patient for a likely nothing. Other radiologists might freak out over the three pixels and call the ED in a panic. Radiologists occasaionally use their judgment, like other MDs.

Scootad's point is a good one. Teleradiology is a big part of the problem.

 

[Apollyon]

We use telerads, but, also, my MRI is M-F, 8-4, full stop. Period. So, that's not an issue for us. As for the telerads, there is a list of them (of course), and my full time radiologist has a check mark next to the names of the ones he likes/trusts. Interestingly, most of them are the women - only a few guys are on the "good" list. Hell, I have one of the teleradiologists in my phone - she's that good.

Ours, though, have a policy to call back, so they HAVE to make contact - if not, they get internally dinged on their end (but they have an administrative assistant to mind it in between points A and B). But, unlike other companies, I've never had one not talk to me, or start yelling or get angry. However, also, I've had more than one tell me I'm at least in the top half - so, when they see my name, they're not thinking "yokel from the nuthouse".

 

[deleted109597]

I'm honestly more worried/annoyed by the fact that the words "a preliminary stat fax of the findings was sent to the emergency department at the time of this dictation" which has, for the record, never occurred.
Sure, most of them call for the big things. Except code stroke, they never call for that, when it delays the neurologist pithing the patient.

 

[DrBowtie]

Rad resident here.

I've had trouble trying to find the right balance between calling findings vs. issuing the report. Too many times getting the annoyed "already saw it" reaction.

I tend to limit calls to emergent/unexpected/recs for additional imaging/and findings likely requiring consult to aid in ED efficiency.

Just curious about your usual workflow in terms of checking to see when the imaging was done and checking on reports, especially related to dispo. I have a feeling my experience may be skewed by academia with more eyes checking on each patient.

 

[DrBowtie]

I'm honestly more worried/annoyed by the fact that the words "a preliminary stat fax of the findings was sent to the emergency department at the time of this dictation" which has, for the record, never occurred.
Sure, most of them call for the big things. Except code stroke, they never call for that, when it delays the neurologist pithing the patient.

Seems like that is an administrative issue on their end. Might be worthwhile to bring up to the admins as the radiologist may not be aware that it isn't happening after they sign off on the report like it is intended to.

 

[link2swim06]

Rad resident here.

I've had trouble trying to find the right balance between calling findings vs. issuing the report. Too many times getting the annoyed "already saw it" reaction.

I tend to limit calls to emergent/unexpected/recs for additional imaging/and findings likely requiring consult to aid in ED efficiency.

Just curious about your usual workflow in terms of checking to see when the imaging was done and checking on reports, especially related to dispo. I have a feeling my experience may be skewed by academia with more eyes checking on each patient.

I never get annoyed by these sort of phone calls. Often in obviously stuff there might not be a surprise but it's a good safety mechanism to make sure findings are communicated.

 

[Hair Police]

Rad resident here.

I've had trouble trying to find the right balance between calling findings vs. issuing the report. Too many times getting the annoyed "already saw it" reaction.

I tend to limit calls to emergent/unexpected/recs for additional imaging/and findings likely requiring consult to aid in ED efficiency.

Just curious about your usual workflow in terms of checking to see when the imaging was done and checking on reports, especially related to dispo. I have a feeling my experience may be skewed by academia with more eyes checking on each patient.

Thats a shame that you've received that reaction. You have the right reasoning for when you call - things that are emergent, change management, etc.

Often I will look at the study the moment they patient gets back or as fast as the images are uploaded, if I think it'll be positive. If it is the chronically ill but not acutely ill multiply-comorbid patient with a BMI>35 and age>65 that the charge tells me was eating in triage, I will check on that prior to DC.

 

[deleted109597]

Rad resident here.
I've had trouble trying to find the right balance between calling findings vs. issuing the report. Too many times getting the annoyed "already saw it" reaction
I tend to limit calls to emergent/unexpected/recs for additional imaging/and findings likely requiring consult to aid in ED efficiency.
Just curious about your usual workflow in terms of checking to see when the imaging was done and checking on reports, especially related to dispo. I have a feeling my experience may be skewed by academia with more eyes checking on each patient.

I get this. Often, if some obvious finding has recently presented in the department, I will answer the phone with "Hey, Dr. McNinja, yeah, I see the (subarachnoid, pneumothorax, whatever). Is there anything else? Frequently they give a little more info, thank me, and hang up. On the flip side, if I see something, I often call them about it. We have a good environment, as we should. All of us are interested in improving the care of patients (or should be). Nobody should be annoyed by the radiologist calling for the obvious, as sometimes in the department, the obvious is unseen until someone points it out.

 

[southerndoc]

I believe radiologists should call in any significant finding. Malignancy, PE's (even subsegmental), pneumoperitoneum, etc. should all be called in. A non-perfed appendix probably doesn't need to be phoned in, but the report needs to be made available very quickly either by fax or other means.

Remember, if you order the test, you are responsible for its interpretation... even if you're not as well trained as a radiologist in reading CT's. It is ultimately your responsibility for any missed pathology. This is why I always review every image I order, 100% of the time. I may not pick up on things the radiologist sees all the time, but I've become proficient at spotting many things over the years. Even obvious things get missed sometimes (had a radiologist miss a head bleed because he accidentally read the one done the week prior).

 

[DrBowtie]

I believe radiologists should call in any significant finding. Malignancy, PE's (even subsegmental), pneumoperitoneum, etc. should all be called in. A non-perfed appendix probably doesn't need to be phoned in, but the report needs to be made available very quickly either by fax or other means.

Remember, if you order the test, you are responsible for its interpretation... even if you're not as well trained as a radiologist in reading CT's. It is ultimately your responsibility for any missed pathology. This is why I always review every image I order, 100% of the time. I may not pick up on things the radiologist sees all the time, but I've become proficient at spotting many things over the years. Even obvious things get missed sometimes (had a radiologist miss a head bleed because he accidentally read the one done the week prior).

This is good discussion. I find it interesting that you say an acute appy who'll need surgery may not need to be called in but the subsegmental PE without right heart strain or infarct who'll go home on lovenox or admitted for heparin and bridged definitely needs to be called report.

In my mind and probably many others which may be incorrect is that the subsegmental PE isn't something that if tx was delayed 30 -60 minutes by the time you see the report wouldn't cause harm. Maybe we are biased by the tons of sub segmental PE we find incidentally in our outpatient cancer f/u population.

 

[gutonc]

I never get annoyed by these sort of phone calls. Often in obviously stuff there might not be a surprise but it's a good safety mechanism to make sure findings are communicated.

I don't work in the ED but I order and personally review a ton of scans (6-8 a day is a slow day for me) in the outpatient setting. I would much rather get a call about something I already saw myself than not get a call about something I didn't know about or missed on my own read.

 

[deleted547339]

This is good discussion. I find it interesting that you say an acute appy who'll need surgery may not need to be called in but the subsegmental PE without right heart strain or infarct who'll go home on lovenox or admitted for heparin and bridged definitely needs to be called report.

In my mind and probably many others which may be incorrect is that the subsegmental PE isn't something that if tx was delayed 30 -60 minutes by the time you see the report wouldn't cause harm. Maybe we are biased by the tons of sub segmental PE we find incidentally in our outpatient cancer f/u population.

Bowtie - first off, thanks for joining the conversation.

As far as what I think should be called:

ANY over-reads. Our radiology department is pretty good. Every once in a while, there will be an attending over-read that changes dispo and it won't get called in. This is very rare, but it makes me crazy when it happens. Usually the attending over-reads are called in by the resident and it is something fairly trival.

Anything that a delay in management could lead to significant morbidity or mortality - SAH, PTX, perf'ed viscous, ectopic, ect. These are usually the same things that we're looking for in real time. If I have someone come in with BP of 240/110 with unilateral weakness and fluctuating level of consciousness, I walk them to the scanner and call nsgy from the tech's room. We have a digital XR system that allows us to view the XRs as they are shot - so I look at all post-intubation CXRs or CXRs when I'm worried; in CT, I'll look over the tech's shoulder.

I don't think it matters whether or not you call on things that aren't time sensitive. If someone has a fracture or pneumonia or diverticulitis, the extra time to get the report out is fine. I read all reports within about 15 mins of when they are release unless something crazy is going on.

I never get mad at rads residents when they call. I do make fun of them when they sound like they are panicking. "OMG, theres a huge brain bleed, AHHHHHH!!!!"

On a somewhat related note, I hate when a rads report suggests I do something other than get another imaging study. I totally get the "recommend non-emergent MRI or 6 month followup CT" or "clinical correlation required" - there are patients with atalectasis vs PNA that have no cough, fever, white count, etc - if you put that in your reports, I'm fine documenting "this isn't PNA because of x, y and z." I've recently seen reports that have recommended I order certain labs and even one that recommended surgical consultation. No.

 

[WilcoWorld]

It seems the discussion has shifted from being about Radiology calling to tell us they're changing a read ("that negative MRI actually had a metastasic lesion") to Radiology calling to inform us of acute reads ("the patient in your trauma bay with a deformed, pulseless leg has multiple fractures").

I feel like it's my responsibility to already know about the acute reads that are obvious (in which case I say "yeah, I agree, thanks") but I think it's Radiology's responsibility to inform me if they're changing a read or calling something subtle but time sensitive

 

[DrBowtie]

Bowtie - first off, thanks for joining the conversation.

As far as what I think should be called:
ANY over-reads. Our radiology department is pretty good. Every once in a while, there will be an attending over-read that changes dispo and it won't get called in. This is very rare, but it makes me crazy when it happens. Usually the attending over-reads are called in by the resident and it is something fairly trival.

Anything that a delay in management could lead to significant morbidity or mortality - SAH, PTX, perf'ed viscous, ectopic, ect. These are usually the same things that we're looking for in real time. If I have someone come in with BP of 240/110 with unilateral weakness and fluctuating level of consciousness, I walk them to the scanner and call nsgy from the tech's room. We have a digital XR system that allows us to view the XRs as they are shot - so I look at all post-intubation CXRs or CXRs when I'm worried; in CT, I'll look over the tech's shoulder.

I don't think it matters whether or not you call on things that aren't time sensitive. If someone has a fracture or pneumonia or diverticulitis, the extra time to get the report out is fine. I read all reports within about 15 mins of when they are release unless something crazy is going on.

I never get mad at rads residents when they call. I do make fun of them when they sound like they are panicking. "OMG, theres a huge brain bleed, AHHHHHH!!!!"

On a somewhat related note, I hate when a rads report suggests I do something other than get another imaging study. I totally get the "recommend non-emergent MRI or 6 month followup CT" or "clinical correlation required" - there are patients with atalectasis vs PNA that have no cough, fever, white count, etc - if you put that in your reports, I'm fine documenting "this isn't PNA because of x, y and z." I've recently seen reports that have recommended I order certain labs and even one that recommended surgical consultation. No.

It can be sometimes frustrating for us since it takes time for complex imaging to hit our list and available for viewing due to the technologist having to create all of the reformatted imaging. We can usually make the major dx off the axial onlys but will need to further analyze the full data set prior to full interpretation.

As for your hatred of the non imaging reccs, I'm not quite sure why. I assure you no one is trying to be insulting of your clinical judgement, just help the patient and make your job possibly easier. (As a stylistic point, I rarely say recommend but rather say consider XYZ or obtaining XYZ may be helpful). Although I try to tailor my report to the ordering physician, I sometimes don't know who exactly is ordering what. We get a significant amount of imaging orders from mid levels providers. I've had the conversation of "Hey I'm calling for XYZ emergent unexpected finding" with absolute crickets and awkward silence on the other end or "how do you spell that?". We get imaging orders from generalists which may not understand what to do with findings that are commonplace for the neuro or ortho.

Another instance is the recs for non emergent consultation/follow up. How many people know at what size you follow a GYN cystic lesion vs needs eval for resection for GYN, or which Bosniak class renal cysts need f/u or resection outside of those fields? Although you may know this, I'd wager most wouldn't without having to look it up. I don't think guiding the patient to the proper consultant is out of line for radiology.

As for the labs, I typically avoid doing that. I will occasionally say specific things to correlate with such as bilirubin or IgG4 or tumor markers if it would help narrow a wide differential I gave, but I don't know anyone saying "Obtain XYZ labs". These may also not be relevant for ED ordering but perhaps the inpatient team or outpt PCP or specialist.

Obviously just my opinion and there is wide variation in reporting.

It seems the discussion has shifted from being about Radiology calling to tell us they're changing a read ("that negative MRI actually had a metastasic lesion") to Radiology calling to inform us of acute reads ("the patient in your trauma bay with a deformed, pulseless leg has multiple fractures").

I feel like it's my responsibility to already know about the acute reads that are obvious (in which case I say "yeah, I agree, thanks") but I think it's Radiology's responsibility to inform me if they're changing a read or calling something subtle but time sensitive

It is our policy in the training program that any significant finding that is discrepant between a prelim and final read is called and documented with the change and person getting results. It can be more problematic in the ED due to the shift work and the person taking the call may not be the guy who saw the patient, but thankfully they are fairly rare.

 

[Gadofosveset]

On a somewhat related note, I hate when a rads report suggests I do something other than get another imaging study. I totally get the "recommend non-emergent MRI or 6 month followup CT" or "clinical correlation required" - there are patients with atalectasis vs PNA that have no cough, fever, white count, etc - if you put that in your reports, I'm fine documenting "this isn't PNA because of x, y and z." I've recently seen reports that have recommended I order certain labs and even one that recommended surgical consultation. No.

Judiciously recommending lab studies is fine. The radiology report is an imaging consult from an MD, not a lab value from a machine. One may argue that the the radiologist doesn't see all of the patient's chart, and that's fair, but the rad doesn't always have to (e.g. follow up B-hCG for a PUL or AFP for an indeterminate mass in a cirrhotic patient). (let's also be fair, a lot of nonrads consultants aren't reading every line in the chart… they perform their analysis on recent clinic notes, targeted H&P, and recommend… which is roughly similar to what I do). I usually take into account who's ordering the study before recommending labs. I'd be more likely to recommend AFP to a FP doc I don't know than a hepatobiliary specialist I see in the halls.

As Dr. Bowtie correctly points out, some joint consensus criteria include "surgical consultation" for certain imaging findings, so many rads probably feel they're just following the rules. I've found that recommending specialist consultations seems also somewhat dependent on where a radiologist trains, and it's more common in radiologists who train overseas. Different hospital dynamic over there.

In general, rads don't like wasting words. If they're providing more words than necessary, then it's probably a legal/hospital requirement or they're going out of their way to do the ordering doc a favor.

 

[meister]

Our department has relatively strict guidelines on which findings require direct communication (tension PTX, unexplained free air, large ICH with mass effect etc.) but there is more leeway with findings that could change management but don't necessarily reach that level of acuity. I tend to lean towards not directly communicating if I can see in the chart the diagnosis is either known or suspected as I feel it would be a waste of a page or the ordering's time. In my relatively limited experience as a radiologist I have never gotten an irritated reply or attitude from an EP when I call downstairs, they are usually the nicest on the phone and most responsive. Perhaps my experience is a consequence of our department's commitment to preliminary reports being available to the ED within 30 minutes, and I like to think we keep to that pretty well. Exceptions are usually related to technical factors.

Keep up the good work in the trenches EPs, god knows I'll never forget my month in the ED as an intern.

 

[shookwell]

Some of the places I work have a "wet read" system, where I type in something if I interpret the test before radiology. That way the radiologist knows what I think and only calls me if there is disagreement or if there are additional findings. Otherwise they just put in their report "Dr. X is aware of the acute appendicitis based on wet read" and don't have to actually call.

When the radiologist recommend something that I don't want to do or isn't emergent, I often just tell the patient and include in the discharge instructions something like: "The radiologist recommends that you get X blood test/see X specialist based on your CAT scan today. Please discuss this with your regular doctor/gynecologist/whatever."

 

[SoCuteMD]

Had a read from telerads the other day that recommended internal medicine consultation for hepatosplenomegaly. Um, thanks? Wouldn't have thought of that? I'm sure the radiologist meant well. It may be a way of calling more attention to a finding and pointing out that it truly is abnormal.

 

[Groove]

Well, it's good to see I'm not in the minority with my radiology woes. I've sent so many emails to the rads chair over the past few months it's insane. The only positive is that I'm getting much better quality reads and more frequent call backs but it's still a real issue in my shop. The problem? Rads doesn't want to give full reads overnight and will give no reads at all on plain films. (50K annual volume shop no less.) The CT/MRIs get a prelim read. Some of these were so crappy it would literally have "NAF". Then the over read in the a.m. will include all types of things "Mass involving pancreatic head of uncertain sig, correlate clinically..., etc.." "Pulmonary nodule 1cm, increased in size when compared to CT in 2014." Again, I had severe mis-reads missing PEs, Fxs, SAH (this one was was a pt discharged by a colleague with head trauma on warfarin.. I still don't know how they missed this one. I looked back at the original and you could see the increased attenuation along the tentorium cerebri....subtle but I definitely didn't have to squint. I don't think I had hindsight bias on that one, it was obvious.) I honestly don't think it's completely a matter of competence as I've noticed that the radiologists quality of interpretation increases dramatically when they are in house during the day. I think they are reading these things on their home computers over dsl/cable ethernet.

The sugsegmental PE.. I can see the argument from both sides but from an EM standpoint, if a radiologist finds anything that might even remotely affect/delay care in the ED setting, I deserve a call back, period.

What is infuriating is the stack of positive plain film reads that the a.m. doc gets in the morning. He's responsible for taking each one and looking up the pt encounter overnight to make sure the finding was caught and if not, making sure the pt is updated or called back, etc.. I get so pissed off when I get a stack of those in the a.m.

How on earth the rads dept has enough political clout to continue their substandard care in the hospital is beyond me. I'm honestly very happy with the day reads and their performance. In my opinion, the hospital should contract telerad nighthawks if the radiologists don't want to provide overnight coverage as long as they understand that they won't get to bill for the read in the a.m. Fair is fair. You guys want to bill for all the night reads? Then provide an in house radiologist overnight. It's infuriating.

 

[scootad.]

Groove, you are 100% spot on. The problem boils down to lack of accountability. When the radiologist is sitting in his pajamas at home reading overnight films giving only prelims (with incomplete one word/sentence reports) quality WILL suffer. There will be misses, lack of phone calls for important findings, and just sloppiness. And this is coming from a radiologist. Gather your fellow EM docs, march down to hospital admin, and demand an in-house radiologist. You and your patients deserve this.

 

[Gadofosveset]

Your outrage is noted. I'm glad to hear that you find radiology to be such a valuable service and that you appreciate my contribution to the workflow of the emergency department... and I'm also glad you support quality vs. quantity radiology.

Telerads provide subpar reads. Full overnight in-house reads are becoming the new normal. It sounds like you're working in a system that's a std dev or two below the norm.

if a radiologist finds anything that might even remotely affect/delay care in the ED setting, I deserve a call back, period.

It's important to understand the radiology work flow. Clinicians have often have a vague misunderstanding of how a modern on-call radiologist works. The on-call radiologist isn't usually sitting around checking his or her email, waiting for your study. Usually it's a race to turn around complex reports as fast as possible while answering phone calls from all over the hospital. It's more like playing tetris while simultaneously trying to talk on the phone. This multitasking is especially tough for rads trainees, but a necessary part of the training process.

The majority of patients in most EDs have some kind of finding which could conceivably affect or delay ED care (minor pulmonary edema? Small pleural effusion? New diagnosis of fatty liver?). Normally these findings will be included in a report. Not all these findings can be called in. I work in a busy place, and if I wait on a study for six minutes trying to get the care provider, three more studies have popped up in its place. Another call, another three studies. Pretty soon the backlog is significant and turnaround time drops off. I'm not sure you can have a call on two-thirds of studies and still have reasonable turnaround time unless the ED provider picks up the phone instantly, or there are many radiologists on overnight, and neither option is very reasonable.

Telerads is often an administrator-level cost saving maneuver. It's considered cheaper than hiring an overnight radiologist. The total number of studies billed by the rads dept wouldn't change if there were telerads or not, right? The studies aren't billed twice. Paying the telerads comes out of the rad dept. budget (at least where I've worked). Do you want to send the telerad the full reimbursement for the read?

The decision to go telerads is not in the interest of ED docs. Telerads is also not really in the interest of radiologists, and we know this. The JACR has stated that they support overnight in-house staffing over telerads. We're all trying to make the ED work more smoothly. I'm sorry your particular experience with telerads has been poor. Tell your administrators that the cost of hiring a new radiologist will be less than the lawsuit generated by the telerads read.

 

[Hercules]

Telerads is often an administrator-level cost saving maneuver. It's considered cheaper than hiring an overnight radiologist. The total number of studies billed by the rads dept wouldn't change if there were telerads or not, right? The studies aren't billed twice. Paying the telerads comes out of the rad dept. budget (at least where I've worked). Do you want to send the telerad the full reimbursement for the read?

.

I know you're a radiologist, but you are mistakenly assuming all radiologists are hospital employees. They're not. At my hospital they are a private group. They use telerads overnight so that they don't have to work at night and enjoy a better quality of life. There is no cost savings in fact it takes money out of their pockets but it's worth it to them. And I completely get it. If I could hire a teleEM company to do all the nights for my group, I probably would. The EM doc who wants to work all nights (and keeps wanting to work all nights for the duration of his career) is rare. But if any of you on here is that night-loving EM doc or knows someone who is, please by all means PM me. My group would give you a very sweet deal.

 

[Groove]

Clinicians have often have a vague misunderstanding of how a modern on-call radiologist works. The on-call radiologist isn't usually sitting around checking his or her email, waiting for your study. Usually it's a race to turn around complex reports as fast as possible while answering phone calls from all over the hospital. It's more like playing tetris while simultaneously trying to talk on the phone. This multitasking is especially tough for rads trainees, but a necessary part of the training process.

Thanks for explaining the concept of multi-tasking. I have absolutely no idea what that's like as an EM doc.

The majority of patients in most EDs have some kind of finding which could conceivably affect or delay ED care (minor pulmonary edema? Small pleural effusion? New diagnosis of fatty liver?)

Seriously? You're comparing a PE vs minor pulmonary edema, small effusion and hepatic steatosis? I said "affect ED care", not affect their PCPs care.. Am I going to push 200mg of lasix to get rid of that edema and turn them into a raisin before discharge? Biopsy their liver? PE on the other hand... You better believe that knowledge will alter my ED management dramatically. Yes, I get the difference between tertiary and saddle emboli but personally, I'd still appreciate a call for that one.

The decision to go telerads is not in the interest of ED docs.

Anything is an improvement over 3-25 character prelim reads.

I hope you realize that my angst is directed towards the radiology services at my particular hospital and not directed towards radiology as a whole. We understand how hard you guys are working. You're contribution to the managing clinician is vital. If it were not so, I wouldn't be so upset.


Scootad, thanks for your advice. I may see if we can escalate the concerns. Can you enlighten me on how common it is for radiologists to read from home on their personal computer? Some of our guys are good. Damn good. I have been shocked at some of the misses when they read from night at home. Its simply got to be lack of image fidelity, fatigue or something related. I think it's the former as when I've been on the phone with them it takes forever for them to load the images and they apologize for the delay. I feel like it takes minutes for everything to load on a CT before they can bring up a particular slice that I'm inquiring about... Isn't that dangerous? If I were a radiologist, I wouldn't want to read from home simply due to the risk of error. I imagine it would be akin to me trying to treat all my patients from home over a webcam. I was under the impression that you needed a 15K set up and T1 connection to adequately read from home. Am I wrong?

It would be easier to escalate if these guys were ass***** but I really like working with most of them. I'm just intolerant of these subpar prelim reads at night. I don't even know what kind of medicolegal situation it puts me in when I treat based off a "preliminary" read that may be wrong in the a.m. Am I on the hook because it was a "prelim" read? Is the radiologist on the hook? Hell if I know.

 

[Gadofosveset]

Thanks for explaining the concept of multi-tasking. I have absolutely no idea what that's like as an EM doc.

I think you're taking this the wrong way. I'm explaining that rads are multi-tasking too, so there are some similarity in our jobs. And part of the reason I brought that up was to describe the tradeoff between calling and turnaround time. They're inversely correlated if it's busy.

Seriously? You're comparing a PE vs minor pulmonary edema, small effusion and hepatic steatosis? I said "affect ED care", not affect their PCPs care..

I'm not sure why the term "PE" is magical, aren't we're all are throwing tiny PEs all the time? I thought the size of the PE and the cardiac reserve is what matters. That being said, if my ED had a request to call for PEs of any size, of course I would be happy to oblige.
As for other small findings, the point of putting that in there was that sometimes it's hard to know what is going to turn out to be important. If the patient's LFTs are rising and the steatosis is a part of a new diagnosis of NASH, then I imagine that would delay emergent care.

My point isn't to argue small points, just to point out that rads are multitasking and calling and turnaround time usually work against each other.

I agree that telerads is pretty awful. I remember when I was an intern rotating in the ED and I would get a little yellow "sticky note" on iSite for an abdominal CT with three letter "NAD"…. and I remember thinking "WTF". I totally get how subpar and ridiculous that is. An in-house 24/7 rad is clearly better and it's the nation-wide trend, but the expense goes up.

 

[Gadofosveset]

I know you're a radiologist, but you are mistakenly assuming all radiologists are hospital employees. They're not. At my hospital they are a private group. They use telerads overnight so that they don't have to work at night and enjoy a better quality of life. There is no cost savings in fact it takes money out of their pockets but it's worth it to them. And I completely get it. If I could hire a teleEM company to do all the nights for my group, I probably would. The EM doc who wants to work all nights (and keeps wanting to work all nights for the duration of his career) is rare. But if any of you on here is that night-loving EM doc or knows someone who is, please by all means PM me. My group would give you a very sweet deal.

That's true, I'm thinking in terms of a busy tertiary care center. You're 100% right that small groups take the income hit for lifestyle, but that model is becoming less plausible, exactly because of Groove's concerns. Many small private groups are now rotating a night radiologist and/or hiring new rad(s) for nights, rather than lose their contract. It'll be interesting to see how that plays out since night rads (anecdotally) have an increased burn out risk, similar to night only EMs.

 

[scootad.]

Scootad, thanks for your advice. I may see if we can escalate the concerns. Can you enlighten me on how common it is for radiologists to read from home on their personal computer? Some of our guys are good. Damn good. I have been shocked at some of the misses when they read from night at home. Its simply got to be lack of image fidelity, fatigue or something related. I think it's the former as when I've been on the phone with them it takes forever for them to load the images and they apologize for the delay. I feel like it takes minutes for everything to load on a CT before they can bring up a particular slice that I'm inquiring about... Isn't that dangerous? If I were a radiologist, I wouldn't want to read from home simply due to the risk of error. I imagine it would be akin to me trying to treat all my patients from home over a webcam. I was under the impression that you needed a 15K set up and T1 connection to adequately read from home.

You are correct that there are spec requirements in terms of internet speed and high-resolution monitors in order to read images remotely from home. I am not a teleradiologist myself so I am by no means an expert on the exact speed/tech requirements, yet I wouldn't be surprised if some try to bypass this. The problem is multifactorial. 1) Reading from home you become a faceless entity, far removed from the patient care setting. You feel less accountable for your reads and are ok simply writing "NAD" even if that adds little value to the ordering doc or even if there are several incidentals that WILL require followup (large lung nodules, indeterminate renal masses, etc). 2) Telerads get paid by the # of CTs/MRIs they crank through. So you can bet your case will get less personalized attention, and you will probably receive few if any phone calls for important findings that change management. 3) While there ARE exceptions, teleradiologists tend to be lower quality radiologists. They often weren't good enough to get traditional PP jobs, so the only jobs left were teleradiology jobs. So you will probably get sub-par reads from them.

 

[RustedFox]

You are correct that there are spec requirements in terms of internet speed and high-resolution monitors in order to read images remotely from home. I am not a teleradiologist myself so I am by no means an expert on the exact speed/tech requirements, yet I wouldn't be surprised if some try to bypass this. The problem is multifactorial. 1) Reading from home you become a faceless entity, far removed from the patient care setting. You feel less accountable for your reads and are ok simply writing "NAD" even if that adds little value to the ordering doc or even if there are several incidentals that WILL require followup (large lung nodules, indeterminate renal masses, etc). 2) Telerads get paid by the # of CTs/MRIs they crank through. So you can bet your case will get less personalized attention, and you will probably receive few if any phone calls for important findings that change management. 3) While there ARE exceptions, teleradiologists tend to be lower quality radiologists. They often weren't good enough to get traditional PP jobs, so the only jobs left were teleradiology jobs. So you will probably get sub-par reads from them.

I'm really good buddies with the rads department at my primary job site. Admin is presently squeezing their nuts over meaningless metric X-and-Y.

You said it all, man. Those in-house guys... they save the day. They really, really do.

 

[shark2000]

Radiology attending a few years in private practice. These are my opinions:

1- We cover all the nights ourselves. No Telerad. Our ED docs, surgeons and IM docs love this. I know many of ED doctors in person and I am close friend with some of them. I play tennis with one of the ED doctors who lives in my neighborhood. I feel when we know each other, the patients get better care, we work easier with each other and generally speaking things go better. Telerad has suboptimal quality and also is faceless which IMO put patient care in danger.

2- Private practice is a different world than academics. I like it more. I feel all of us are there to do our responsibilities, provide patient care and albeit get paid well.

3- I always call ED doctors, IM or surgeons with any finding that I feel needs more attention. Even if I think they have already seen the abnormality, I just give them a call. They may be busy with something else and even if it is a very obvious finding, they may not get to see it. Also it is radiology's responsibility to interpret the imaging test. ED doctors are very good at what they do and we are very good at what we do. That is the reason we have different specialties. I don't know how to resuscitate a patient or make a clinical assessment as good as an ED doctor and obviously he does not know how to interpret a CT as good as me. After all, we have to work together.

4- I have found talking with referring physicians very helpful. Over time, I think we both learn something from each other. My reports get better and esp I get to know what is important for them to their clinical management.

5- I feel if you have close friendship with the referring doctors, they never get annoyed because you called them or vice versa. If they call me with a question about something on imaging, even if I don't know them, I try to be helpful and I expect the same attitude. Our ED doctors are very good.

6- About recommending consult or lab test or ... : Honestly, I don't blame if someone put that in their report. I usually don't but in radiology esp these days we get orders from all sorts of people. If it comes from an ED doctor, he/she knows very well how to manage the results. But if it comes from an NP or PA the story is different and sometimes I have to guide them to send the patient to ED or to consult someone.

7- Calling critical results: It is the responsibility of radiology to call you about any results that need immediate action. period.

8- Prelim report: I am not a fan of prelim report. I think the overnight radiology service should provide final reports. The exception is academics.

As Gadofosveset mentioned, overnight in-house call by radiology group (not telerad or some crappy service) is becoming more and more common. Probably it takes another 5-6 years to become the norm. But it will. I think many of the above-mentioned problems will automatically solved. The night radiologists belong to the same group that covers the hospital. He feels that the hospital is his practice. His attitude will be way different than some faceless telerad radiologist on the other side of the country who does not even know where your ED is located.

 

[Docinthetrenches]

At my old job we had this problem. The on call radiologist at night would only give "wet reads" and since the call rotated, we often had a breast radiologist reading neuro CT's, etc. It was not uncommon for the prelim read to be "amended" in the morning when it was read by a well rested, appropriate radiologist. At my new job we use teleradiology which certainly has its issues but a least the reads are "official" and read by someone trained in that area where they are reading. Also, we get calls for "critical" findings - not sure if a small subsegmental PE would get us a call but it certainly would be in the report which we get within about 20 min of the study being completed.

 

[shark2000]

At my old job we had this problem. The on call radiologist at night would only give "wet reads" and since the call rotated, we often had a breast radiologist reading neuro CT's, etc. It was not uncommon for the prelim read to be "amended" in the morning when it was read by a well rested, appropriate radiologist. At my new job we use teleradiology which certainly has its issues but a least the reads are "official" and read by someone trained in that area where they are reading. Also, we get calls for "critical" findings - not sure if a small subsegmental PE would get us a call but it certainly would be in the report which we get within about 20 min of the study being completed.

Yes and no. Telerad is not always sub specialized despite being advertised like that. Anyway, like everything else in medicine the quality depends largely on the amount of time and energy your are willing to spend. Even if you are the best radiologist or the best ER doctor in the world, if you don't care the quality of your work will be suboptimal. As I said, one big problem with tele radiology is that they don't feel that they are part of the team.

BTW, reading a head CT is not that difficult. A breast radiologist should be able to read it well unless he doesn't care about the quality of his work.