crabby radiology residents

[powermd]

What's the deal with angry-as-**ck, crabby radiology residents? I am currently floating on medicine and I dread having to page the radiology resident to do even the simplest tasks. I've never met such an unhelpful group of doctors. Before you jump on me- yes, I am courteous, and yes- I do know the relevant details of the patient's case. Surgeons are usually pretty miserable, but I've never encountered nearly as much attitude from them when asking for a consult. If someone pages me at 3am asking my opinion on a medical issue, I might be annoyed with the page if it's not very serious, but I'm not going to be mean or arrogant about it. Just the other night I was asked to follow up on an MRI of a patient's c-spine. The primary indication was to look for non-acute arthritic changes that could account for the patient's neck pain, but the patient was also febrile with a white count. There was reason to at least take a look and rule out paraspinal abscess or osteomyelitis. The answer from the radiology resident was "I don't know how to read MRIs, no one here does. If an MRI is done after 4:30pm it will be read in the morning." The least he could have done was ask how serious the situation was and offer to take a peak and see if there might be an indication to call in an attending to do a formal read. He wouldn't even look! This is just one example, but this kind of unhelpful attitude seems to be pervasive among rads residents at places where I have trained. These guys are in what is basically a very happy field with great hours and the promise of riches when they graduate. They have every reason to be among the most pleasant residents in the hospital. Why is that so often untrue?

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[RADRULES]

Sorry to hear about your bas experiences. There have been a lot of complaints lately about the new breed of radiology residents, all with very high USMLE scores but bad attitudes.

Having said that, rad residents get pestered by the most idiotic physicians a LOT, requesting absolutely absurd exams and such, this is especially true in the ER.

You were probably dealing with a lower lever resident who doesn't know how to read neuro MR. He was probably just be truthful.

I always go out of my way to help a physician who comes to me for help. I feel this is my job as a consultant. However, if someone is in anyway condescending, then I will smoke their ass. This method has served me well, and I have little problem with most physicians.

What many young radiologist don't understand is that if we don't provide the service, someone else will, maybe from Bangalore.

 

[Neuron]

The answer from the radiology resident was "I don't know how to read MRIs, no one here does. If an MRI is done after 4:30pm it will be read in the morning." The least he could have done was ask how serious the situation was and offer to take a peak and see if there might be an indication to call in an attending to do a formal read. He wouldn't even look!

This is not the resident's fault. If he has not been trained to read H&N MR, he can't read it. You seem to think that he should have looked at it anyway. Why? If he had offered to give you his "opinion", how much importance would you have placed on it? The thing is, if you have not been trained, there is little use in pretending that that opinion matters (except in cases of obvious pathology, in which case you could have picked it out yourself).

The fault here is with a system in your institution where there is no one with the appropriate expertise at the "point of care". If the patient needs a study to be done and interpreted before appropriate management can take place, then your hospital/radiology department should provide that service. If they aren't, they shouldn't be accepting such patients.

If the patient is there, under your care, and you need to get a reliable read urgently, then get it. If there is no appropriately trained in house resident, move up. Was there a fellow? No? Then move up. Call the attending. You have every right in the world to do that, because you are the one who has to deal with the patient in front of you. If he can't read it from home, then he has to come in. If he yells at you, yell back that that's his job.

If he is under the impression that a Rads attending should never have to leave home after hours, then it is his (and his department's) responsibility to put appropriate arrangements in place so that he doesn't have to (ie. PACS to his home/ in house fellows/ whatever). If he believes that he shouldn't be providing his opinion on call, he shouldn't be taking (and getting paid for) call.

 

[Neuron]

On a related but more controversial issue:

There was a very interesting discussion some time ago on another medical (doctors only) board. A clinician brought up the issue of point-of-care interpretation. His point was, if you work in a hospital where, for whatever reason, the radiologist won't provide an interpretation of the study when you, as the clinician, need it to make a clinical decision, then he shouldn't be re-imbursed for it when he makes a belated interpretation the next afternoon, or two days after, or whenever he gets around to it. The person who should be paid is the person whose reading of the film is what the management is based on.

It's all very well for you if you're a rads attending who can make a rare diagnosis of something in the comfort of your dark room two days after a clinical attending desperately needed a read on a film but couldn't get you to wake up, had to read it himself, and make his management decision based on that. But you shouldn't get diddly squat for it. Since it's his ass on the line, if anyone should be re-imbursed it's him.

Seems to make sense to me.

 

[powermd]

This is not the resident's fault. If he has not been trained to read H&N MR, he can't read it. You seem to think that he should have looked at it anyway. Why? If he had offered to give you his "opinion", how much importance would you have placed on it? The thing is, if you have not been trained, there is little use in pretending that that opinion matters (except in cases of obvious pathology, in which case you could have picked it out yourself).

The fault here is with a system in your institution where there is no one with the appropriate expertise at the "point of care". If the patient needs a study to be done and interpreted before appropriate management can take place, then your hospital/radiology department should provide that service. If they aren't, they shouldn't be accepting such patients.

If the patient is there, under your care, and you need to get a reliable read urgently, then get it. If there is no appropriately trained in house resident, move up. Was there a fellow? No? Then move up. Call the attending. You have every right in the world to do that, because you are the one who has to deal with the patient in front of you. If he can't read it from home, then he has to come in. If he yells at you, yell back that that's his job.

If he is under the impression that a Rads attending should never have to leave home after hours, then it is his (and his department's) responsibility to put appropriate arrangements in place so that he doesn't have to (ie. PACS to his home/ in house fellows/ whatever). If he believes that he shouldn't be providing his opinion on call, he shouldn't be taking (and getting paid for) call.

I'm not sure if the rads resident "should" have looked at the MRI for me, given that the primary indication was non-urgent, but that if something acute happened to exist on the MRI (a possibility, not sure how likely), it would be better to know now (9pm), rather than morning. Just as I could have taken a look myself to see if anything was grossly abnormal, he probably could have done the same, and with better eyes than me. At the very least he might be able to tell if there was anything that would justify calling an attending in.

This is just the most recent incident I have experienced where a rads resident has been unhelpful, there are many, many others. I remember as a medical student I was asked by my resident at 11pm to get the "wet-read" on a patient's CT brain (probably for r/o subdural- I don't remember exactly, just that it was serious), but I got busy and forgot to do it until 2am as I was getting ready to go to sleep in the call room. Realizing the potential seriousness of missing this diagnosis, I got on the phone immediately with the radiology resident, who proceded to grill me and shred my confidence in knowing what was happening with the case. Ultimately, he refused to do the read ("when you figure it out, you can call me back!" imagine the most arrogant, f-you attitude possible). I was too shaken to call him back and fight. I paged my intern, who said not to worry about it. Sure, I made a mistake, and may not have known what I was doing, but I was a medical student for crying out loud! Who the *uck was he to treat me that way?

I recall one month in to my third year being asked by my intern to request a spiral CT to r/o PEs in a lady with DVT who we were about to put on coumadin. The attending who runs the CT unit (Cook County Hospital) ripped me apart when I didn't know the patient's story that well, and I didn't know that he would want to know the patient's creatinine. I explained it wasn't my patient, and I was just doing my resident a favor. You should have seen this guy- you'd think steam was coming out his ears! Later I learned he has a reputation for being a jerk.

 

[oldandtired]

"But you shouldn't get diddly squat for it. Since it's his ass on the line, if anyone should be re-imbursed it's him."

There is almost always a radiologist on call in most hospitals and the clinician would be faulted for not seeking his expertise, especially if his interpretation were wrong. Juries are very unforgiving of physicians who attempt procedures for which they have little or no training.

Remember, the radiologist does not only read the study. He supervises the technologist and assumes all responsibility for anything that may happen during the test(contrast extravasation, radiation exposure during pregnancy, quality control, patient falling off CT couch, etc.).

The radiologist provides a complete interpretation of ALL images including non emergent findings (lung nodules, adrenal nodules, etc). The radiologist assumes all legal responsiblity.

 

[Neuron]

I'm not sure if the rads resident "should" have looked at the MRI for me, given that the primary indication was non-urgent, but that if something acute happened to exist on the MRI (a possibility, not sure how likely), it would be better to know now (9pm), rather than morning. Just as I could have taken a look myself to see if anything was grossly abnormal, he probably could have done the same, and with better eyes than me. At the very least he might be able to tell if there was anything that would justify calling an attending in.

This is just the most recent incident I have experienced where a rads resident has been unhelpful, there are many, many others. I remember as a medical student I was asked by my resident at 11pm to get the "wet-read" on a patient's CT brain (probably for r/o subdural- I don't remember exactly, just that it was serious), but I got busy and forgot to do it until 2am as I was getting ready to go to sleep in the call room. Realizing the potential seriousness of missing this diagnosis, I got on the phone immediately with the radiology resident, who proceded to grill me and shred my confidence in knowing what was happening with the case. Ultimately, he refused to do the read ("when you figure it out, you can call me back!" imagine the most arrogant, f-you attitude possible). I was too shaken to call him back and fight. I paged my intern, who said not to worry about it. Sure, I made a mistake, and may not have known what I was doing, but I was a medical student for crying out loud! Who the *uck was he to treat me that way?

I recall one month in to my third year being asked by my intern to request a spiral CT to r/o PEs in a lady with DVT who we were about to put on coumadin. The attending who runs the CT unit (Cook County Hospital) ripped me apart when I didn't know the patient's story that well, and I didn't know that he would want to know the patient's creatinine. I explained it wasn't my patient, and I was just doing my resident a favor. You should have seen this guy- you'd think steam was coming out his ears! Later I learned he has a reputation for being a jerk.

Yeah, you just have to remember medicine is an equal opportunity employer: we give dicks jobs too.

Seriously though, I think it?s simplistic the way we often label people. All of us have a barrier beyond which we?ll start engaging in behavior some people will consider lame.

I think part of the training in residency is to get us to become aware of professional obligations ? our duty to behave professionally. For you, that might have meant that when you remembered that CT head at 2 am, it might have been a good idea to think through that patient?s details to have ready for the resident when you called him. Every service has a list of things they like to know for different problems. For the resident, it might have meant that no matter how busy he was at that hour, he had on obligation to behave like a professional, and ask nicely, etc. And not chew out a med stud.

But there?ll always be clowns in every specialty that just never learnt any manners, you?re right. We just have to deal with them.

 

[Neuron]

"But you shouldn't get diddly squat for it. Since it's his ass on the line, if anyone should be re-imbursed it's him."

There is almost always a radiologist on call in most hospitals and the clinician would be faulted for not seeking his expertise, especially if his interpretation were wrong. Juries are very unforgiving of physicians who attempt procedures for which they have little or no training.

Remember, the radiologist does not only read the study. He supervises the technologist and assumes all responsibility for anything that may happen during the test(contrast extravasation, radiation exposure during pregnancy, quality control, patient falling off CT couch, etc.).

The radiologist provides a complete interpretation of ALL images including non emergent findings (lung nodules, adrenal nodules, etc). The radiologist assumes all legal responsiblity.

Posts like this mystify me.

Me:
Premise X: A + B = C
Premise Y: C ≠ D
Hence, A + B ≠ D

You:
Er, I should like to imply blah blah blah using my strawman blah blah blah that you are not quite right blah blah blah .

Blah blah Hence, my dazzling conclusion blah blah blah blah which you could never have guessed blah blah blah is that A + B = C.

 

[oldandtired]

Neuron may be missing a few. WTF did he just ramble about?

 

[Swaydaa]

What a freakin nut.

 

[Goober]

The answer from the radiology resident was "I don't know how to read MRIs, no one here does. If an MRI is done after 4:30pm it will be read in the morning." ?

This response from a resident is either baffling or you are not telling the whole story. While it may be true that a junior resident may be unqualified to read a MRI exam, I highly doubt that there is no mechanism in place that will allow a read of a MRI after 4:30 pm at a teaching institution! Our chain of command after the junior resident was senior resident->fellow (body or neuro)-> attending.

If you really wanted the study looked at all you had to do is say you are going to call the attending on back up call yourself and tell him you are calling him because the resident refuse to look at the scan.

 

[powermd]

This response from a resident is either baffling or you are not telling the whole story. While it may be true that a junior resident may be unqualified to read a MRI exam, I highly doubt that there is no mechanism in place that will allow a read of a MRI after 4:30 pm at a teaching institution! Our chain of command after the junior resident was senior resident->fellow (body or neuro)-> attending.

If you really wanted the study looked at all you had to do is say you are going to call the attending on back up call yourself and tell him you are calling him because the resident refuse to look at the scan.

Like I said before, the primary indication for the the study was a non-urgent interest (from a neurology consultant) to look for arthritic problems of the c-spine that could contribute to the patient's pain. I was asked by the primary medicine team to follow-up the study by having the radiology resident look at it to ensure that no acute problems that would be better treated at 9pm that day, rather than 12 hours later were caught. I'm not sure if this justifies calling in an attending, however it makes sense to me that a junior radiology resident could probably to do a rough read of the film and note any gross abnormalities that would justify calling for an attending read.

 

[Hotsauce21]

I agree with powermd. im at a well respected academic program, and ive encountered far too many rude rads residents. my experience with surgeons, and other consultants, has been far, far better. excellent actually. i dont like to be contested on every test i order, even when the indications have been explained.

 

[radiojimi]

bad attitudes really aren't acceptable, and I have trouble justifying the meanness of more experienced physicians when they rip their junior colleagues apart for implied incompetence, but try not to let that impression generalize to all radiologists.
People tend to remember the particularly negative experiences much better than they do the neutral or positive experiences, so we are all at risk of recall bias. I myself try and believe that surgeons can be good people, and there are many who help reinforce this belief, in spite of my own personal experiences.

 

[Goober]

Like I said before, the primary indication for the the study was a non-urgent interest (from a neurology consultant) to look for arthritic problems of the c-spine that could contribute to the patient's pain. I was asked by the primary medicine team to follow-up the study by having the radiology resident look at it to ensure that no acute problems that would be better treated at 9pm that day, rather than 12 hours later were caught. I'm not sure if this justifies calling in an attending, however it makes sense to me that a junior radiology resident could probably to do a rough read of the film and note any gross abnormalities that would justify calling for an attending read.

It may not justify calling the attending but it certainly is worth calling a senior resident or fellow if you were going to start treatment that night. A junior resident who truly has no experience reading MRI would probably only marginally better than you, mostly only on anatomy.

Anyways a bad attitude is not called for, but once you work in the ER as a rad resident and get some really outrageous requests, you get jaded. I have had clinicians bring me outside films to look at that have nothing to do with ER patients including a 4 body part MRI study from Mexico, a mammogram of a clinician's wife and all kinds of stuff when I am getting totally hammered from all sides.

 

[Neuron]

What a freakin nut.

Thanks for your insightful comment.

I suppose I'll have to spell it out.

In post #4, I commented on an opinion I've heard bandied about that if a radiologist expects to be paid for his services, then like any medical professional his services must mean something to patient care. With radiology, for this to happen, the diagnostic impression must be available to the clinician when the information will impact patient care.

To illustrate this with an example from powermd, let us say you've been consulted on a stroke pt. You are would like to know whether the pt has had an intracranial bleed. You order a non enhanced CT. It is done. You yourself cannot see a bleed, but you would like the radiologist's impression - since that's his area of expertise, and that's what he is there for.

The resident tells you there is no attending in hospital, and he does not know how to read a CT (bear with me, this is an example. I'm sure most residents will be more helpful). He gives you the distinct impression he does not want to call his staff man. So you make the call, give lytics, and the patient dies from a brain bleed. Two days later, the radiologists report says there a small bleed that he can see on the scan.

Now, it's great that he can see all that, but where was he when the patient needed him at 3.10 AM? And guess who gets paid to do this fabulous read two days later?

Does this happen? I have never seen it at my institution, but my place is not typical - one of the so called "elites", where you can get a sub-sub specialist consult in anything under the sun if you wanted to. But if you think there are programs where this doesn't happen you're in for a surprise.

What I was saying is that if radiologists expect to get paid for their services, they should be real services: ie, available to the primary clinician when he needs it.

Now, in response to that post, resident genius oldandtired trots out the party line about the how important the radiologist is, and the scope of his expertise, etc etc. He could have saved it, because I know that, I wasn't disputing that, and I don't need to be told that. Use that line with people you're fighting your turf wars with.

My post was not about that, it was about a separate issue. The reply I got to that post was a strawman, and I pointed it out.

 

[Hotsauce21]

no problem mate, i know there a very nice rads too. =)

bad attitudes really aren't acceptable, and I have trouble justifying the meanness of more experienced physicians when they rip their junior colleagues apart for implied incompetence, but try not to let that impression generalize to all radiologists.
People tend to remember the particularly negative experiences much better than they do the neutral or positive experiences, so we are all at risk of recall bias. I myself try and believe that surgeons can be good people, and there are many who help reinforce this belief, in spite of my own personal experiences.

 

[Goober]

Thanks for your insightful comment.



To illustrate this with an example from powermd, let us say you've been consulted on a stroke pt. You are would like to know whether the pt has had an intracranial bleed. You order a non enhanced CT. It is done. You yourself cannot see a bleed, but you would like the radiologist's impression - since that's his area of expertise, and that's what he is there for.

The resident tells you there is no attending in hospital, and he does not know how to read a CT (bear with me, this is an example. I'm sure most residents will be more helpful). He gives you the distinct impression he does not want to call his staff man. So you make the call, give lytics, and the patient dies from a brain bleed. Two days later, the radiologists report says there a small bleed that he can see on the scan.

Now, it's great that he can see all that, but where was he when the patient needed him at 3.10 AM? And guess who gets paid to do this fabulous read two days later?

Does this happen? I have never seen it at my institution, but my place is not typical - one of the so called "elites", where you can get a sub-sub specialist consult in anything under the sun if you wanted to. But if you think there are programs where this doesn't happen you're in for a surprise.


.

Completely unrealistic example. No resident in the country would be on call who could not read a bleed on a head CT. In addition, if you were going to make a decision that immediately affected patient care based on a result of a head CT you have every right to call the attending yourself if the resident refused to get help. Would you accept treating the patient based on a critical lab value if the lab technician decided he didn't know how to do a specific test?

I am probably more aware of the radiology residencies programs around the country than you are, and I would say that the scenario you give is extremely unlikely. Every program that I have known, has backup readily available. If you encounter a resident that refuses to read a scan of an ER or hospital patient, bring it up with the chairman. I assure you it won't happen again.

In the "real world" attending radiologists cover the hospitals 24/7.

 

[Neuron]

Completely unrealistic example. No resident in the country would be on call who could not read a bleed on a head CT. In addition, if you were going to make a decision that immediately affected patient care based on a result of a head CT you have every right to call the attending yourself if the resident refused to get help. Would you accept treating the patient based on a critical lab value if the lab technician decided he didn't know how to do a specific test?

I am probably more aware of the radiology residencies programs around the country than you are, and I would say that the scenario you give is extremely unlikely. Every program that I have known, has backup readily available. If you encounter a resident that refuses to read a scan of an ER or hospital patient, bring it up with the chairman. I assure you it won't happen again.

In the "real world" attending radiologists cover the hospitals 24/7.

I know it wasn't a very good example - not because I think that "no resident in the country would be on call who could not tell a bleed on a CT" (I have met a quite a few who couldn't, and who had to be gently instructed by my staff neurosurg - this not at podunk, corp. but at top5 institution). It was a poor example because most people in that situation will call the emeritus professor if they had to. I you read the thread, I advised powermd never to take stop at a lower level resident if he did not feel comfortable.

I disagree with you that radiologists never fail to be in house when they are needed in "real world" hospitals.

 

[Voxel]

I think this brings up several points. 1) know your patients 2) if the resident on call in not comfortable reading something, go higher up in the chain to the senior radiology resident, fellow, or attending if need be. 3) how urgent is the study? can it wait until the morning to be read.

There is a lot of bs that night float is following up that can wait until the AM to be read out by the attending. Non-emergent, non-urgent studies can wait until the AM. Learn when things are urgent/emergent and when things can wait. It's an acquired skill.

I will always be willing to look at anything urgent/emergent on call. But everything in life has to be triaged. So when the radiology resident on call is dealing with multi-trauma patients, r/o pe on recently intubated patients, you need to give the radiologist an impression on what is going on and how urgent the study is because believe it or not we are very busy and we need prioritize what gets read when. I'll always get back to you but if it's only semiurgent it may take a little while.

 

[RADRULES]

Neuron = Typical freak-job neurosurgery resident who couldn't get laid if he paid for it.

 

[Apollyon]

There's something creepy that happens at our program (I was going to name it, but I've decided against it) - when we order studies from the ED, the "doc in the box" preliminary reads it, and that - dictated by Powerscribe - goes online. We see that in real-time, and go with it. Then, in the morning, the attending reads out, and, on occasion, the rads resident has been WAY OFF - severely - and the attending's reading (usually towards the "it's not abnormal - it's normal variant" side) is what goes into the record - in place of the rads resident's prelim read. The final read differs in appearance only by the presence of the attending's name on the "approving MD" line, with the prelim read not there - versus the prelim read and an attending's note differing (like we have on our EM program we use). More than once, we have gone with what the read says, and, when the final read comes out the next day, and all the hot findings turn out not to be, we look like we're insane, pulling stuff out of thin air.

This is NOT to rag on rads residents - I am happier to err on the side of there being a subluxation in the c-spine than saying it isn't - but there is something, as I say, creepy about changing the record that someone (electronically or otherwise) has signed.

I myself strive to help rads out, because they help me out. I am frustrated that the indication for an exam that I put on the order sheet is not entered by the clerk, unless I get the clerk's attention and state verbally that the "4th distal phalanx is the area of interest" or that the testicular ultrasound is NOT for torsion, but for hyperdensities we saw on bedside U/S that we can't explain.

Our rads program has a few people that are more inclined to being serious and humorless, but having my own house in order goes a long way towards loosening them up.

A friend of mine at a mid-tier univeristy program with a community non-trauma ED was saying how weak their ED is (and, from the studies she has to see, I can agree - they're too afraid to use NEXUS in the ED, and the rads chair is a doormat), and how the most BS studies come through. She said there used to be a guy that was EM-trained and GOOD - the seniors said the guy ordered next to nothing, and, whenever he did, there was a gross abnormality (and, not infrequently, textbook-quality cases). The seniors really appreciated that, but, the guy only lasted 2 years, because he couldn't deal with the crap from the balance of the department.

 

[Whisker Barrel Cortex]

There's something creepy that happens at our program (I was going to name it, but I've decided against it) - when we order studies from the ED, the "doc in the box" preliminary reads it, and that - dictated by Powerscribe - goes online. We see that in real-time, and go with it. Then, in the morning, the attending reads out, and, on occasion, the rads resident has been WAY OFF - severely - and the attending's reading (usually towards the "it's not abnormal - it's normal variant" side) is what goes into the record - in place of the rads resident's prelim read. The final read differs in appearance only by the presence of the attending's name on the "approving MD" line, with the prelim read not there - versus the prelim read and an attending's note differing (like we have on our EM program we use). More than once, we have gone with what the read says, and, when the final read comes out the next day, and all the hot findings turn out not to be, we look like we're insane, pulling stuff out of thin air.

This is NOT to rag on rads residents - I am happier to err on the side of there being a subluxation in the c-spine than saying it isn't - but there is something, as I say, creepy about changing the record that someone (electronically or otherwise) has signed.

If there is a significant change in the findings as interpreted by the attending versus the attending, they should make every effort to contact you regarding those changes. That is our policy. Sometimes it is difficult to track down who to talk to, but we always do it if the result is different enough to effect treatment. If this is happening the way you describe, it is downright wrong.

As for the "serious" radiology residents, I think that is a matter of stress rather than their real personality. Most residents in my department are fun people who joke around a lot. When it comes to call, that can change depending on how busy it is. Pages come very frequently on radiology call, worse than intern call as a resident. It often interrupts your train of thought as you are looking through an extremely complex study and can cause you to miss things (I have experienced this first hand). Its great when you get paged 3 times by the same person while you are trying to convey results to someone else on the phone. If a rads resident is not answering your page right away, he/she is not ignoring you, he/she is busy as hell.

If you think of our examination of a study as your patient interaction, imagine what it would be like if you were paged 4 times before you were even through the HPI (that happened sometimes in intern year and it sucked). It is extremely stressful.

I enjoy helping clinicians, but can't stand the rude, inconsiderate ones.

 

[Neuron]

There's something creepy that happens at our program (I was going to name it, but I've decided against it) - when we order studies from the ED, the "doc in the box" preliminary reads it, and that - dictated by Powerscribe - goes online. We see that in real-time, and go with it. Then, in the morning, the attending reads out, and, on occasion, the rads resident has been WAY OFF - severely - and the attending's reading (usually towards the "it's not abnormal - it's normal variant" side) is what goes into the record - in place of the rads resident's prelim read. The final read differs in appearance only by the presence of the attending's name on the "approving MD" line, with the prelim read not there - versus the prelim read and an attending's note differing (like we have on our EM program we use). More than once, we have gone with what the read says, and, when the final read comes out the next day, and all the hot findings turn out not to be, we look like we're insane, pulling stuff out of thin air.

This is NOT to rag on rads residents - I am happier to err on the side of there being a subluxation in the c-spine than saying it isn't - but there is something, as I say, creepy about changing the record that someone (electronically or otherwise) has signed.

No you're right, it is 'creepy'. It may not be as uncommon as you think. I heard that the chief resident at my program got so pissed off at neurorads doing this all the time that he once printed off copies of the prelim report, waited for a day, then printed off the final 'altered' report. Apparently the attendings weren't pleased when he confronted them, but I'm really not sure it has stopped the practice. It's better though.

I agree with WBC that it's 'wrong'; it also has legal ramifications.

 

[Hotsauce21]

the problem partially, at least where i am, is they dont pay staff to see selected cases at night. literally, around 50% of PE CT's get changed from prelim read to attg read. unless its a lobar embolism, you might as well flip a coin. im not dogging the residents, they just dont have the experience to read them. but that doesnt help me much at night. the plain film reads are quite good, generally, and ct's of head, etc. some cases we could use attg input though.

No you're right, it is 'creepy'. It may not be as uncommon as you think. I heard that the chief resident at my program got so pissed off at neurorads doing this all the time that he once printed off copies of the prelim report, waited for a day, then printed off the final 'altered' report. Apparently the attendings weren't pleased when he confronted them, but I'm really not sure it has stopped the practice. It's better though.

I agree with WBC that it's 'wrong'; it also has legal ramifications.

 

[Whisker Barrel Cortex]

the problem partially, at least where i am, is they dont pay staff to see selected cases at night. literally, around 50% of PE CT's get changed from prelim read to attg read. unless its a lobar embolism, you might as well flip a coin. im not dogging the residents, they just dont have the experience to read them. but that doesnt help me much at night. the plain film reads are quite good, generally, and ct's of head, etc. some cases we could use attg input though.

I doubt your number of 50% is accurate. First of all, about 90% of PE CTs ordered (at least at my hospital) are negative and unnecessary.

Sample conversation regarding getting a PE CT:
Radiologist: You think the severe pulmonary edema / large bilateral effusions / frank lobar pneumonia / etc seen on a simple chest x-ray could be causing this shortness of breath?

Clinicial Resident: Ummmmm, there was a chest x-ray? It could still be a PE! His SOB was acute onset over the past 4 days.

Radiologist: Yeah, thats when the edema / effusions / aspiration started.

Clinical Resident: Yeah, my attending demanded this study. Do you want to talk to him.

Radiologist: Ok, I geuss we'll do it, but its gonna be negative.

Lo and behold, it is negative.

The best was when I had this conversation with a resident on someone who had severe edema on CXR. After the study was done, the attending came by to look at another study on his clinic patient and I mentioned the negative PE study. He said, "Oh yeah, I didn't think he was gonna have a PE." Talk about creepy. I've caught many residents downright lying to me about the clinical history in order to get a study done quicker. That takes away time from patients who may have had a more emergent situation.

 

[Whisker Barrel Cortex]

Another "creepy" lying resident:

Back story: Pt has thoracic aortic dissection. Has been followed by q2day MRA despite lack of change in symptoms.

Me: We have an order for another MRA on Ms. Johnson. She's had one every two days for the past week. Why another one?

Resident: She has acute back pain. We're worried about it extending down.

Me: Well, we've got 2 stroke MRs coming in, another "STAT" MRA that is gonna get going, plus the MRA protocol itself will take close to an hour. So she probably won't get the scan for close to 4 hours. I think a CTA will be much quicker and evern more accurate. (there I go trying to be helpful again)

Resident: We've been following this on MR, so we want to get an MR.

Me: This dissection might advance by the time we can get the MR. Get a CTA.

Residnet: My attending wants an MRA.

Me: Ok.

6 hours later when the patient comes down, we discuss her symptoms. She's had some back pain off and on. They told her once she has this scan, she can go home. Yeah, sounds like they were really worried about acute extention of the dissection. By the way, the dissection was exactly the same on every single one of the 4 $1800 MRAs we did.

 

[Apollyon]

A 90 year old lady falls, and has R hip pain. It's Sunday afternoon/evening (~5pm). Plain films are unrevealing. My attending is thinking possible intertrochanteric fracture. If it's there, he says, we're done. I talk with the doc in the box, and she and I agree that MRI would be definitive. She tells me, though, that they won't do the MRI unless Ortho will operate that night, but getting it Monday morning will be NO problem. She even calls her senior, and sells the case to her. The senior talks to my attending - he says, "If the CT is positive, we're done", and she (the senior) says, "but if it's negative, we do the MRI anyhow". So, the patient spends the night in our evaluation unit (well within the operative window), and gets the MRI Monday morning. Everyone's happy.

Being the bum I am, I don't know the result.

 

[powermd]

It's incredibly frustrating when you have to "sell" a study to the radiologist that you personally don't believe is indicated, just because your paranoid and ignorant attending wants it. I have been asked several times to obtain MRAs for patients for whom they weren't indicated, or were not the optimum study. My latest example of being stuck between a rock and a hard place occured last week. This was over a portable CXR that one attending (not the patient's primary attending, just a consultant) called for several times overnight on a patient he wanted to do GI procedure on in the morning (don't want to reveal too much detail). His indication was r/o PE. R/o PE??? There was no indication for this based on the clinical history (no acute onset SOB), and the patient had a story better fitting COPD/CHF. A CXR was already performed in the ED when the patient came in (that night) and it showed a R sided effusion. For some reason this attending was demanding a stat CXR at 3am over the phone. If he was that worried about PE he should have been ordering a CTPA. At 5am I received several pages from the nurses on this patient's floor telling me the attending had called several times demanding to know the results of the CXR. I went to the radiology resident and told him this ridiculous story. He was kind enough to interrupt reading a CT just to give me a quick answer on the CXR. It wasn't really a big deal, but I still felt awful having to interrupt the resident for this BS. I would have loved to argue with the attending over his reasoning for the study, but that could get me into trouble. Sometimes it really sucks being a resident.

 

[Whisker Barrel Cortex]

Having been an intern myself, I understand the frustration stemming from unreasonable attendings. It is only when the resident lies in order to get a study that I get frustrated. Be honest with me and tell me if you don't think its indicated and the attending wants. If I really think it should be done in the AM, I will be happy to tell him/her directly. I think radiology is a field where we consult for directly attendings directly much more than other specialties.

 

[RADRULES]

I remember being told as a resident, when calling an attending to ask about why a patient needed a Chest CT for an uncomplicated, free-flowing pleural effusion.... "Did you see my name at the top of the request, that is all that you need!"

Needless to say, prior to my finishing the program, I had it out with that guy.....

Rest assured, young Jedi rads... every year that passes you have more and more knowledge and more and more power.... until you enter private practice and cannot ever refuse a request.

 

[drandrew]

Most of our frustration as Radiology residents (even the attendings say this too) comes from one thing in my opinion. We are consultants, not short order cooks. We have expertise and know a thing or two about diagnostic imaging, perhaps more than most clinicians in the hospital. All too much i've heard from residents (especially in the ED) "Why are you questioning so much just read the darn study/call in the sonographer/MRI tech/angio team, etc...". In addition, appropriate clinical history is rarely provided. Chances are if I am calling you to clarify an order or tell you a study isn't indicated its not because i'm lazy, its because I'd like to know more information to read the thing or the study likely is not indicated.

At my hospital on an on call shift on a weeknight, we have to look at some 40-60 CT studies, and there is always a queue of 20-30 waiting to be done any point in time. (weekend 24 hr shifts we can see upwards of 80-100 CT cases). Of those 20-30, at LEAST 10 are clearly NOT indicated (CT with contrast of the spine to rule out osteo, non-contrast CTs of the A/P for abscess in a patient who has had 2-3 of them in last week for example). So we do need to prioritize studies so that the true emergencies do get done. That doesnt help when every specialty in house thinks their studies are more important than everyone else's.

Not that the CT volume keeps me busy enough, I do get tired quickly of the new night floats calling me up and saying stuff like "did you see the chest-xray on Mrs. Smith that just got a subclavian line?". We are consultants, and i'm sorry, you SHOULD be able to look at a CXR yourself for line placement. You don't consult the gastroenteroligst to do a rectal exam for you, right? If there is a question, i'll be more than happy to answer it, but to just give a prelim read on a plain film study you haven't looked at is a waste of my time (CT/MR is a different story)

And the issue of calling for an attending read on stuff, or better yet calling the attending directly. This should NEVER occur on a resident->attending level. If I ever found out a resident called an attending directly to look at a study, i'd have words with them. Only others attendings and the radiology resident should call the radiology attending.

And yes, there are still some CT/MR things I still am not comfortable with on call, and if there TRULY is an emergent indication for calling an attending for a read (in that MRI case, was it made clear to the resident on call that you were looking for epidural abscess or something like that and not just degenerative change or a disc issue?), it should be done. Granted we have NightHawk backup from 8PM-7AM, but I always send anything i'm not comfortable reading, not something another resident in the hospital is uncomfortable with my read, unless of course, their attending asks for it. After all, you don't ask for a surgeon to come in the middle of the night to make sure their residents can handle a appendix consult? You trust in the surgery resident to know if an attending needs to come in emergently to opreate.

Basically my advice to interns/residents in other specialities is to respect the radiologist like you would any other consultant.