Justification of Radiolgist reads in certain instances

[skiz knot]

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I am not here to start a flame war, but I had an honest question. While thinking of ways the healthcare system in the US wastes a lot of money I thought radiology is often utilized by the ordering physician without any need for a radiology read, e.g. serial repeat CXR following a PNA, following an ileus, and the one that irks me the most, post-op xrays on ORIF of a fx! I love how the radiologist read is always to the tune of "interval surgical changes demonstrating adequate alignment and fixation of fx fragments."

Nobody cares what the radiologist says in these (and other) cases so, besides the medicolegal reasons, what justification is there for the radiologist to read and be paid for these studies?

 

[hans19]

You wanna read films yourself? Then read all of the films, and you deal with the liability yourself as well. Don't pick and choose the easy, low liability stuff and dump the rest on a radiologist. If you don't like it, and want the films yourself, then you deal with the 2 am dobhoff tube position checks from the nurses as well. Sure it doesn't require a radiologist to confirm the tube position, but guess what, they don't call the clinician they call the on call radiologist.

How would you like it if someone else got only the easy consults and you got dumped with the "self-pay" train wrecks?

Its an all or none deal. The hospital contracts for the radiologist to READ all of the films.

 

[ringhal]

I am not here to start a flame war, but I had an honest question. While thinking of ways the healthcare system in the US wastes a lot of money I thought radiology is often utilized by the ordering physician without any need for a radiology read, e.g. serial repeat CXR following a PNA, following an ileus, and the one that irks me the most, post-op xrays on ORIF of a fx! I love how the radiologist read is always to the tune of "interval surgical changes demonstrating adequate alignment and fixation of fx fragments."

Nobody cares what the radiologist says in these (and other) cases so, besides the medicolegal reasons, what justification is there for the radiologist to read and be paid for these studies?

You are missing the main problem in your observation. In terms of wasting money, it's not the radiologist read, its the ordering physician. Serial repeat cxr for pna. If the patient's clinical condition is stable or improving, there is no need for daily a cxr. Particularly since the literature shows that the cxr can remain abnormal for over 4 weeks after clinical improvement. That cxr, then, is a waste of money and resources. Furthermore, as imaging has improved, its importance in evaluation has increased. In my ER, CT's are ordered by triage nurses before the patient is seen by the resident or attending. When I was a resident, it was common to get calls from the ER docs asking for results before they had even seen the patients.

One big East Coast trauma center did a study looking at physical exams on trauma patients compared with imaging findings. They found that the residents were missing too many things that should have been obvious with what the study guidelines considered an adequate physical exam. They concluded that the poor physical exams were actually a hindrance to prompt and proper treatment and removed most of it from the initial trauma evaluation.

Also, clinicians are notorious for being myopic in evaluating films. I trust the orthopod to be able to see that the anterior shoulder dislocation has been reduced. What he's gonna miss is the adeno ca sitting in the lung apex.

Lastly, adding to what Hans said, clinicians don't really want the responsibility for imaging. At one of the hospitals where I've worked, the ER docs have the ability to enter their prelim on any plain films. They enter prelims on normal cxr's, obvious wrist fractures and lobar pneumonia. But they won't touch a diabetic foot, a c-spine with disc disease, or chest film on someone older than about 55. If they want the responsibility, they have to take it all.

A few years ago, the ER wanted to be able to interpret and bill for ultrasound readings - but they did not want to say any images. That way, no one could question their findings later. This is basically self-referral, another huge expenditure black hole - best left for another thread.

 

[colbgw02]

You are missing the main problem in your observation. In terms of wasting money, it's not the radiologist read, its the ordering physician. Serial repeat cxr for pna. If the patient's clinical condition is stable or improving, there is no need for daily a cxr. Particularly since the literature shows that the cxr can remain abnormal for over 4 weeks after clinical improvement. That cxr, then, is a waste of money and resources. Furthermore, as imaging has improved, its importance in evaluation has increased. In my ER, CT's are ordered by triage nurses before the patient is seen by the resident or attending. When I was a resident, it was common to get calls from the ER docs asking for results before they had even seen the patients.

One big East Coast trauma center did a study looking at physical exams on trauma patients compared with imaging findings. They found that the residents were missing too many things that should have been obvious with what the study guidelines considered an adequate physical exam. They concluded that the poor physical exams were actually a hindrance to prompt and proper treatment and removed most of it from the initial trauma evaluation.

Also, clinicians are notorious for being myopic in evaluating films. I trust the orthopod to be able to see that the anterior shoulder dislocation has been reduced. What he's gonna miss is the adeno ca sitting in the lung apex.

Lastly, adding to what Hans said, clinicians don't really want the responsibility for imaging. At one of the hospitals where I've worked, the ER docs have the ability to enter their prelim on any plain films. They enter prelims on normal cxr's, obvious wrist fractures and lobar pneumonia. But they won't touch a diabetic foot, a c-spine with disc disease, or chest film on someone older than about 55. If they want the responsibility, they have to take it all.

A few years ago, the ER wanted to be able to interpret and bill for ultrasound readings - but they did not want to say any images. That way, no one could question their findings later. This is basically self-referral, another huge expenditure black hole - best left for another thread.

Well said, and thanks for posting. This thread is yet another example of how radiology is one of the most poorly understood specialties in medicine.

Regarding the bolded part above, I'm aware of a paper published by a large East Coast trauma center that says that CT picks about 10-15% of serious or life-threatening injuries that are not clinically apparent to the trauma surgeons. This basically jives with what you've said, but my understanding from the paper was that the injuries are occult even to an adequate physical examination. I'm wondering if we're talking about the same paper from the same center or if there is conflicting literature out there. Anyway, thread hijack over.

 

[ioncell]

You are missing the main problem in your observation. In terms of wasting money, it's not the radiologist read, its the ordering physician.

Excellent analysis 😎

 

[skiz knot]

You are missing the main problem in your observation. In terms of wasting money, it's not the radiologist read, its the ordering physician. Serial repeat cxr for pna. If the patient's clinical condition is stable or improving, there is no need for daily a cxr.

Agreed.

Also, clinicians are notorious for being myopic in evaluating films. I trust the orthopod to be able to see that the anterior shoulder dislocation has been reduced. What he's gonna miss is the adeno ca sitting in the lung apex.

Most likely would have been seen on the pre-reduction film which is read by the radiologist. If not found then, not likely to be found on the immediate post reduction film.

Lastly, adding to what Hans said, clinicians don't really want the responsibility for imaging. At one of the hospitals where I've worked, the ER docs have the ability to enter their prelim on any plain films. They enter prelims on normal cxr's, obvious wrist fractures and lobar pneumonia. But they won't touch a diabetic foot, a c-spine with disc disease, or chest film on someone older than about 55. If they want the responsibility, they have to take it all.

That wasn't the point of my question. I whole heartedly support having the radiologist read every film that is for a new or unique problem. I do not think it is appropriate for ED docs, or anybody else, to be "officially" diagnosing problems radiographically. It is not what they are trained to do, as they could easily miss important things. However, being paid to read the films on the distal radius post reduction, OR spot films, post op films, 2 week, 4 week, 2 month, 3 month, 6 month, 1 year, etc follow up films on that distal radius is of almost no value. Most of the reads aren't available until after the patient is long gone from the office and medical decisions have already been made based on the radiographs.

 

[ioncell]

Agreed.


. Most of the reads aren't available until after the patient is long gone from the office and medical decisions have already been made based on the radiographs.

justification for emergency radiology fellowship 😀

 

[ringhal]

However, being paid to read the films on the distal radius post reduction, OR spot films, post op films, 2 week, 4 week, 2 month, 3 month, 6 month, 1 year, etc follow up films on that distal radius is of almost no value.

Again, if the interpretation of the film is of no value, then perhaps it should not have been ordered. At my current hospital, the PA's and ortho residents routinely order elbow, forearm, wrist and hand films to follow-up that radius fracture. That's where the problem originates.

Most of the reads aren't available until after the patient is long gone from the office and medical decisions have already been made based on the radiographs.

I don't know what things are like where you are, but where I trained, the bone reading room was in the ortho clinic. We usually had the films read before the ortho residents had seen them, certainly before the attending did, if they deigned to do so. Whether or not they looked at our readings before they made their decisions is entirely another matter.