Over radiating What is the right thing to do morally and ethically

[spudboy]

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"What is the right thing to do?"

I am kinda in a dilema as a CT tech wondering what is the right thing to do.
I will try and make this as short,sweet and to the point as much as I can.

I have been a CT tech and supervisor just shy of 20 yrs now. I feel that I do have alot of experience and knowledge when it comes to my profession. I worked with a group of excellent radiologist for about yrs. They were very experienced,smart,proactive, great
with pateint care and so forth. They were part of a very large radiology group in a major city. I was able to work with them very close on a daily basis and was always
learning from them. When it came to CT scanning protocols they were very hands on
and helpful in doing what was right,according to them. Thats what I was taught and beleived in and seemed to me to be a very high standadrd of patient care when it comes to exposing people to radiation. Basically there was really no need for non contrast studies with a few exceptions(nodule follow ups, kidney stones, multi phase exams of liver,panc,renals,cta's, trauma heads are they few that come to mind). We rarely would scan some with and without for general abd pain(just with oral and IV) and definetly no delays unless a liver,renal lesion was seen.No sense in irradiating someone when it was not neccesary. Thats how we operated and the CT dept was ran. We had a protocol book in our scheduling dept on what was to be ordered(or suggested) when an office called in with a diagnosis when scanning . According to the radiologists having contrast gave more information, than what a non con could do(except for certain studies) so no sense exposing someone when it's not needed or would not be benefical.

I moved on to a different job as a regular staff CT tech. I work for another
very large group of radiologist. I expected things to be a little different, no problem.
I will try and keep this part short. I feel at this time we are over scanning way to much and nothing is being done about it and I am very frustrated and do not know what to do.Basically a good part of our exams are ordered with and without and delays are routine on all abd/pel CT's. I have been able to change some orders when doing so, just to a with only, but I feel that is not doing enough. The first thing I wonder is," why arent the radiologist calling and complaing to us or they should be calling the ordering dr's on why the exams are being ordered that way?" If I was back at my old job we would have been called on the carpet for that. Here it is a different story. It's like they don't care or want to step up and say and do whats right. It just blows me away that a physician(radiologist) who reads these exams,aware of radiation and what it can do lets this go. Maybe I am wrong and scanning some with and without is acceptable and the without phase and delays are benefcial. If thats the case I can live with that and go on . Example, I called a radiologist about scanning someone with and without and I felt it only needed to be done one way and I suggested that when I called. They agreed with me, but then they asked who ordered it and they said just do it with and without because the ordering physician would through a fit. Or if it was ordered that way they would just say "do as ordered".So basically somone was scanned one to many times for the sake of an ordering Dr not throwing a fit.

It's like they don't want to be bothered with it, or I hope not, but for financial benefits for reading and billing for a with and without study. I have approached my supervisors and they do feel the same, but it's like the pink elephant in the room. Everybody knows it's there but does nothing about it. I am dumbfounded by this!

If I am wrong on this principle I would like to know. I know there is no law on saying how someone should be scanned. But it seems like to me any radiologist with a conscious would know better morally,ethically. I am hoping some governing body will step up and start looking at doses more and putting the clamps on the physicians being more responsible. .As we all know there is alot more talk on radiation in the general public concerning CT scans. Yes they are benefical and a great and valuable diagnostic tool, but it needs to be used in a more responsible manner with clinical corralation and evaluation of the patient.

Is it wrong to scan someone with and without and delays? I know
there are exceptions, but this situation weighs heavy on my mind and the radiologist that I work for seem to not even bother if someone is scanned that way. A lot of politics involved,radiologist having different opinions among themselves in the group, not caring and sometimes Dr's can be very difficult to deal with, sorry no offense. I just feel strongly about this issue and I want to know what is right. I was trained a ceratin way for many years and now it's the opposite and does not seem right.

 

[colbgw02]

If you address this issue an a patient by patient, exam by exam basis, there's really no way of coming to satisfactory solution.

An individual radiologist can and should have a great deal of latitude to perform any specific examination how he feels most comfortable. If the radiologists makes the decision that he cannot fully interpret the study unless X phase of contrast is obtained or Y MRI sequence is done, then that is well within his pervue. That might make him a bad radiologists, but it's still his decision. After all, it is his name at the bottom of the report, and there are enough liability concerns already within tying someone's proverbial hand behind their back by limiting image acquisition.

Ordering providers request imaging studies all the time that are either 1) completely unnecessary, 2) have no hope of providing useful or relevant information, or 3) both. It would be a full-time job just to contact everyone and try to explain to them why the study doesn't need to be done, that it should be done a different way, or that a completely different modality is preferred. From a practical standpoint, except with really egregious orders (an ultrasound to evaluate a lung nodule, for instance), a radiologist isn't going to spend any significant amount of their day doing that.

Moreover, when discussing an individual patient, it's next to impossible for a radiologist to talk a provider out of doing a study. On a small scale, the risk:benefit analysis falls apart. Take a CT pulmonary angiogram, for example. The patient is low-risk, has a negative d-dimer, and had recent negative lower extremity Doppler ultrasounds. And oh, by the way, something like 97 or 98% of CTPAs are negative for pulmonary embolism. As a radiologist, you're thinking, "this is stupid; there's no way this person has a PE - just like he didn't have a PE the last four times we did this scan in the last 12 months." But the guy on the other end of the phone isn't thinking like that. He's thinking, "what if this guy didn't read the textbook? What if he developed a DVT since last Thursday? He did say this chest pain is a little different than the pain 2 months ago. What if this is a PE and what if I miss it? I better order a CT scan."

That says nothing of how defensive and unreasonable the providers can be. They've already made the decision that they want the examination, and too often a call from the radiologist gets interpreted as an implicit indictment of their clinical acumen rather than advice from an expert. These physicians represent the radiologist's referral base; no one survives long in any business by angering his customers. The simple and sad truth is that just doing the study as ordered is the path of least resistance, and that resistance is substantial.

There are also coding and reimbursement issues to consider, which probably vary quite a bit from state to state. If an examination is ordered without contrast, but contrast is required to answer the question, then the group will probably not get paid the proper amount.

As best as I can tell, the only way to fix this issue is at a hospital systems level. There needs to be some imaging software system that requires providers to input their reasons for ordering a study. If the reasons are insufficient, then they cannot order the study. Clearly clinicians could push the fudge the system to get what they want, but they're doing that already (I know I've been lied to in order to get a study or get it quicker). At least with this system, it's forcing them to record in a legal document their thought process. Obviously this isn't a well developed idea and it's well beyond my ability to detail it much further.

The other place where I think intervention would work is to track an individual's dose in a cumulative matter in the EMR. And then put that dose into terms that other physicians and patients can understand (equivalent # of CXRs, estimated increased cancer risk). Have that dose pop-up whenever someone tries to order a new study. Maybe that will cut down on unnecessary exams.

Anyway, these are just a few thoughts as to why your radiologists do what they do. Of course, it's entirely possible that they are just lazy.

 

[spudboy]

If you address this issue an a patient by patient, exam by exam basis, there's really no way of coming to satisfactory solution.

Thats what I use to do . I would pull the schedules up well enough in advance to evaluate the pt's history,prior exams, diagnosis for ordering and based on our protocols and if the ordering physician did not order the correct exam per our radiologist the office was called and I would say 97% of the time the exam was changed to be done pee radiologist protocol.
The ordering physicians respected our head radiologist enough to follow
what has required for scanning that patient. Of course you had a few hardliners who wanted it their way, but overall reallly no issues.


An individual radiologist can and should have a great deal of latitude to perform any specific examination how he feels most comfortable. If the radiologists makes the decision that he cannot fully interpret the study unless X phase of contrast is obtained or Y MRI sequence is done, then that is well within his pervue. That might make him a bad radiologists


Yes I would agree that would make him a bad radiologist with poor interpretation skills.



Ordering providers request imaging studies all the time that are either 1) completely unnecessary, 2) have no hope of providing useful or relevant information, or 3) both. It would be a full-time job just to contact everyone and try to explain to them why the study doesn't need to be done, that it should be done a different way, or that a completely different modality is preferred. From a practical standpoint, except with really egregious orders (an ultrasound to evaluate a lung nodule, for instance), a radiologist isn't going to spend any significant amount of their day doing that.

To me that is a poor excuse. If you can't put the effort(time) into doing what is right then you are just as liable as the ordering physician for not doing the correct exam and letting this happen. Myself and the radiologists compiled a small reference guide that was distrubuted and available within our intranet that was available to educate the Dr's so they understood what was needed and we had orders that stated"contrast per radiologist"




Moreover, when discussing an individual patient, it's next to impossible for a radiologist to talk a provider out of doing a study. On a small scale, the risk:benefit analysis falls apart. Take a CT pulmonary angiogram, for example. The patient is low-risk, has a negative d-dimer, and had recent negative lower extremity Doppler ultrasounds. And oh, by the way, something like 97 or 98% of CTPAs are negative for pulmonary embolism. As a radiologist, you're thinking, "this is stupid; there's no way this person has a PE - just like he didn't have a PE the last four times we did this scan in the last 12 months." But the guy on the other end of the phone isn't thinking like that. He's thinking, "what if this guy didn't read the textbook? What if he developed a DVT since last Thursday? He did say this chest pain is a little different than the pain 2 months ago. What if this is a PE and what if I miss it? I better order a CT scan."


True you do have your hardiners and they want what they want. Then you go ahead, but those are few compared to the rest. Yes alot of it is CYA and that is unfortunate medicine has come to that.

That says nothing of how defensive and unreasonable the providers can be. They've already made the decision that they want the examination, and too often a call from the radiologist gets interpreted as an implicit indictment of their clinical acumen rather than advice from an expert. These physicians represent the radiologist's referral base; no one survives long in any business by angering his customers. The simple and sad truth is that just doing the study as ordered is the path of least resistance, and that resistance is substantial.


Yes that is sad and alot of the responsibility does fall into the ordering physicians lap. Thats were education comes in and like I mentioned before
I think something needs to happen as far as a governing body to watch
radiation doses and hold theses doctors accountable. Then it turns into a cya thing again, sad but true.

And yes again it would be a very hard battle to fight, but doing what is right and patient care far more outweighs anything else. I feel that it is something that can accomplished with time,effort, the right tact and education it can be done.