More Consequences of IT: The Disappearance of Radiology Rounds

When I was a med student, the Beating Heart of the Hospital of the University of Pennsylvania (HUP) was not the CEO’s suite, the neurosurgeon’s OR, or the Dean’s lair. It was the seat of one Wallace Miller, Sr., in the decidedly unglamorous Chest Reading Room.

Do you even know where the chest reading room of your radiology department is?

Everybody – and I mean everybody, from the lowliest student to the seniorest clinician – brought their films to “The Wal” to figure out what was going on. For students like me, the trip to Mecca was both fun and terrifying. “What’s this opacity?” he asked me once, the memory seared in my medulla oblongata. “A… a pneumonia?” I stammered. “Mooiaaa” retorted the Oracle, turning his head away in mock disgust. I loved it.

One night last week, my ward team got 8 new admissions. After sprinting through the H&Ps and doing a little teaching, I suggested that we head to the radiology department to review the key films. I might as well have asked the team to hop on one foot and cluck like chicken. They humored me, but it was clear that they saw this as an odd, and rather unusual, request.

Contrast this with attending rounds in the Days of the Giants, in which the attending could no more skip radiology rounds than the med student could skip the patient’s social history. After reviewing the new admits, we all trekked to Radiology to review the films, each ward team passing through like cars in a car wash. Back then, this was all accomplished in a single reading room, since virtually all the films were of the thorax. The KUB didn’t show very much, the CT was a grainy daguerreotype, and magnetic resonance was what you learned in Organic Chem.

This review of the films was collegial, educational, and fascinating. It also provided focus and direction. “This is a 52-year-old woman with lupus, shortness of breath, and fever. What do you think, Wally?, we asked.” “Well, might just be the atelectasis of lupus lung, but it looks a bit hypovascular on the right side. Is she at risk for a PE?” The back-and-forth brought the clinicians ever closer to a thoughtful plan or a correct diagnosis.

We went to the Radiology Department for all these wonderful interactions. But we also went there because we wanted to look at our films.

Remember films?

In my last post, I wrote about how the electronic medical record has de-tethered – I call it “dis-located” – providers from the patient floor, since the docs no longer are hostage to a paper chart. The same type of dis-location – this time brought to you by PACS – allows us to review our “films” without ever stepping foot in the radiology department. In my 2006 New England Journal article, I considered the other key implication of this dis-location; namely the emergence of teleradiology, including the cross-border variety.

Lest you think I’m a total Luddite (I do have a blog, after all), you should know that I think that digital x-rays are a good thing. But the fact that we no longer have to go to radiology to see our films has real consequences. And this is why, when my teams do take the time to visit the radiology department, I conduct a little sociology experiment with them. Standing outside one of the reading rooms, I say something like this:

“Watch what happens when we enter. Does anybody turn around and welcome us, ask ‘how can I help you?’ and seem genuinely enthusiastic? When they go over the film, do they delve a layer deeper than the dictated reading? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?”

In UCSF’s radiology department, a visit to our neuro reading room always results in “yes” answers to all these questions; which is why I always look forward to these visits.

But some areas of our department have traditionally had a different culture. I won’t say which one or ones – in part because all of them have become more service-oriented in the past few years (for example, on two visits last week, one of the prior problem areas was spectacular), for which I am grateful. But the bad experiences still occur from time to time; they’re easy to recognize. They look like this:

I tell my team to enter the room but then to stand near the door, silently, and simply observe. The first thing you notice is a sea of backs – no radiologist turns around. (Has the entire radiology department been in a bus accident, their necks in cervical collars?) After a couple of awkward minutes, one of the radiologists begrudgingly rotates (has his C-spine been magically cleared?) and notices us. “Oh, do you need something?” No, we got lost on the way to the morgue, I nearly blurt, but I restrain myself. “Sure, can you help us with some films?” He does, sorta, but the reading is stilted, devoid of enthusiasm, in a passive whisper. Sometimes the passivity reaches phantasmagoric proportions, as in: “We don’t see an infiltrate.” I can’t help but wonder who this “we” is – is the ghost of Roentgen sitting on the radiologist’s shoulders?

Then, just when I think it can’t get any worse, it does. “What do you think of this area?” I might ask, pointing to a confusing patch of whiteness. The response: “Did you look at the official reading?” In other words, are you an illiterate moron?

The mostly unspoken message from this un-Passion Play is: “Get out of my space, I’m busy.” Now, I understand that – the radiologist might well be busy, and it has to get a bit annoying having clinicians interrupt you every few minutes to go over films, particularly after you’ve just reviewed the same ones with the pulmonary or ID consultants. But that is the radiologist’s job, and last I checked they are compensated reasonably well to do it.

I only make a fuss over this because I believe we are at a Tipping Point in this particular part of the Medical Universe. We are now training the first generation of clinicians who will never experience the need to go to radiology to review films. Whether they do or don’t visit the department and interact with radiologists will be entirely determined by the quality of their experiences when they do make the effort to go.

In my NEJM article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.

Or the country.

11 Responses to “More Consequences of IT: The Disappearance of Radiology Rounds”

  1. ACG January 31, 2008 at 2:47 pm #

    Both Wally Jr. and Wally Sr. are still teaching med students and residents at HUP that not only is it OK to visit the radiology department, it is very useful for the radiogists to hear a more detailed clinical desription. Additionally, they see it as an opportunity to hear longitudinal feedback regarding the patient to refine their diagnositic accuracy (i.e. was the tree-in-bud pattern really MAC?). This may explain why the Wallys have no problems making a definitive diagnosis (versus the frequently long, non-commital differential and “please correlate clinically”).

    If only there were more Wallys in the world.

  2. Bob Wachter January 31, 2008 at 5:52 pm #

    It’s wonderful to hear that the Wally Miller tradition lives on at HUP! And I’ve already heard off line from a couple of friends who told me of their Wally equivalents at their institutions. As Streisand said, they are very special people.

    It is also important to note that those of us coming to the radiology department bear some responsibility as well. We should have our list of films and patients ready to go, be prepared to present them briefly (including having formulated the question we’d like answered by the film), and be fully engaged in the conversation. I can well imagine radiologists around the country reading my post and griping about watching the members of the medical team fumble through index cards to get a patient list together (message to IT: wouldn’t it be nice is we just said “Team G” and the system automatically pulled up all our films), or seeing us multi-task while they’re trying to teach. It does take two to tango…

  3. davisliumd February 2, 2008 at 1:04 pm #

    As always your articles are hilarious and very insightful. What many doctors are quite oblivious to and what these set of articles illustrate is how technology is fundamentally changing healthcare delivery in unexpected ways. As someone who graduated from med school in 1997, which wasn’t that long ago, I remember quite fondly radiology rounds for the opportunity to collaborate, understand another colleagues perspective (why is it that clinical correlation is always recommended?), and gain priceless insight which would ultimately improve patient care.

    Instead, technology both professionally and personally has made people more connected (email, instant messaging, etc) and somewhat more distant (people may feel to need to read every message hitting their Blackberry inbox despite talking to a person face to face, college professors lamenting that their students aren’t paying attention with their faces buried in their laptops). Perhaps this is why more than ever we value face time.

    Radiology, in particular with its use of technology and at times less than service oriented focus, is at risk to be the first medical specialty to be effectively outsourced in the near future. Yes, like many industries have found out already, jobs can be sent overseas. Technology will fundamentally change healthcare delivery in unexpected ways.

    Yet, many organizations like Cisco and American Airlines with their technology groups haven’t outsourced overseas even though their labor costs would be substantially cheaper and the talent as good. The reason is the collaboration among individuals and groups locally results in better results and productivity. You can’t put a price on the intangible value of having a discussion in person. I hope our radiology colleagues get it because if they don’t not only will they realize that the world is flat but also discover how quickly their careers and income will flatten as well.

  4. twdeyer February 8, 2008 at 11:46 pm #

    From a radiologists perspective I think the problem is two fold. First, radiologists are busier than ever. We read an ever increasing number of studies. Unexpected, poorly organized visits from rounding teams disrupts an already busy schedule. This brings up the second point – mutual respect. Rounding teams walk into the reading room (often the wrong reading room for the study) without warning, stand behind you loudly talking and expect you to immediately drop what you’re doing. I can only imagine the response I would get if I unexpectedly walked into an examination room to get some history (on your colleague’s patient) that hadn’t been included on the request. Interaction between services is good for learning and for the patients. However, radiology rounds should be organized and planned.

  5. chris johnson February 11, 2008 at 5:22 pm #

    I had a similar experience during my pediatric residency at Vanderbilt in the late seventies. Pediatrics is a smaller world, of course, but the radiologists (Richard Heller, are you out there?) really were part of the care team; you would go to them not just to see a film but for advice about a clinical problem, such as “what’s the best way to figure this out?” I do understand that everyone is busier now, including our colleagues in radiology, but the free-form discussions that arose when the ward team trudged to the reading room (uphill, both ways) were often great teaching moments.

  6. edita falco May 20, 2008 at 9:31 pm #

    Sorry to read that this wonderful tool is perhaps dissapearing in medical permanet training
    live in South America but went for many years to Columbia Prebyterinan Hospital in New York and treasured every thursday when Profesor Walter Berdon and after Professor Shapiro conducted radiology rounds
    It was a most valuable experience and a privilege to be able to attend
    dra falco
    montevideo

  7. mshah July 26, 2008 at 4:51 am #

    This is the radiologist’s perspective in the matter. The clinical information provided to the radiologist is more often inadequate. Moreover, before the advent of digital images, the physician who was interested in looking at the images of his patients had to retrieve the films from the file room of the patient and had to carry it to the radiologist and would usually wait for a consultation till the radiologist was free from whatever work he was doing at the time. Now, the so called clinicians take it foregrated that any image can be pulled over at any station and feel free to interrupt the radiolgist. Imaging the radiologist barging on to the floor and disrupt the clinical rounds to get some clincal information. A radiologist reading the films on his station should be accorded the same status as a physician examining his patient in his examination room. I agree that it is the job of the radiologist to provide consultation to the referring physician, but it is also the job of the referring physician to provide adequate clinical information in the first place.

    As a matter of fact, if a radiologist is reading a trauma case where the CTs of head, C. Spine, Chest, Abdomen and Pelvis are ordered, reading these examinations requires probably more attention than the physical examination of the patient. Thses type of blanket orders are not at all uncommon.

    About half of the residents/fellows/medical students who approach me for an urgent report/consultation bltantly tell me that they don’t know anything about the patient and the patient is not theirs.

    In emergency radiology there are situations when ordering a particular radiologic examination sometime requires a specialist’s input. I will give an example. An ER physician once oredered x-rays of lumbar spine in a 10 week pregnant patient for history of trauma and patient complaining of back pain. I asked for a reconsideration of the order due to radiation hazard to the embryo during organogensis stage and suggested that neurology/neurosurgery consult should be obtained first before we proceed with X-rays. However, the consultants will not come and examine the patient till the imaging an all other relevant tests have been performed.

    The specialists visit the radiology station and check the labs on computer first before even looking at the patient.

  8. jeffreyfrog May 8, 2009 at 12:08 pm #

    The easiest way to think of it is that they aim an area like a lump in the lung & give the lump a straight shot of radiation at it to kill the cells. The area around the lump is not harmed by the radiation, just the lump. Radiation can only be used for localized cancer, not any that have spread to other areas. Sometimes they will do both radiation with chemo to prevent the tumor spreading.Radiation oncology is the term used for the specialty of treating cancer patients with radiation. Good luck.

  9. stephen arendale M.D. December 21, 2009 at 1:51 pm #

    As an “ole time” radiologist I have always enjoyed the interaction with referring physicians. As far as multiple visits for one case, I learn something from each visit and can give a more intelligent discussion with each subsequent visit. Nothing is quite as fun as letting an intern know that I know what the WBC count or sed rate or etc., is.

    I hope this never disappears.

    SA

  10. idon'tknowpayme December 23, 2009 at 7:08 pm #

    “If the radiologist doesn’t have the courtesy to immediately drop what he is doing and give me full attention whenever I may choose to wander into his work area, then I’ll just send my radiographs to India.”

    “And deal with the Indian radiologist over the phone.”

    “Just like dealing with customer service at Dell.”

    “Uh, well, on second thought …”

  11. DocDave April 16, 2010 at 4:33 pm #

    Problem with outsourcing to India is that they are facing a radiologist shortage worse than out own! With their own radiologists already operating at capacity it is hard to see how work from the US can be shifted there without dire
    consequences for their own healthcare system. Australia and New Zealand may have a slightly better availabilty but the price differential is much closer, savings may not be that dramatic. Make no mistake the problem is a global shortage of radiologists.

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