American ER Doc Gone Walkabout Episode 008
Plenty of differences in practice between Tasmania and my home hospitals in the US existed — the accent, the patient population, billing, interactions with consultants, roles of the residents and registrars — but didn’t really have an impact on clinical functioning. However, imaging did change clinical practice.
During the day shift on weekdays, there wasn’t much difference — perhaps a bit less dependence on imaging to confirm every clinical impression, or to “rule out” really unlikely diagnoses. And, significantly, the absence of real-time written reports. They weren’t available for days. So, if we were satisfied with our own reading, we were good. Otherwise, it involved phoning or walking over to radiology to talk with the radiologist. And, there were occasional discrepancies in the verbal report and what showed up much later in the paper chart — that could be quite significant.
But the off hours were a horse of a different color. The technicians and radiologists were at home. Any imaging involved a call to the radiologist who would then wait until he had collected a few requests, then radiologist and tech would come from home to perform and read the studies. In the truly emergent studies, we still had a built-in delay of 30 minutes or more, and for urgent studies, often delays of many hours — OK for the clinical decision-making but certainly killed efficiency.
And, when a system is less than optimal, any personality issues, such as an obstructionist radiologist, could make the system truly awful.
My favorite part of the system was the technique for providing after hours readings: you may not be aware, but it is actually possible to put 4 CT readings on a single 3×3 inch (8×8 cm) yellow post-it pad. Stick it on the wall. And call it good. What could possibly go wrong with that system? And, it is ecologically sound — it saves a lot of ink.
There were a few differences between what I saw in the US and how we functioned in Tassie:
We do lots more imaging in the US, and consequently have lots more normal studies. Some of the excess is fear of liability: if I get sued, the mere fact that I did a “test” shows my concern, even if it had no bearing on the outcome of the case. Some is patient perception: Doctor, my friend got an MRI when his baby hit him on the head with a rattle — I’d feel so much better if I got an MRI, also. ( And, note that in the US, some of our remuneration is governed by “satisfaction surveys” — the dread Press-Ganey score. So, if I get a lower satisfaction score from some pissed off patient, because I didn’t order an unnecessary test that the patient wishes to have, and that bad satisfaction score then costs me a couple bucks of income, why wouldn’t I order it?) Some is financial incentive: if I make a pure clinical diagnosis (say, a cluster headache) based on a detailed history and exam, I will earn less money on insurance billing for that patient than if I order an imaging test just to “make sure” that there isn’t a tumor, or neurocysticercosis, or porcelinization of the ludicrous nematode.
I doubt that many doctors are ordering unnecessary tests explicitly for such financial reasons, but it’s hard to believe that there isn’t a subtle, if subliminal, pressure to order that test when all of the motivators — financial and legal — urge it.
So, what are the differences;
Real time written reports: even at the paper chart ER’s where I work in the US, there is a real-time written report in the PACS system. Advantage: avoids translation errors between the verbal report and the written report, avoids missing a secondary but important finding, and when supervising a junior resident, avoids having to take the translation of the junior as to what is really important (my favorite is the mistranslation of the resident of “epiploic appendagitis” into “acute appendicitis”).
The drawback: it becomes waaaaay too easy to just read reports and never look at the image yourself. The radiologists are good, but they really do occasionally miss the important finding — we have an advantage of trying to correlate the clinical with the imaging, and sometimes find the pertinent item on the image. Sometimes, the imaging report has a hard time conveying the true magnitude of the pertinent finding: there is a difference between “Free fluid visualized within Morrison’s pouch and between loops of bowel may correlate with the findings of multiple densities within the splenic parenchyma” and “Holy Mother of Jesus, look at all that blood — it’s everywhere, let’s call the Surgery Reg!”
And, critically, the immediate feedback by correlating visualized images with the recently performed clinical exam is a critical part of the learning process. If you don’t look at the images yourself, the feedback to the clinical exam is lost, and the clinical exam skills are not enhanced.Let me repeat that: Critically, the immediate feedback by correlating visualized images with the recently performed clinical exam is a critical part of the learning process. If you don’t look at the images yourself, the feedback to the clinical exam is lost, and the clinical exam skills are not enhanced.
After-hours imaging reading and reports: I’m aware of 3 current models of after- hours readings: in house 24 hour radiologist; off site readings by staff radiologist — i.e. the same guys as during the day time, but reading at home over the internet; off site readings by an outside organization (might be in the US performed by overnight radiologists, or in a distant hemisphere — often Australia or India by guys reading in the distant daytime). I’ve worked in all 4 systems and they all work just fine in general. The remote readings require a little trust in radiologists that you’ve never met nor worked with directly, and the off site local readings sometimes requires reminding the radiologist to really wake up before reading the film — that’s a model that is dying out, I think.
It has been many years since I’ve had to call in a radiologist from home for a reading, and that really didn’t work very well — as it doesn’t in Launceston. Having to call a technician and a radiologist in from home has too many competing agendas. The radiologist may be ready to help even if he’s tired and a bit grouchy, or he may be tired and grouchy before you even call and no matter how critically time dependent the study is, he’ll drag his feet. (Perhaps, the least favorite line during my entire stay in Tassie: “If you did a better neurologic exam, you wouldn’t need a CT scan.”) On the other side is the ER Doc who cries “Wolf!” (“Tasmanian Tiger!”) too many times, and the radiologists appropriately start to question the true need and time dependence of the study.
Finally, at least in the US, this is a situation where the financial incentives probably did line up well with the clinical needs. Once our radiologists realized that there was money to be made even after midnight, and money to be lost to radiologists in Sydney and Mumbai reading US films at night, they quickly ramped up systems for 24 hour service to the ER’s and critical care units. I think that spilled over so that even the public service hospitals, like my little 8 bed Indian Health Service ER — where profit motive is not an issue, have ramped up to have 24 hour readings standard practice — using off site remote, but real time readings.
Lonnie really ought to catch up on this one.
American ER doc