Categories

Tag: Radiology

Who Is the Better Radiologist?

flying cadeuciiThere’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

Continue reading…

Radiologist: Thou Shalt Disclaim by Law

There is an old joke. What’s a radiologist’s favorite plant? The hedge.

Radiologists are famous for equivocating, or hedging.

“Pneumonia can’t be excluded, clinically correlate”. Or “probably a nutrient canal but a fracture can’t be excluded with absolute certainty, correlate with point tenderness”.

Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice in the Breast Density Law.

The law requires radiologists to inform women that they have dense breasts on mammograms. So far so good.

The law then mandates that radiologists tell women with dense breast that they may still harbor a cancer and that further tests may be necessary.

You may quibble whether this disclaimer is an invitation or commandment for more tests, or just shared decision-making, the healthcare equivalent of consumer choice.

But it’s hard to see why any woman would forego supplementary tests such as breast ultrasound, magnetic resonance imaging and 3 D mammogram, or all three, when their anxiety level is driven off the scale.

What piece of incontrovertible evidence inspired this law, you ask?

Perhaps a multi-center trial run over 10-15 years that randomized women with dense breasts to (a) mammograms plus additional screening and (b) screening mammograms alone, show that additional screening saves lives, not just find lots of small inconsequential cancers.

No. The law was instigated by a heart-rending anecdote, which avalanched into the “breast density awareness” movement, cloaked by an element of scientific plausibility: women with dense breasts may have a higher incidence of cancer; a conjecture of considerable controversy.

Wasn’t  the Affordable Care Act (ACA) supposed to usher an era of rational policy-making, guided by p values, statistics not anecdotes?

Continue reading…

Radiologist: Commoditize Thyself

There is little in the health care world as amusing as watching radiologists work themselves into a froth over some real or perceived threat to their profession. Usually the villain is non-radiologists daring to encroach on radiologists’ turf. See, for example, Radiologists pull out the long knives as the radiology community attacks self-referral by non-radiologists. But the latest story (JACR article fires broadside against teleradiology firms) is about radiologists going after one another.

Gentlemen, we have met the enemy, and he is us! I didn’t pay $30 to access the article itself, but instead refer to an extensive summary on AuntMinnie.

David Levin, MD, and co-author Vijay Rao, MD, of Thomas Jefferson University in Philadelphia, make their case that teleradiology outsourcing contributes to the commoditization of radiology, lowered reimbursement, displacement from hospital and outpatient reading contracts, greater encroachment by other specialties, and lowered quality.

Here’s the problem:

Radiologists have been content to live off the fat of the land, working bankers’ hours and outsourcing inconvenient night and weekend duties to teleradiology firms rather than taking call themselves. Even when they’re around, radiologists in general don’t do a good job of serving the physicians who refer to them, staying in their dark rooms and not being proactive or even responsive. As radiology groups are finding, if they demonstrate they’re not crucial to the success of a hospital on nights and weekends, that also makes a pretty good argument for why they’re not necessary during weekdays either. Once hospitals understand the truth they can dispense with the local, intransigent radiology group entirely.

Continue reading…

Registration

Forgotten Password?