Second Opinion: It's the Same Everywhere and Other Indefensible Excuses

Leap, Edwin MD

doi: 10.1097/01.EEM.0000403708.94789.49
Second Opinion

My partners and I read our own plain x-rays after 5 p.m. and for most of the weekend. Imaging studies are sent to radiologists digitally, but the garden-variety chest x-rays, bone films, spine films, and the like are read by yours truly and friends. This is our system despite the fact that those old-fashioned roentgenograms are digital and fully capable of being transmitted anywhere, from across the street to across the Pacific.

When we have protested this in years past, the excuse was always this: “It's the same everywhere.” Hospitals across the country (presumably nonteaching ones) have radiology coverage during the day, then over-reads the next morning. And when the emergency department films are read — the next day — they are billed as emergency readings. This, we are told, is standard practice.

For a while, we tried to bill for our readings and pay for over-reads, but the cost was prohibitive. We would have paid more in follow-up interpretations than we made for looking at the x-rays ourselves. When we once considered trying to bill for ED ultrasound, we were told that the radiology group “was the only group allowed to perform radiology services” in our hospital. And still, when 5 p.m. rolled around, we were looking for the subtle pneumothorax, the subtle fracture, the obvious free air, and all the rest.

Of course, what that means is the dreaded callback. “Hey, Ed, that guy you saw last night with the pneumonia? He has some pulmonary nodules. They'll need CT follow-up. Thanks!” “Hey Ed, that C-spine had a little subluxation of C-5 on C-6. You might want flexion-extensions.” (Eight hours later, of course.) Or this gem: “The teleradiologist service read that CT head as negative, but there looks to be a subtle subdural hematoma. He was discharged? Oh, well, he'll need a repeat study.” In fact, a not insignificant amount of time is spent going over discrepancy forms, and deciding who to call back.

Doesn't it make sense, in an era of litigation and patient satisfaction, that films should be read immediately, by the most qualified person available, so that there aren't misses? Missed findings can obviously run the gamut from irrelevant (spina bifida occulta) to the tragic (subtle free air or thoracic aneurysms). Missed findings like potentially malignant nodules can also lead to unpleasant results, when the suspicious lymph node is discovered the next day in the patient who has already left the hospital and is subsequently nowhere to be found, with no working phone number or current address.

In our digital, high-speed age, why should I (or you) be reading x-rays when someone else went to residency for the sole purpose of doing that? I don't want to lose the skills I have, and I'm happy to look at them. But doesn't it make sense that radiologists read all films, and do it contemporaneously? And by that, I mean at the time the clinical service is being provided?

I simply don't understand how we have allowed a specialty to defer its responsibilities and put them in the lap of another and yet continue to bill for the specialty service. I'm sure it has to do with effective lobbying, but it still seems fundamentally wrong.

And what it does is this: It allows radiology groups to hire fewer physicians, and dilute their incomes by a lesser amount. Twenty-four-hour-a-day readings require either a) more staff or b) contracts with companies that provide that kind of coverage, which means c) less money per physician. But if the emergency physician is the acting radiologist? Voilà! Problem solved!

And what it also does is this: It slows down emergency physicians. When we have to read every film and arrange every callback, our ability to provide face-to-face patient care is diminished by ever increasing increments of time. And our already complicated thought processes are clouded by one more decision-making activity that is technically, contractually, and financially the purview of another kind of physician altogether.

Sadly, this isn't only an issue with radiology. Consider the stunning lack of availability of psychiatric care. Who is the default psychiatrist in America today? Most times, it is the emergency physician. A friend of mine was once asked, “What makes you think you're qualified to give psychiatric medicines?” His answer was short and to the point: “You force me to! There's nowhere else for psychiatric patients to go and no one else for them to see!” Be assured, the mental health professionals of the world are self-congratulatory about the way they use their advanced training to reach out to the mentally ill masses. But they are not apologetic about the fact that other specialties are filling sandbags against a tidal wave of mental illness in America.

And how about stroke care? Remember how important it was? Remember brain attack? At our hospital, we are now reduced to telemedicine, where after hours the neurologist in a referral center views the patient over an expensive monitor and the nurse walks the patient through his neurologic exam in preparation for giving what may be a life-threatening drug. The reason? Local neurologists find call too onerous. Critical specialty, requiring years of experience and knowledge of complex neurologic patheways? Sure. But after 5 p.m.? Just not that essential to the community.

I'm not interested in giving up the skills unique to my specialty. I am good at obtaining IV access, caring for trauma, managing the difficult airway, and negotiating with drunks. But the parallel to everything I'm complaining about would be this: After 5 p.m. and on weekends, our group hires several family medicine residents to cover our department. Not with us, mind you, but instead of us. And then we bill for the services of a board certified, residency trained emergency physician.

Sounds dangerous, doesn't it? Sounds indefensible, doesn't it? That's my point exactly. If a specialty is essential, it should be essential regardless of the position of the sun, whether above or below the horizon. And if it isn't, then maybe compensation needs to be adjusted accordingly.

Before long, we'll all be competing more aggressively for fewer and fewer dollars. If I were betting, I'd bet on the physicians who remain at the bedside, day or night.

Like you and me.

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