Radiologists and primary care doctors need to talk to one another

Recently, I spoke with a primary care physician (PCP) about a young runner who had a syncopal episode. Because of the increasing awareness of sudden cardiac death in athletes, she had an electrocardiogram and an echocardiogram to look for structural abnormalities of the heart.

The PCP was inclined to dismiss the syncope as an isolated episode. However, the echocardiogram, otherwise normal, equivocated: “possible hypertrabeculation of the left ventricular apex, consider cardiac MRI to exclude non-compaction of the left ventricle.” The PCP was inquiring how to order a cardiac MRI.

I asked about the circumstances that led to the echocardiogram.

With the absence of a family history, no palpitations and a normal left ventricular function (she ran five minute miles, enough said), I speculated that the finding on the echocardiogram was most likely an overcall. The cardiac MRI would likely overcall as well, as these diseases are defined by numbers that are inevitably shared with normal individuals. I expressed lukewarm enthusiasm for the cardiac MRI. The PCP agreed. The athlete was spared another diagnostic test, a cardiology referral and possibly a lifelong label.

This is not a discussion of overdiagnosis of non-compaction. This is to restate a banal truism: physicians should speak to one another. In particular, PCPs and radiologists should talk to one another, preferably when an expensive test is being contemplated.

One silver lining of the preceding decade of over utilization of imaging is that radiologists have developed a rich mental atlas of imaging findings of clinical irrelevance. Such findings are charitably known as incidentalomas. However, they do not remain incidental for long. Like the miscommunications that led to Romeo’s poisoning, incidentalomas can balloon out of control unless nipped (ignored) in the bud.

Furthermore, most radiologists, whether general or sub-specialized, have encountered uncommon diseases and uncommon manifestations of common entities, because of the sheer volume of cases read.

PCPs and radiologists have complementary knowledge. The combination of strong knowledge of the patient and deep knowledge of the limitations and downstream consequences of imaging can rationally gate keep costly advanced imaging, costlier specialists and even costlier hospitals.

To be sure, there will be challenges. My conversation with the PCP took less than five minutes. Because of the historical inertia this may appear insurmountable.  Then, there is the belief that all problems in healthcare can be solved by a checklist-regurgitating computer program. Some can, many still need recourse to that quaint habit of talking.

There is the prevailing culture etiquettes to deal with. Radiologists might not wish to offer unsolicited opinion that might be ignored or misconstrued as questioning of clinical reasoning, fears though grossly inflated nonetheless prevail.

Finally, there is a feeling that no good deed in medicine can take place without a CPT code. How will physicians bill for consultation about a diagnostic test that was not performed? But value is what we add in between billing for medical services. Billing codes follow value. Value does not follow CPT codes.

The health of a healthcare system, regardless of how it is financed, depends on the strength of its most decentralized units. This is basic epistemology. The alliance of primary care and radiology could be that strengthening force, an improbable alliance, even a marriage of inconvenience. But these are inconvenient times calling for improbable solutions.

Saurabh Jha is a radiologist.

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  • Peter Elias

    I agree totally and enthusiastically with the premise, but I fear that some of the discussion reflects insufficient understanding of the barriers: “My conversation with the PCP took less than five minutes.”

    When I want/need to talk to a consultant (radiology, cardiology, neurology, surgery – it really is the same issue) the disruption in my day is not necessarily reflected by the time on the phone with the consultant. In my world, there is generally a 2:1 ratio between the time spent getting access to the consultant and the time spent actually discussing the patient.

  • NewMexicoRam

    How about if radiologists put down what they really think rather than “consider more _______ radiological studies” ?
    I depend very heavily on that report. So make it count for the patient, please, not some big ticket lawyer.

    • ninguem

      Oh, c’mon, that’s not fair.

      You forgot “clinical correlation suggested”.

  • doc99

    When Radiology is viewed as a consult service, outcomes should improve.

  • azmd

    “My conversation with the PCP took less than five minutes.”

    Speaking as a specialist who frequently calls PCPs about their patients who have been admitted to my service, I can say that taking the call may have taken you less than five minutes. For the person initiating the call, it takes considerably more time than that to chase down the phone number, call the office, explain to the receptionist why I need to talk to the doctor, interrupt what I am doing later when the PCP calls me back and then document the conversation, since I am the one with liability concerns.

    I always make these calls, because it’s the right thing to do for the patient, and also because my hospital actually calculates this type of activity into my patient load.

    However, if I were a PCP in private practice, billing at a much lower rate for my services than a radiologist is able to do, not being compensated for this type of activity, and having 10 or more such calls to make in the course of a day, I might also have a hard time feeling that “value is what we add in between billing for services,” if those unreimbursed services were adding an hour of more of uncompensated work to my (already fairly low-compensated) workday.

    • Kristy Sokoloski

      “Also, I agree with other posters that it’s sort of ironic that the PCP ends up being responsible for doing the work to make sure that an overread study doesn’t result in unnecessary and wasteful”.
      Interesting. Isn’t this something that others say comes under part of the job Primary Care Physician’s job of coordinating care for the patient?

      • azmd

        Others like to say that it is part of the PCP’s job, but they haven’t seen fit to provide any means by which the PCP can be paid for doing it.

        • Dr. Drake Ramoray

          Indicate in your notes that you reviewed the actual films (I always do for ultrasounds and MRI’s if done by someone other than me (U/S). Include the time spent talking to the radiologist, and looking up the number in your E/M time and bill accordingly. Assuming you have 50% face time of the total time you are good to go.

          This is touching on one of my major issues with changing to bundled payments for problems. You can’t bill for time. It is conceivable that this ACO model can turn into paid over a given time of patient care, say 6 mos regardless of how many visits or how much time you spend on a particular patient. Then we will really have issues with not getting paid for our work.

          • rbthe4th2

            Have you considered passing that tidbit on to others Dr. Ramoray? That sounds like it would be worth trying for some docs.

          • Dr. Drake Ramoray

            Disqus ate my initial reply. I think all doctors should take a coding course. It was the best return on investment (financial wise at least) that I have ever had from CME. Coding isn’t taught formally, if it all, during medical school or residency.

            The controversial part of my original post was that I pointed out that if I decide this doctor thing doesn’t work out I can get my recertification work for the hospital and terrorize my former physician colleagues as a an aryan goosestepping coder (not the term that didn’t make it past the filter). What have we come to when I can’t even make fun of myself on the Internet.

          • rbthe4th2

            ROFL … you could always join Zdoggmd.
            Fascinating comment … thank you Dr. Ramoray.

  • Steven Reznick

    Radiologists need to take the time to call the referring doctor when they find something that they believe is abnormal and requires additional testing. The referring doctor needs to provide the radiologist with the clinical information they need to utilize their expertise for the patients best interests. Talking is both doctors professional responsibility. The patient is owed that level of communication

    • NPPCP

      I completely agree. We always send an accurate diagnosis and what we are looking for with every order. The reports show it too.

  • saurabh jha

    To clarify, I am advocating a conversation even or particularly before imaging is requested, as such conversations often reduce unnecessary tests. Not always, but sometimes, certainly more often than currently takes place.

    Hedging is a real and unfortunate problem, as has been pointed out. If both sides know each other’s clinical reasoning, useless disclaimers will reduce with time.

    There are operational challenges, no doubt. But of the three: hyper efficiency, reimbursement and value, something will have to give, at least in the beginning.

  • buzzkillerjsmith

    I’d have run that case by cardiology–after 5 or 6, of course, not during clinic hours. The guys and gals up in Spokane always talk to me, sometimes immediately.

    I agree that we and rads should talk about unusual cases.

    Also agree with azmd that non-pt-care docs sometimes don’t appreciate how we clincians are trying to swim through oatmeal all day every day.

  • buzzkillerjsmith

    Yeah, but it’s a hospital you never heard of. Maybe dimming for dim trainees.

  • Rachel Phillips

    Why aren’t we using web technology to consolidate the findings of different specialties on one screen to create a “big picture” of the patient’s clinical needs and connect physicians electronically?

    I’ve seen attending physicians order consults and then never take the time to turn back a couple of pages to read their consults assessments and suggestions. As a utilization/case manager I had to pour over my patient’s charts (MD notes, orders, labs, nursing notes, radiology results) and created a page that could sit directly in the front of the MD notes so all could read. Believe it or not, some physicians did not want this a permanent part of the chart as they complained it might lead to legal issues if they did not address the issues in a timely manner (?!!!). So I had to use post-it notes on the most current physician note in order to “bring forward” and consolidate everything daily that I found in the chart.

    This was very helpful to the physicians.but it made me wonder why we are not utilizing technology to assist physicians (and the rest of the healthcare team) with data consolidation..This is also why current EHR technology is so ineffective. It requires so much data entry without utilizing that data in a more organized, consolidated manner to assist providers with improved quality of care.

  • Name

    This is a ridiculous case presentation that should never happen—the PCP should have sent (not called up and tried to get an over the phone diagnosis) the patient to a cardiologist. Let the cardiologist decide if any further testing is required. Ridiculous to think that heart care can be managed by PCP-radiology phone collaboration!!! And don’t expect a specialist to do phone therapy either–

  • AKMaineIac

    A friend, William Burman, MD, of New York, introduced me to the term, “VOMIT Syndrome”… Victim Of Modern Imaging Technology…

    I see it routinely as a physical therapist with musculoskeletal imaging generated in advance of an attempt at rehabilitation. This has resulted in visits to an orthopedist and a prolonged period of disability, disuse, compensation, prior to a physical therapist evaluation and implementation of a plan to recover absent further intervention.

    There are cases in which the “need for referral for imaging and a specialist consult” are fairly obvious. I don’t like seeing them coming through my door either, and I can recognize them quickly enough for myself when they do. Usually, I call the PCP and discuss what I found and observed with them. I’ve never had one say, “No… I don’t think the patient needs X (MRI/CT, x-ray and referral to ortho). We work together for the betterment of the people who come to us. We must communicate honestly and without playing “gotcha”.

    In other cases, frankly a discussion could be had about it and nobody would necessarily be wrong. Unless it was their approach that was wrong. :)

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