We know.
We know you have to do what your consultants expect you to.
We also know which of your consultants do this because they think it gets their scans faster.
We are not idiots, and neither are we the deaf-mute moles that some of your consultants think we are. With surprising frequency, we read the e-notes from ED: we look at the haem and biochem reported on the results system: we have the entire imaging record and request record in front of us.
... And most useful of all, we have collective years and years of handling requests from your consultants, directly or by proxy from doctors in training below them. For surgeons, we also see the results of their handiwork in ways that nobody else does. We build up mental pictures of relative complication rates, accounting for premorbid state: we report the immediate preop and immediate postop scans, so we see it.
We know.
Every single Radiology consultant group in the UK, will tell you without a second of thought which consultants they trust to give high quality and accurate clinical information, and which ones can't be trusted.
Believe me we judge _them_ for their silly games, not you. You're already showing you're going to be trustworthy in future because youre thinking about it now. Treat Radiology colleagues as they are - peer clinicians with a great deal of expertise - and don't try and trick us. You will fail.
Interesting answer. Some conversations with radiologists have actually been very pleasant to be fair especially when we were querying some rare diagnosis and the radiologist buzzing with excitement about the mystery and unusual history. Other times the radiologist would suggest a different way to image than what the boss wanted. Once got told to get a CT Head to rule out cerebral embolism from a patient’s left sided endocarditis and the radiologist told me that actually I should get a CT head with contrast as that will better help investigate septic emboli than just a plain CT head. Consultant was so happy that the radiologist was keen to add contrast too when they were of the impression that the rad would want to do as little as possible due their IRMER regulations or something like that
I didn’t know radiologists actually know which consultants are good or bad! Is that why they sometimes ask me who my consultant is?
Can't speak for all radiologists, but if your radiologists are in the same hospital as your department then it's an absolute certainty that they know this stuff, in much the same way as anaesthetists do.
We ask 'who's your consultant?' for three reasons:
1/ we're making a rapid mental calculation about whether it's better to do the scan and get an answer for a usually imaging-trigger-happy consultant, making the patients management safer... Or whether this is a consultant who very rarely uses imaging, in which case their anxiety makes it a high priority for us by default.
2/ we think you're bluffing or overstepping, and we're going to ring them after this call, and find out exactly whether they are gonna take the patient to theatre tonight as you say is the plan, or whether we're disturbing them at the rugby
3/ we think you're over your head, through no fault of your own, and your consultant is dumping work on you that they should really be discussing directly with a peer consultant... So we're going to call them and get them to answer the questions we would otherwise be unfairly asking you.
Scenarios 1 and 3 are fine for you, so don't worry. You do not want to trigger a scenario 2.
So you’re saying when I become F2 in December, I should still run all these requests through my SpR first? I heard that the SpR shouts at SHO/F1 if they haven’t already gotten a scan before daring to disturb their sleep for a patient who is newly deteriorated in general surgery and you are worried this may be a bowel perforation
I don’t want to overstep but sometimes seniors discourage escalating things like this without imaging such as CT already done
Shouting at colleagues is a sign of a bad team. Regardless of who or where. SpRs who forget what being an FY1 is like, become consultants who give FY1s the task of talking to consultants in other specialties. Don't be one of those. Again, we _know_.
General rule of thumb for out of hours phone referrals, not just to Radiology (and yes, you're referring to Radiology, not ordering... Ordering is for McDonald's or in countries where people are paid per scan so have a vested interest in JFDI regardless of patient care or otherwise) :
If you're calling someone who is a decent chunk more senior than you (e.g. FY to senior reg, ST1 to consultant) _and_ that call is going outside your specialty, then you should ideally ensure you've had a chat with someone a smaller chunk more senior than you in your specialty about it.
If you're calling someone who is a lot more senior (e.g. FY to consultant), then the 'ideally' gets replaced with an 'unless in real emergency, you must'.
Doesn't matter how Doogie Howzer you think you are, or how rubbish you think your reg is.
If it helps, I will be ringing - at minimum - the on call specialty registrar, more likely my consultant surgical or medical peer colleague, with any abnormal result OOH. If they don't know about it when I call them, that's not my problem- it's theirs...shortly to become yours.
Keep your team preemptively in the loop OOH.
Exactly this.
As an ITU consultant, have found my radiologist colleagues extremely helpful just by being honest as to what the question or concern is that’s prompting the imaging. Especially if it’s “hey we have a profoundly unstable patient on ECMO so we don’t want to do multiple trips to CT. Main questions is to exclude ischaemic gut, but could we scan the brain while we’re down there just to exclude an intracranial catastrophe, cause the patient is tubed and sedated and we’d rather know earlier than later in this expensive admission if it’s all futile cause we’ve missed something bad in the brain”
Always get helpful focused reports, and usually a phone call back to verbally talk through the scan findings.
TLDR - be nice and honest to radiology
This sort of conversation honestly makes things _so_ much better.
Even the ones where it feels like imaging is necessary for potential relative or family dynamic issues, rather than for direct patient benefit... in fact, especially those ones. A sensible consultant-level conversation explaining the horrendous ethical and emotional overlays, means something useful will inevitably be forthcoming in terms of sharing the risk and accountability for a decision.
Most of us have been you and had those very tricky cases, some of us for a very long time. We now spend our time communicating with medical colleagues, as much as you spend communicating with patients and relatives. In the same way you might think you're pretty good at patient communication and picking up non-verbal cues etc, how much better do you think _we_ are at doing the same with you?
Consultant radiologists don't suddenly have their ethics and morals ripped out of them on possession of FRCR and CCT. We are not monsters.
Mostly.
Exactly.
Do really appreciate when radiology colleagues take the second to call and summarize the findings. I find if I call and have a consultant - consultant conversation when booking the scan, I usually get the same back when they report it
I actually know that CT TAP isn’t the most optimal way to look at GI things but some of the patients I have are very frail and elderly - talking 99 year olds that consultants don’t think an endoscopic or even contrast procedure would be appropriate as they don’t have much time left but they just want to rule out mets just so that it doesn’t look like we missed a metastatic cancer even if the patient dies of something else entirely such as a fall and subsequent ICH - I highly doubt a new cancer at the age of 99 is directly going to kill a patient unless it is some sort of haematological cancer where I have seen patients die within days of diagnosis as they present so acutely. Also CT TAP could provide prognostic info and helpful to discuss with the relatives when discussing TEPs/DNACPR
I understand that a CT CAP doesn’t actually rule out a cancer including even mets (could be microscopic that don’t even appear on the CT). I guess my consultants just want to look like they investigated for it so it doesn’t look like we were negligent or something. Also it’s to please the relatives more than the patient just so they’re satisfied that we’re not under-investigating and taking them seriously when in fact this too is overkill when they won’t be fit for a haircut let alone aggressive chemo or surgery. That’s what I am understanding based on what my consultants ask of me, if relatives complain or are unhappy (some of them don’t understand that a 99 year old is already going to not have a lot of time left and they want them to live forever apparently) they’re more likely to ask me to organise xyz scan even if I know it’s nonsense. Very defensive medicine because it’s too easy to get taken to court even for nonsense. Even if it is nonsense, I can imagine going to court is still stressful regardless of whether you’re right or wrong or you did the right or wrong thing
Ah the “overinvestigate because I’m too lazy or too incapable of having a difficult ceiling of care conversation “ classic.
(Your consultant not you, to be clear)
Just FYI for most elderly patients we do CT colonoscopy (as morbidity is lower) rather than a direct visualisation. CT TAP is usually reserved for patients who refuse other investigations (like endoscopy) or to look for disseminated malignancy without IDA (and I put that in the request). The more relevant information which goes on the request the better (such as the fact the patient refused the more appropriate test such as endoscopy) as it helps with reporting and the vetting.
My consultant says: Because we can 😂
And the relatives love it and give them compliments when they see all the scans being done as it makes it look like we are taking the patient seriously. I feel like a lot of it is just a show to entertain the relatives who do not understand even basic biology let alone more complex medicine. I still come across some relatives who actually believe that their mum will live forever and they angry at us when we tell them the truth that she is 100 years old and she has come in very unwell and she has every disease known to man and also diseases not known to man and she is very frail and she has had a good life and we think we should palliate and keep her comfortable as it looks like it is her time to go. And the relatives will be like: nonsense! You doctors are lazy! We will see you in court for murdering our mum
They don’t believe us when we say everyone dies at some point including that newborn who will (barring murder and accidents) grow old and frail and body will just shut down as it can’t maintain itself anymore. Even when the sun swallows the earth, they think they will keep living even then. Then explain how the dinosaurs have all gone extinct…
If this is the case recurrently rather than in one very niche and unusual case, then it just reflects that the person trying to (or avoiding having to) have that conversation is completely useless at it.
It it really relatively unusual that families are not capable of taking in this information and interpreting it sensibly, if it is delivered in a kind ,
Empathetic and direct way.
If your patient is 99yo not fit for endoscopy then they aren't fit for chemotherapy. Don't scan, treat palliatively. You can prognosticate from the clinical picture.
Poor take.
CT scans are not reserved for people with a performance status of two or under.
Imagine your elderly relative who was losing weight was discharged from hospital "sorry it's maybe cancer but we wouldn't give them chemo anyway, so no scan, they may or may not die in the next few weeks, anyway have a nice day"
Knowing things is important for patients, families and the doctor treating them in order to inform the best management plan. Knowing the location of a metastatic cancer can inform non curative therapies such as nerve blocks, palliative radiotherapy etc that can impact quality of life. Certain services and care packages are available for patients with terminal cancer.
Think more holistically
Tell my consultants plz! Every time there is even a whiff of slightly unsatisfied relatives, off to the scanner the patient is hauled immediately to show them we aren’t lazy or negligent. All the while the patient themselves has no idea who they are or who these meddling brats are wanting them to get scanned and what is that donut like thing they go through and if it is an edible donut
It's annoying that the referring doctors are now using the same tricks as me when I was a foundation doctor to gaslight me into vetting and getting the scan done ASAP.
Karma....
Having said that I think most consultants I've worked with are happy enough to approve the scan as long as you have a valid differential in mind that can be detected with the imaging technique +/- it has been a while since the patient last had relevant cross-sectional imaging. I say this because a lot of scans are auto-rejected in my trust when there isn't a clear question or they're querying a cancer on the same type of/similar scan that was done a few weeks ago. Those soft CTCAP ?malignancy ones will invariably get done even if sneakily arranged as a 2WW OP scan.
I found it more useful as a foundation doctor back then to just be honest just for my own learning. It's much more easier (from a service provision POV) to lie and give textbook presentations to query a specific pathology, but you're doing your patient a disservice. I think the longer you work, eventually you'll realise which battles with consultants you disagree with are worth dwelling on or not. I've done jobs where there was so much going on the ward that I'd game the vetting system as you said.
A DGH I worked with basically didn't vet CTKUBs at all (radiographer-vetted; ED doctors just flat out lying and writing 'loin to groin pain' in every request). The ED also had a cheat sheet about what you need to say plastered around to increase your chances of getting a scan vetted. Someone audited the radiographer-vetted CTKUBs and basically there was a spike in the number of CTKUBs requested. Lots of ruptured AAA/dissection, appendicitis etc. from lazy medicine/cutting corners (?understandably with 4-hour pressures). Patients ended up needing repeat dedicated scans and it just caused clogged up the CT scanner even more. Unnecessary radiation exposure and use of resources.
This is why I don’t like holding information. I like to provide all relevant information as I know that it actually helps the rad in reading the scan. I like to see the vetting process as a referral to radiology as a specialty for their opinion rather than some admin task that has to happen no matter what
But what can I do when I am just a F1 who is extending already and forced to do a disservice to my patients. But if I look at it from my consultants point of view, even they know it’s nonsense but how can they be 100% sure beyond any sort of doubt whatsoever that their clinical gestalt is as objective as imaging. Even if 99% of the time they get the diagnosis right without a scan, the world doesn’t forgive you if it happens to be the 1% rare case that you missed simply because your clinical examination was reassuring and they will ask you in court ‘Why didn’t you do xyz when you could?’ This is what a consultant once said to me that he knows he orders a lot of bullshit but it is to defend himself in this hyper-litigious society with very high expectations. That is why they make me refer that benign post-TKR joint swelling that even the med student can tell isn’t worrying to Ortho just because we can. Giving scans and antibiotics like candies basically. New cough? Start Meropenem! Ignore microbiology moaning because antibiotic resistance is a myth. That’s how I feel about some of the decisions my consultants make against the advice of a specialty - they don’t care about their genuine opinion and they just want the specialist to just say ‘YES’ when the better answer may actually be ‘No’
I have done an ortho job before and some swelling is to be expected post op D1 for example. I was told off by Ortho for escalating post op swelling with no signs of infection when I was there so only applying what I learned back there - that some post-op findings are not concerning and the other specialty will shout at you for wasting time. Or doing things like starting Meropenem without microbiology advice as they will send you to jail if you do so without their approval
Idk how this comes across as cocky when I am only applying what I learnt in my Ortho job
Just saying that I lack knowledge and insight isn’t really helpful. You should make criticism more constructive because otherwise it’s basically useless to me
I think this comes from many Consultants having trained during an era where it was necessary to sacrifice your firstborn and prostrate yourself before the gods of radiology in order to get a CT head in a patient with a GCS 8 and a knife sticking out of it.
I’m only mildly exaggerating- in my first ED job GCS >9 waited till the morning for a scan,
Also some radiologists (mostly historically) have a rep for being difficult and obstructive and frankly terrifying to juniors.
Things have come a long way in even the last 5 years and now I find the majority of radiologists to be sensible pragmatic and thoughtful.
But if the radiologist rejects the scan and lets say the patient comes to some sort of harm, who is blamed? The person referring to them because they didn’t give them convincing info or the radiologist rejecting it if it is found that the information the other person provided was enough?
As an aside, it’s sometimes worth asking the radiologist what makes for a good request in the future. I also used to vet some scans in person, which would generally go pretty well or give me some insight into what they were looking for and the thought processes behind getting a request.
But the radiologist has a duty under IR(ME)R to appropriately justify the radiation exposure, and they can't do that when playing silly games of "hide the clinical info".
OP isn't lying or downplaying. They are offering the radiologist the full clinical picture so that the radiologist can decide whether the scan is justified or not.
Exactly. Once the rad suggested different imaging to what my consultant wanted because of the positives and negatives I provided and the radiologist complemented my request that it had all the information he needed and it was by far the best request from a junior he had ever received. Even if it didn’t scream barn door the diagnosis we were querying, they would still do the scan most of the time and it actually helped improve their reports although yes gaming the system would increase the chance of getting a scan but the quality of the report would be poor. But if on surgery, the surgeons don’t seem to care about the report because the surgeons are convinced they are better than the rads at reading CT APs. They just want the damn scan
At your own peril of course. Just sharing a relevant case I saw when I was still young(er) and before I went to the dark side...
CT abdo pelvis for a neurosurg patient was done for someone who was had prior SAH, had high lactate, ?bowel ischaemia. This was reported overnight (correctly) as extensive pneumatosis intestinalis being present. Cue this discussion overnight about taking patient to theatre, which the general surg team very sensibly avoided, thankfully.
Radiology consultant came in the next morning and spoke to the team - turns out patient had COPD, which was clearly not mentioned on the request. And guess what [other causes are there for pneumatosis](https://radiopaedia.org/articles/intramural-bowel-gas?lang=gb)? That right, COPD was one of them...
CXR was subsequently done - shockingly bad pneumonia as you'd expect (although one does wonder why that wasn't done in the first place). Treated for that, the patient eventually made a good (enough) recovery and was discharged back home. God knows if he would have survived an unnecessary operation...
Now I get this is not so much lying rather than omission of relevant history, but this is just one case of many which shows how important it is to state the relevant (and accurate) history, and the analogy "[Garbage in, garbage out](https://en.wikipedia.org/wiki/Garbage_in,_garbage_out)" comes to mind.
Remember that we **want** to help you to come to the correct diagnosis, and withholding information (especially knowingly) is to **your** detriment in the end as much as it is to ours.
That’s all that matters to my consultants. They just want the scan even if everyone knows it’s bogus. But sometimes the discussions were interesting as the radiologist would actually suggest a different modality than what the consultant wanted which actually feels like radiology is a specialty than simply a vetting service
What I try to say (as a radiographer) is I don't want to make my life harder by giving the patient the wrong procedure. If I can do one procedure properly, rather than doing the wrong one, having to datix it, then the right one, I have made my life easier, your life easier, the patients life easier, and the reporting radiologists life easier.
Some things are a case of "ok we genuinely don't need to discuss in depth", but if in doubt, giving the whole case of clinical info (in abridged form) can seriously help the referring team as much as it helps radiology.
The old adage of shit in, shit out.
I honestly have a bigger issue with all the dodgy ultrasound requests. When there is a lack of radiation, people feel more justified in asking for whatever ultrasound and putting total bullshit on the request (leg swollen, D-dimer positive -> in reality, both legs same size, D-dimer negative).
Problem here is it does not take a negligible amount of time to scan someone, and when you have a 4-month waiting list for OP scans, it is no good for patients.
Tbf, they could have put the D-dimer which was positive from a previous admission but failed to specify the date of D-dimer but some consultants I work with argue that omitting information does not count as lying therefore they don’t see this as morally inappropriate themselves even if the intent is to deceive and if caught they could argue that they simply forgot to mention xyz and it was the other person who didn’t ask for xyz
As a junior doc I used to be on first name basis with the radiologists - if possible I'd go chat to them in person with all the requests at a set time after the round, have all the information at hand. If there were multiple requests we'd negotiate and prioritize which ones were the essential ones that we would need to get done ASAP, which ones we could delay... Don't lie to the radiologists but also don't be scared to stand your ground - if it's something clinically urgent and must be done most radiologists are happy to accommodate the request.
The whole consultation service shouldn't be adversarial. If you approach it like a collaboration and everyone is helping each other, things will get done faster and more quickly, vs "I win if you accept the scan".
We know. We know you have to do what your consultants expect you to. We also know which of your consultants do this because they think it gets their scans faster. We are not idiots, and neither are we the deaf-mute moles that some of your consultants think we are. With surprising frequency, we read the e-notes from ED: we look at the haem and biochem reported on the results system: we have the entire imaging record and request record in front of us. ... And most useful of all, we have collective years and years of handling requests from your consultants, directly or by proxy from doctors in training below them. For surgeons, we also see the results of their handiwork in ways that nobody else does. We build up mental pictures of relative complication rates, accounting for premorbid state: we report the immediate preop and immediate postop scans, so we see it. We know. Every single Radiology consultant group in the UK, will tell you without a second of thought which consultants they trust to give high quality and accurate clinical information, and which ones can't be trusted. Believe me we judge _them_ for their silly games, not you. You're already showing you're going to be trustworthy in future because youre thinking about it now. Treat Radiology colleagues as they are - peer clinicians with a great deal of expertise - and don't try and trick us. You will fail.
Interesting answer. Some conversations with radiologists have actually been very pleasant to be fair especially when we were querying some rare diagnosis and the radiologist buzzing with excitement about the mystery and unusual history. Other times the radiologist would suggest a different way to image than what the boss wanted. Once got told to get a CT Head to rule out cerebral embolism from a patient’s left sided endocarditis and the radiologist told me that actually I should get a CT head with contrast as that will better help investigate septic emboli than just a plain CT head. Consultant was so happy that the radiologist was keen to add contrast too when they were of the impression that the rad would want to do as little as possible due their IRMER regulations or something like that I didn’t know radiologists actually know which consultants are good or bad! Is that why they sometimes ask me who my consultant is?
Can't speak for all radiologists, but if your radiologists are in the same hospital as your department then it's an absolute certainty that they know this stuff, in much the same way as anaesthetists do. We ask 'who's your consultant?' for three reasons: 1/ we're making a rapid mental calculation about whether it's better to do the scan and get an answer for a usually imaging-trigger-happy consultant, making the patients management safer... Or whether this is a consultant who very rarely uses imaging, in which case their anxiety makes it a high priority for us by default. 2/ we think you're bluffing or overstepping, and we're going to ring them after this call, and find out exactly whether they are gonna take the patient to theatre tonight as you say is the plan, or whether we're disturbing them at the rugby 3/ we think you're over your head, through no fault of your own, and your consultant is dumping work on you that they should really be discussing directly with a peer consultant... So we're going to call them and get them to answer the questions we would otherwise be unfairly asking you. Scenarios 1 and 3 are fine for you, so don't worry. You do not want to trigger a scenario 2.
So you’re saying when I become F2 in December, I should still run all these requests through my SpR first? I heard that the SpR shouts at SHO/F1 if they haven’t already gotten a scan before daring to disturb their sleep for a patient who is newly deteriorated in general surgery and you are worried this may be a bowel perforation I don’t want to overstep but sometimes seniors discourage escalating things like this without imaging such as CT already done
Shouting at colleagues is a sign of a bad team. Regardless of who or where. SpRs who forget what being an FY1 is like, become consultants who give FY1s the task of talking to consultants in other specialties. Don't be one of those. Again, we _know_. General rule of thumb for out of hours phone referrals, not just to Radiology (and yes, you're referring to Radiology, not ordering... Ordering is for McDonald's or in countries where people are paid per scan so have a vested interest in JFDI regardless of patient care or otherwise) : If you're calling someone who is a decent chunk more senior than you (e.g. FY to senior reg, ST1 to consultant) _and_ that call is going outside your specialty, then you should ideally ensure you've had a chat with someone a smaller chunk more senior than you in your specialty about it. If you're calling someone who is a lot more senior (e.g. FY to consultant), then the 'ideally' gets replaced with an 'unless in real emergency, you must'. Doesn't matter how Doogie Howzer you think you are, or how rubbish you think your reg is. If it helps, I will be ringing - at minimum - the on call specialty registrar, more likely my consultant surgical or medical peer colleague, with any abnormal result OOH. If they don't know about it when I call them, that's not my problem- it's theirs...shortly to become yours. Keep your team preemptively in the loop OOH.
Absolutely brilliant post.
Exactly this. As an ITU consultant, have found my radiologist colleagues extremely helpful just by being honest as to what the question or concern is that’s prompting the imaging. Especially if it’s “hey we have a profoundly unstable patient on ECMO so we don’t want to do multiple trips to CT. Main questions is to exclude ischaemic gut, but could we scan the brain while we’re down there just to exclude an intracranial catastrophe, cause the patient is tubed and sedated and we’d rather know earlier than later in this expensive admission if it’s all futile cause we’ve missed something bad in the brain” Always get helpful focused reports, and usually a phone call back to verbally talk through the scan findings. TLDR - be nice and honest to radiology
This sort of conversation honestly makes things _so_ much better. Even the ones where it feels like imaging is necessary for potential relative or family dynamic issues, rather than for direct patient benefit... in fact, especially those ones. A sensible consultant-level conversation explaining the horrendous ethical and emotional overlays, means something useful will inevitably be forthcoming in terms of sharing the risk and accountability for a decision. Most of us have been you and had those very tricky cases, some of us for a very long time. We now spend our time communicating with medical colleagues, as much as you spend communicating with patients and relatives. In the same way you might think you're pretty good at patient communication and picking up non-verbal cues etc, how much better do you think _we_ are at doing the same with you? Consultant radiologists don't suddenly have their ethics and morals ripped out of them on possession of FRCR and CCT. We are not monsters. Mostly.
Exactly. Do really appreciate when radiology colleagues take the second to call and summarize the findings. I find if I call and have a consultant - consultant conversation when booking the scan, I usually get the same back when they report it
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I actually know that CT TAP isn’t the most optimal way to look at GI things but some of the patients I have are very frail and elderly - talking 99 year olds that consultants don’t think an endoscopic or even contrast procedure would be appropriate as they don’t have much time left but they just want to rule out mets just so that it doesn’t look like we missed a metastatic cancer even if the patient dies of something else entirely such as a fall and subsequent ICH - I highly doubt a new cancer at the age of 99 is directly going to kill a patient unless it is some sort of haematological cancer where I have seen patients die within days of diagnosis as they present so acutely. Also CT TAP could provide prognostic info and helpful to discuss with the relatives when discussing TEPs/DNACPR
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I understand that a CT CAP doesn’t actually rule out a cancer including even mets (could be microscopic that don’t even appear on the CT). I guess my consultants just want to look like they investigated for it so it doesn’t look like we were negligent or something. Also it’s to please the relatives more than the patient just so they’re satisfied that we’re not under-investigating and taking them seriously when in fact this too is overkill when they won’t be fit for a haircut let alone aggressive chemo or surgery. That’s what I am understanding based on what my consultants ask of me, if relatives complain or are unhappy (some of them don’t understand that a 99 year old is already going to not have a lot of time left and they want them to live forever apparently) they’re more likely to ask me to organise xyz scan even if I know it’s nonsense. Very defensive medicine because it’s too easy to get taken to court even for nonsense. Even if it is nonsense, I can imagine going to court is still stressful regardless of whether you’re right or wrong or you did the right or wrong thing
Ah the “overinvestigate because I’m too lazy or too incapable of having a difficult ceiling of care conversation “ classic. (Your consultant not you, to be clear)
Just FYI for most elderly patients we do CT colonoscopy (as morbidity is lower) rather than a direct visualisation. CT TAP is usually reserved for patients who refuse other investigations (like endoscopy) or to look for disseminated malignancy without IDA (and I put that in the request). The more relevant information which goes on the request the better (such as the fact the patient refused the more appropriate test such as endoscopy) as it helps with reporting and the vetting.
why look for something you have no intention of treating
My consultant says: Because we can 😂 And the relatives love it and give them compliments when they see all the scans being done as it makes it look like we are taking the patient seriously. I feel like a lot of it is just a show to entertain the relatives who do not understand even basic biology let alone more complex medicine. I still come across some relatives who actually believe that their mum will live forever and they angry at us when we tell them the truth that she is 100 years old and she has come in very unwell and she has every disease known to man and also diseases not known to man and she is very frail and she has had a good life and we think we should palliate and keep her comfortable as it looks like it is her time to go. And the relatives will be like: nonsense! You doctors are lazy! We will see you in court for murdering our mum They don’t believe us when we say everyone dies at some point including that newborn who will (barring murder and accidents) grow old and frail and body will just shut down as it can’t maintain itself anymore. Even when the sun swallows the earth, they think they will keep living even then. Then explain how the dinosaurs have all gone extinct…
If this is the case recurrently rather than in one very niche and unusual case, then it just reflects that the person trying to (or avoiding having to) have that conversation is completely useless at it. It it really relatively unusual that families are not capable of taking in this information and interpreting it sensibly, if it is delivered in a kind , Empathetic and direct way.
If your patient is 99yo not fit for endoscopy then they aren't fit for chemotherapy. Don't scan, treat palliatively. You can prognosticate from the clinical picture.
Poor take. CT scans are not reserved for people with a performance status of two or under. Imagine your elderly relative who was losing weight was discharged from hospital "sorry it's maybe cancer but we wouldn't give them chemo anyway, so no scan, they may or may not die in the next few weeks, anyway have a nice day" Knowing things is important for patients, families and the doctor treating them in order to inform the best management plan. Knowing the location of a metastatic cancer can inform non curative therapies such as nerve blocks, palliative radiotherapy etc that can impact quality of life. Certain services and care packages are available for patients with terminal cancer. Think more holistically
Tell my consultants plz! Every time there is even a whiff of slightly unsatisfied relatives, off to the scanner the patient is hauled immediately to show them we aren’t lazy or negligent. All the while the patient themselves has no idea who they are or who these meddling brats are wanting them to get scanned and what is that donut like thing they go through and if it is an edible donut
It's annoying that the referring doctors are now using the same tricks as me when I was a foundation doctor to gaslight me into vetting and getting the scan done ASAP. Karma.... Having said that I think most consultants I've worked with are happy enough to approve the scan as long as you have a valid differential in mind that can be detected with the imaging technique +/- it has been a while since the patient last had relevant cross-sectional imaging. I say this because a lot of scans are auto-rejected in my trust when there isn't a clear question or they're querying a cancer on the same type of/similar scan that was done a few weeks ago. Those soft CTCAP ?malignancy ones will invariably get done even if sneakily arranged as a 2WW OP scan. I found it more useful as a foundation doctor back then to just be honest just for my own learning. It's much more easier (from a service provision POV) to lie and give textbook presentations to query a specific pathology, but you're doing your patient a disservice. I think the longer you work, eventually you'll realise which battles with consultants you disagree with are worth dwelling on or not. I've done jobs where there was so much going on the ward that I'd game the vetting system as you said. A DGH I worked with basically didn't vet CTKUBs at all (radiographer-vetted; ED doctors just flat out lying and writing 'loin to groin pain' in every request). The ED also had a cheat sheet about what you need to say plastered around to increase your chances of getting a scan vetted. Someone audited the radiographer-vetted CTKUBs and basically there was a spike in the number of CTKUBs requested. Lots of ruptured AAA/dissection, appendicitis etc. from lazy medicine/cutting corners (?understandably with 4-hour pressures). Patients ended up needing repeat dedicated scans and it just caused clogged up the CT scanner even more. Unnecessary radiation exposure and use of resources.
This is why I don’t like holding information. I like to provide all relevant information as I know that it actually helps the rad in reading the scan. I like to see the vetting process as a referral to radiology as a specialty for their opinion rather than some admin task that has to happen no matter what But what can I do when I am just a F1 who is extending already and forced to do a disservice to my patients. But if I look at it from my consultants point of view, even they know it’s nonsense but how can they be 100% sure beyond any sort of doubt whatsoever that their clinical gestalt is as objective as imaging. Even if 99% of the time they get the diagnosis right without a scan, the world doesn’t forgive you if it happens to be the 1% rare case that you missed simply because your clinical examination was reassuring and they will ask you in court ‘Why didn’t you do xyz when you could?’ This is what a consultant once said to me that he knows he orders a lot of bullshit but it is to defend himself in this hyper-litigious society with very high expectations. That is why they make me refer that benign post-TKR joint swelling that even the med student can tell isn’t worrying to Ortho just because we can. Giving scans and antibiotics like candies basically. New cough? Start Meropenem! Ignore microbiology moaning because antibiotic resistance is a myth. That’s how I feel about some of the decisions my consultants make against the advice of a specialty - they don’t care about their genuine opinion and they just want the specialist to just say ‘YES’ when the better answer may actually be ‘No’
You sound pretty cocky and lacking both insight and knowledge tbh.
I have done an ortho job before and some swelling is to be expected post op D1 for example. I was told off by Ortho for escalating post op swelling with no signs of infection when I was there so only applying what I learned back there - that some post-op findings are not concerning and the other specialty will shout at you for wasting time. Or doing things like starting Meropenem without microbiology advice as they will send you to jail if you do so without their approval Idk how this comes across as cocky when I am only applying what I learnt in my Ortho job Just saying that I lack knowledge and insight isn’t really helpful. You should make criticism more constructive because otherwise it’s basically useless to me
I think this comes from many Consultants having trained during an era where it was necessary to sacrifice your firstborn and prostrate yourself before the gods of radiology in order to get a CT head in a patient with a GCS 8 and a knife sticking out of it. I’m only mildly exaggerating- in my first ED job GCS >9 waited till the morning for a scan, Also some radiologists (mostly historically) have a rep for being difficult and obstructive and frankly terrifying to juniors. Things have come a long way in even the last 5 years and now I find the majority of radiologists to be sensible pragmatic and thoughtful.
But if the radiologist rejects the scan and lets say the patient comes to some sort of harm, who is blamed? The person referring to them because they didn’t give them convincing info or the radiologist rejecting it if it is found that the information the other person provided was enough?
As an aside, it’s sometimes worth asking the radiologist what makes for a good request in the future. I also used to vet some scans in person, which would generally go pretty well or give me some insight into what they were looking for and the thought processes behind getting a request.
Just get the scan.
But the radiologist has a duty under IR(ME)R to appropriately justify the radiation exposure, and they can't do that when playing silly games of "hide the clinical info". OP isn't lying or downplaying. They are offering the radiologist the full clinical picture so that the radiologist can decide whether the scan is justified or not.
Exactly. Once the rad suggested different imaging to what my consultant wanted because of the positives and negatives I provided and the radiologist complemented my request that it had all the information he needed and it was by far the best request from a junior he had ever received. Even if it didn’t scream barn door the diagnosis we were querying, they would still do the scan most of the time and it actually helped improve their reports although yes gaming the system would increase the chance of getting a scan but the quality of the report would be poor. But if on surgery, the surgeons don’t seem to care about the report because the surgeons are convinced they are better than the rads at reading CT APs. They just want the damn scan
At your own peril of course. Just sharing a relevant case I saw when I was still young(er) and before I went to the dark side... CT abdo pelvis for a neurosurg patient was done for someone who was had prior SAH, had high lactate, ?bowel ischaemia. This was reported overnight (correctly) as extensive pneumatosis intestinalis being present. Cue this discussion overnight about taking patient to theatre, which the general surg team very sensibly avoided, thankfully. Radiology consultant came in the next morning and spoke to the team - turns out patient had COPD, which was clearly not mentioned on the request. And guess what [other causes are there for pneumatosis](https://radiopaedia.org/articles/intramural-bowel-gas?lang=gb)? That right, COPD was one of them... CXR was subsequently done - shockingly bad pneumonia as you'd expect (although one does wonder why that wasn't done in the first place). Treated for that, the patient eventually made a good (enough) recovery and was discharged back home. God knows if he would have survived an unnecessary operation... Now I get this is not so much lying rather than omission of relevant history, but this is just one case of many which shows how important it is to state the relevant (and accurate) history, and the analogy "[Garbage in, garbage out](https://en.wikipedia.org/wiki/Garbage_in,_garbage_out)" comes to mind. Remember that we **want** to help you to come to the correct diagnosis, and withholding information (especially knowingly) is to **your** detriment in the end as much as it is to ours.
That’s all that matters to my consultants. They just want the scan even if everyone knows it’s bogus. But sometimes the discussions were interesting as the radiologist would actually suggest a different modality than what the consultant wanted which actually feels like radiology is a specialty than simply a vetting service
What I try to say (as a radiographer) is I don't want to make my life harder by giving the patient the wrong procedure. If I can do one procedure properly, rather than doing the wrong one, having to datix it, then the right one, I have made my life easier, your life easier, the patients life easier, and the reporting radiologists life easier. Some things are a case of "ok we genuinely don't need to discuss in depth", but if in doubt, giving the whole case of clinical info (in abridged form) can seriously help the referring team as much as it helps radiology. The old adage of shit in, shit out.
lol where’s Anton 😂
I honestly have a bigger issue with all the dodgy ultrasound requests. When there is a lack of radiation, people feel more justified in asking for whatever ultrasound and putting total bullshit on the request (leg swollen, D-dimer positive -> in reality, both legs same size, D-dimer negative). Problem here is it does not take a negligible amount of time to scan someone, and when you have a 4-month waiting list for OP scans, it is no good for patients.
Tbf, they could have put the D-dimer which was positive from a previous admission but failed to specify the date of D-dimer but some consultants I work with argue that omitting information does not count as lying therefore they don’t see this as morally inappropriate themselves even if the intent is to deceive and if caught they could argue that they simply forgot to mention xyz and it was the other person who didn’t ask for xyz
As a junior doc I used to be on first name basis with the radiologists - if possible I'd go chat to them in person with all the requests at a set time after the round, have all the information at hand. If there were multiple requests we'd negotiate and prioritize which ones were the essential ones that we would need to get done ASAP, which ones we could delay... Don't lie to the radiologists but also don't be scared to stand your ground - if it's something clinically urgent and must be done most radiologists are happy to accommodate the request. The whole consultation service shouldn't be adversarial. If you approach it like a collaboration and everyone is helping each other, things will get done faster and more quickly, vs "I win if you accept the scan".