Editorial: The scourge of “outside” studies

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

You're sitting in your cozy reading room moving efficiently through loads of studies. Whimsically, you think, "Maybe I'll get out of here before rush hour starts in earnest." Suddenly, your daydream ruptures as the door flies open and there stands your friendly, neighborhood internist colleague holding what looks like a year's worth of radiographs, CTs, and MRIs from the U.S. Olympic Team. Actually, these films belong to a single patient who has been transferred to your illustrious institution from Elsewhere General for definitive care, sometimes referred to as "pre-mortem care."

Clinician: "Would you mind taking a quick a look at these outside studies"? (The studies are from the last 4 years on a Mr. Zepicholawiscki, a 90-year-old gentleman with some kind of really bad illness.)

You think: "Yes, I certainly would mind looking at these. It will take me until next Thursday just to get them in order and we don't have view boxes anymore." Moreover, you ponder: "Why in the Lord's name would you want me just to have a quick look? How about I just give them my slow, but still careless, perusal?" An official "dictated" interpretation will take another week. ¹

You say: "Of course, I'd be happy to."

Clinician: "Just let me know if you agree with all the interpretations of the other 37 radiologists. Oh, by the way, I think some of the films are stuck together because of the flood at Elsewhere General. We can repeat anything you are concerned about."

You think: "I would like to do a barium enema on you, my clinical friend, with enough air to make your eyes pop out."

You say: "Well, I'll do my best."

Clinician: "Also, he's scheduled for the OR in an hour, and the surgeons would really like your opinion. They respect you so much."

You think: "I'm going to clean out that OR with an Uzi."

You say: "Sure, no problem, glad to help."

Perhaps I'm slightly exaggerating the difficulties we radiologists may experience when asked to review outside imaging studies. There are a lot of thorny issues wrapped up in this process. On the positive side, at least one of your colleagues respects your opinion over that of the largely unknown outside radiologist, even though there is no real data to suggest that you would be worthy to clean off that radiologist's monitor. For all you know, that other radiologist may be the world's expert on Mr. Zepicholawiscki's strange malady.

If you question the accuracy of the interpretation of these studies involving numerous outside radiologists (many of whom attended your daughter's wedding), you may be creating a medicolegal issue for one or more of you if Mr. Z takes a sudden turn for the worse. Well, perhaps you can give just a "roadside" or "hall-side" or "bathroom-side" opinion. Unfortunately, your lawyer friend (is this an oxymoron?) told you that the radiologist reading films held up to an overhead light ¹ is legally termed the "defendant."

OK, you can ask the file clerk (the person who used to lose your films) to digitize the entire set of studies to the PACS network for an official, written-in-stone, for-the-world-to-see interpretation. This approach requires you to get the clinician or his appointed minion to request a second interpretation of the studies in your ordering system. (This small task often proves to be more of a stumbling block than getting all of the films digitized.). Interestingly, one request suffices for all 87 studies to be reinterpreted, and the potential reimbursement will almost buy a gallon of gas. Obviously, the third-party payers don't have much respect for your opinion. They go with the first call; anything after that is gravy.

To add salt to your wound, you notice that Mr. Z. has had many studies performed in the private offices of your major rural competitors, since your big city hospital is too far to drive to and actually charges for parking. If Mr. Z survives this visit to your hospital, he will wind up getting all his follow-up work done at that group with the gravity-free massage chairs and a Starbucks in their waiting room.

OK, I got it. If I just take a real quick look and tell them what I think (off the record ¹ ), I can give the films to the file clerk, then no one will ever see them again. Oh, how I long for the good old days when you could really depend on some things. Gee, I hope they're not just copies.

For the serious-minded among you, check out the American College of Radiology (ACR) guidelines below.

Informal Communications: Occasionally, a diagnostic imager may be asked to provide an interpretation that does not result in a "formal" report but is used to make treatment decisions. Such communications may take the form of a "curbside consult," a "wet reading," or "informal opinion" that may occur during clinical conferences, interpretations while involved in other activities, or review of an outside study. These circumstances may preclude immediate documentation and may occur in suboptimal viewing conditions without comparison studies or adequate patient history. Informal communications carry inherent risk, and frequently the clinician's documentation of the informal consultation may be the only written record of the communication. Diagnostic imagers who provide consultations of this nature in the spirit of improving patient care are encouraged to document those interpretations. A system for reporting outside studies is encouraged. ¹