Cynical critical results

By C. Douglas Phillips, MD, FACR
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Applied Radiology Editorial Advisory Board.

All of us take our jobs seriously, and we all can appreciate and understand the concept of getting a “critical” finding to a responsible clinician. Well, the critical finding part is serious. The concept is serious. The actual delivery of the critical finding is another matter, as is the actual criticality of the finding.

How many have called the responsible clinician to find that they are out of town/dead/out of the country/not taking calls/no longer seeing that patient/unsure of who you are referring to/etc., and not been given a forwarding number/new responsible person/word of encouragement/etc.? I have. And how many have stat delivered an incidentaloma? Or wrenched yourself into knots for a modestly bogus stat request?This leads me to today’s little chat, which began as a Freudian slip by a resident. I loved it. We had looked at a normal outpatient exam, lumbar spine, which was scheduled (don’t you just love the modern data trail?) 2 weeks earlier, with the request “stat read please.” The words from the resident were, and I quote, “Do you want me to call the cynical results to the clinician?” Ha! Critical finding? Nope, cynical finding. Let’s deliver this hot piece of info.

These are typical cynical findings. In each case, request reads: “Please call report ASAP.”

Normal exam, incidental finding in a patient who, it turns out, has other and more pressing problems. You call the listed 4 numbers. You finally reach a colleague of the physician who gives you their private cell number, which they don’t answer, but at least you leave a voice mail with the cynical finding: “Mrs. Pfarr’s scan is normal. There is an incidental finding, which you can call me about, and we can discuss. I’m following protocol for the cynical finding.”

Minimal spine abnormality in a patient who was in a tennis outfit in the waiting room, and who left immediately, bounding out of the imaging center to their sports car and off to the club. Your fourth call gets an operational voice mail service: “Mr. Throckmorton has a small disk bulge at L4-5. I tried to stop him and give him the results, but he’s quick, and he outran me to his car, and I couldn’t follow him to the tennis club. I’m just following protocol for the cynical finding.”

Cynical incidentalomas on an ED patient are the most problematic, for different reasons. Whatever the incidentaloma is, it MUST be explained away prior to the patient being discharged from the ED. Trauma. No significant findings. But in calling in the cynical finding,you can literally feel yourself teeing up the “emergent—ASAP” follow up exam. “The exam is normal. There is a small skull lesion, likely a dermoid, which I’m so sure you’ll want an MR to correlate that I’ve already sent the patient to MR. I’ll call you with the cynical finding on THAT examination when the MR is complete. Please put in a request for the MR please, and don’t forget to write ASAP on it.”

Keep on plugging, folks. Mahalo.

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Cynical critical results.  Appl Radiol. 

July 13, 2011

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