Wet Read: The Referral Vortex

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I bet, you call, and he overcalls.
—Overheard in a reading room

Simple fact: None of us are perfect. We strive for it (well, most of us, anyway) and we’d like to think we’re pretty damned good. And, most of us are. However, we can shade this a little, and find some edges that are pretty interesting. If I asked if you tend to overcall or undercall, what would you say? What’s that? Neither? Wrong. I’ll bet your colleagues would place you somewhere else.

Undercalls are, in my opinion, the most likely to be widely known, because they can also translate loosely to “misses.”

“Yeah, I saw that, but I thought it was a nothing… ,” which is real close to “I didn’t see that… .”

On the other hand, overcalls are, in my opinion, the most likely to lead to what I have come to see as “the referral vortex.” Let me explain.

“I think this is a subtle finding, but I think you should get a high-resolution MR to better visualize it … .” Invariably, the request is always for something “high resolution.” Regular resolution just won’t do. And when that study is normal, the smart money would be to back off. But the true overcaller will often double, even triple, down.

“Wasn’t high enough resolution… .”

“Didn’t do a 3D COOL EPONYM sequence… .”

“Should get a PET (or angiogram, or Nuc Med study, or something)….”

It’s an odd form of self referral: I thought I saw a squirrel, and now I want to prove it. Allow me to prove this is a squirrel. I’ll do the test.

We all keep track of our undercalls, or misses. That’s QA material. But I think we should also keep track of overcalls. And those who double down should get the appropriate credit. Or scorn. Finding the subtle thing that’s real is a talent; bringing everyone back for more imaging is NOT. It’s a vortex that spirals into absurdity, and yea, verily, verily, I have seen it.

I don’t have a good idea of what an appropriate hit rate should be when you call someone back because you think you see a squirrel. But it ought to be pretty high. The referral vortex is a huge deal. It’s nerve wracking for patients. It’s a time suck. And it costs money. So, what do you think?

Read ’em right, try not to read ’em wrong, and read ’em out.

Keep doing that good work. Mahalo.

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Phillips CD.  Wet Read: The Referral Vortex.  Appl Radiol.  2020;49(3):48.

By C. Douglas Phillips, MD, FACR| May 05, 2020
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About the Author

C. Douglas Phillips, MD, FACR

C. Douglas Phillips, MD, FACR

Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.

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