Quality control in radiology: Knowing your (in)limit

“We are limited.” I heard this statement more than once during my fellowship almost 2 decades ago. It was often uttered by one of the participants, when she opened an imaging study and saw it marred by motion artifact, poor contrast phase, poor positioning, etc.

She said it in a particular tone of voice, a mixture of regret and disappointment. Both understandable: we were all ready to showcase our diagnostic capabilities, and we were given crummy tools. We were expected to accomplish less for a patient than we otherwise could have done.

Still, something about it didn’t sit well with me. I can’t say exactly when I put my finger on it, but when I did, my feeling crystallized: “What do you mean by ‘we’?

I’m far from perfect, radiologically speaking or otherwise. Even after realizing that I’m often my own harshest critic, I know I have a lot of limitations. Maybe I could/should have overcome more at this point in my life, but I think I can forgive myself for not getting past Usain Bolt or being more physical than Stephen Hawking.

Struggling with all the limitations I have due to circumstances and as an imperfect mortal, I don’t think I need to appropriate anything more. When it comes to doing the best diagnostic radiology job possible, for example, I adamantly refuse to take an iota of blame when given a lousy case to read.

Of course, my name is on the report, and anyone who reads it — especially hungry ambulance chasers — might just try to tie the imagery’s shortcomings to me personally. Let it be their burden; I will do nothing to make it easier for them. That includes not blaming me about it.

Maybe that sounds ruthless. Or an abdication of responsibility, if you think radiologists have the ability to take corrective action in the name of quality control. I like to imagine other rads actually working in environments where they can identify problems and fix them personally or talk to someone who can (and, more importantly, will). This goes for everything from substandard hardware/software to personnel, regardless of the outcome of performing or analyzing the imaging substandard.

Personally, I haven’t worked anywhere that works this way. I’ve worked in places that paid lip service to the idea. In my residence, for example, an MSK participant often told the house staff that they should “teach the technicians how to take better films”.

Maybe the techs would have followed his instructions, but I can guarantee you it wouldn’t happen that way if someone less brilliant than him tried to pull it off. A resident would at least be told yes, maybe laughed at the room. Probably unhappy.

During my first post-fellowship jobs, I received all kinds of verbal support from managers: if the imaging wasn’t great, especially in my sub-specialty areas, I should speak up. They would support me if I needed it.

As a not so big surprise, they didn’t. When the pressure came, it was easier to retain techs who couldn’t (or didn’t care) to do better than to seek out new, better ones (who might need to be paid more). as software, hardware, etc. ; Saying “we have the best” does not necessarily mean buying and keeping the best.

Meanwhile, I had been living in the world of limited radiology for over a decade by then, and it was clear that people with far more influence than me weren’t more effective at forcing quality . They worked in the same places I did, sometimes carrying impressive titles that presumably gave them the power to make things happen, but the limited studies never seemed to go away. They certainly complained enough about the issue, so it wasn’t a matter of not caring.

If I had any illusions that I could do a quality crusade and work things out, they vanished when I started doing telerad. Whatever influence I had working on site in small radiology groups did not translate as I became one of hundreds of remote telerads that each covered dozens of facilities. “Hey, can we ask Hospital #493 to start uploading previous scans without us having to ask each one?” “Of course, Chief. If we beg them for a few more years, they’ll eventually take us seriously.”

Maybe that was also a sign of the changing times, or maybe it was that the facilities that offload their work to telemedicine tended to be on a lower rung of the quality ladder, but studies seemed to be limited over time. It has become rare for me to receive a chest CT scan that is not full of respiratory motion artifact, even when on an outpatient basis for subsequent nodules. Do technicians even tell patients to hold their breath?

When I’m feeling particularly cynical, I almost enjoy the limited stuff I get, especially the really awful stuff. At some point, a study is so ruined that, as one of my former assistants said, “it’s so hard it’s easy.” A sufficiently mangled scan, with zero contrast and a dozen different types of artifacts, becomes an extremely fast read. Anything you manage to diagnose (or rule out) makes you a hero. Also, the way our RVU system works, reporting a non-diagnostic scan earns you as much as a good scan would.

Am I satisfied with the state of things? Of course not. Although I have chosen the serenity to accept what I cannot change in my profession, I can always wish it were otherwise, but part of this serenity is not to entangle myself with the limits that I surround me or feel guilty about them.

It’s not my fault, and if I had the chance to fix them, I would. I can live with that.

About Sally E. Bartley

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