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Melvyn H. Schreiber, MD, Editor
NHC The clinical information on this patient's requisition says "microcylic hypochronic anorexia." Since radiologists are the Rosetta stone of physicians, translating this hieroglyphic was not difficult. "Two-thirds castrectomy" was similarly comprehensible (J. P. Donleavy wrote a novel about a man with three testicles). "Rectal hypertension" is what we produce each time we do an air-barium double-contrast enema study, but it is elusive as a complaint recorded on a request for a chest radiograph. Who is responsible? "Not me," says the referring physician, when we finally get her on the telephone. "I didn't make out that requisition." Of course you didn't, I think to myself; that's the problem. "I don't know who you're talking about; I ' m not on that service anymore. I probably saw the patient in the clinic and told the intern to get the study, but I ' m on orthopedics now." Oh. I guess being on orthopedics excuses a person from all previous responsibilities. "Yes, I ' m the faculty person on the service. I asked the senior resident to obtain the study. He must have passed it along to the junior resident, who told the intern, who got the ward clerk to make out the request. Sorry." These are old conversations and don't occur much anymore, not because the requisitions are any clearer or more precise but because w e ' v e learned the futility of calling the physician whose name appears on the requisition. The rules in our place require that a physician request the appropriate diagnostic studies, but only the writing of such an "order" in the right place on the patient's chart is enforced. Other lower level functionaries fill out the requisitions, even forging the physician's name. Lest you complain that it's worse than that, that even nurse-practitioners and physician's assistants request diagnostic studies, permit me to step to their defense. We deal with a small handful of such people regularly, and they are almost always well informed about their patients, personally fill out the requisitions with lots of valuable clinical information, and almost always use good judgment about which test to request. The problem is not carelessness on the part of physicians; more likely it's busy-hess. More and more patients in our hospital and clinics are taken care of by fewer and fewer physicians, more and more of whom are family practitioners and fewer and fewer of whom are specialists. It's no wonder that once a diagnostic study has been decided on that the paperwork is left to others.
1142
Nowhere is disregard of the real reason for making radiologic images more rampant than in the intensive care units. Here's what we get on almost all the requisitions: "Tube placement," "Pulmonary edema," and "Follow-up post-op." I think, for variety, the ward clerk just alternates them. Luckily, the same faculty person presides over interpretation of the images from patients in the intensive care units most days; personal consultations and telephone calls keep that person informed about the true condition of most of the patients. I keep worrying that the Paper Police, who inspect us for one organization or another periodically, will discover that not all of our requisitions are comprehensible, not all of the referring physicians whose names appear on the requisitions are still here. Probably nothing to worry about. I ' m sure they have internal problems of their own. The answer to the question posed earlier--namely, Who is responsible?--is this: All of us are. It's someone else's job to make out the requisition properly, but when we have it in hand and it doesn't make sense or seems not to correspond to the image we are examining, then we radiologists must act to decipher the request or find out what's really wrong by talking to the referring physician or to the patient. The historytaking skills of the people in my section, including the technologists, have greatly improved with practice, necessitated by ambiguous requisitions. It may turn out that we spend as much time talking to our patients as the referring physician.
Melvyn H. Schreiber, MD University of Texas Medical Branch Galveston, Tex
30PRAN( I don't remember when I first heard her voice, but it wasn't more than a year ago. Since then I have bought most of her compact disks, and I listen to her sing while I am reading or writing in the evening. Sometimes I take her disks to work and play them on the residents' boom box while I ' m checking their work in the reading room or emergency department. Even when I ' m not playing her recorded voice, I hear it in my head. I am seriously infatuated. Cecilia Bartoli is a coloratura mezzo-soprano with an absolutely gorgeous voice and a playful and engaging smile. Serious opera lovers tell me that her voice is a little thin and does not carry as well from the stage as the big boomers. But what do they k n o w - - t h e y are not in love.
NHC The clinical information on this patient's requisition says "microcylic hypochronic anorexia." Since radiologists are the Rosetta stone of physicians, translating this hieroglyphic was not difficult. "Two-thirds castrectomy" was similarly comprehensible (J. P. Donleavy wrote a novel about a man with three testicles). "Rectal hypertension" is what we produce each time we do an air-barium double-contrast enema study, but it is elusive as a complaint recorded on a request for a chest radiograph. Who is responsible? "Not me," says the referring physician, when we finally get her on the telephone. "I didn't make out that requisition." Of course you didn't, I think to myself; that's the problem. "I don't know who you're talking about; I ' m not on that service anymore. I probably saw the patient in the clinic and told the intern to get the study, but I ' m on orthopedics now." Oh. I guess being on orthopedics excuses a person from all previous responsibilities. "Yes, I ' m the faculty person on the service. I asked the senior resident to obtain the study. He must have passed it along to the junior resident, who told the intern, who got the ward clerk to make out the request. Sorry." These are old conversations and don't occur much anymore, not because the requisitions are any clearer or more precise but because w e ' v e learned the futility of calling the physician whose name appears on the requisition. The rules in our place require that a physician request the appropriate diagnostic studies, but only the writing of such an "order" in the right place on the patient's chart is enforced. Other lower level functionaries fill out the requisitions, even forging the physician's name. Lest you complain that it's worse than that, that even nurse-practitioners and physician's assistants request diagnostic studies, permit me to step to their defense. We deal with a small handful of such people regularly, and they are almost always well informed about their patients, personally fill out the requisitions with lots of valuable clinical information, and almost always use good judgment about which test to request. The problem is not carelessness on the part of physicians; more likely it's busy-hess. More and more patients in our hospital and clinics are taken care of by fewer and fewer physicians, more and more of whom are family practitioners and fewer and fewer of whom are specialists. It's no wonder that once a diagnostic study has been decided on that the paperwork is left to others.
1142
Nowhere is disregard of the real reason for making radiologic images more rampant than in the intensive care units. Here's what we get on almost all the requisitions: "Tube placement," "Pulmonary edema," and "Follow-up post-op." I think, for variety, the ward clerk just alternates them. Luckily, the same faculty person presides over interpretation of the images from patients in the intensive care units most days; personal consultations and telephone calls keep that person informed about the true condition of most of the patients. I keep worrying that the Paper Police, who inspect us for one organization or another periodically, will discover that not all of our requisitions are comprehensible, not all of the referring physicians whose names appear on the requisitions are still here. Probably nothing to worry about. I ' m sure they have internal problems of their own. The answer to the question posed earlier--namely, Who is responsible?--is this: All of us are. It's someone else's job to make out the requisition properly, but when we have it in hand and it doesn't make sense or seems not to correspond to the image we are examining, then we radiologists must act to decipher the request or find out what's really wrong by talking to the referring physician or to the patient. The historytaking skills of the people in my section, including the technologists, have greatly improved with practice, necessitated by ambiguous requisitions. It may turn out that we spend as much time talking to our patients as the referring physician.
Melvyn H. Schreiber, MD University of Texas Medical Branch Galveston, Tex
30PRAN( I don't remember when I first heard her voice, but it wasn't more than a year ago. Since then I have bought most of her compact disks, and I listen to her sing while I am reading or writing in the evening. Sometimes I take her disks to work and play them on the residents' boom box while I ' m checking their work in the reading room or emergency department. Even when I ' m not playing her recorded voice, I hear it in my head. I am seriously infatuated. Cecilia Bartoli is a coloratura mezzo-soprano with an absolutely gorgeous voice and a playful and engaging smile. Serious opera lovers tell me that her voice is a little thin and does not carry as well from the stage as the big boomers. But what do they k n o w - - t h e y are not in love.