Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy
■ Clinical Practice Management
■ Training & Education ■ Leadership

Diagnosis: Interpretus Interruptus

Workflow disruptors can result in...Wait I gotta take this call...Uh, what was I just saying?

One day, while interpreting an MRI, your phone rings five times with technologists asking for a protocol and a secretary walks in with documents to sign. After each interruption, you try to remember where you left off last and, being conscientious, end up reviewing some images that you already reviewed at least once so that you are certain you did not miss anything. Because of this fragmented review, the report for the MRI is constructed piecemeal.

Now suspend belief for a minute and imagine that the patient whose MRI you are interpreting turned invisible and is quietly standing in the reading room during your interpretation of his/her MRI. What might that patient think? Maybe something along these lines: "You've got to be kidding me! The insurance company and I are shelling out hundreds of dollars for this and the radiologist isn't allowed to focus on this one task for ten minutes uninterrupted?"

My primary care provider (PCP) has never been interrupted during my annual physical with a phone call, page, or paperwork to sign. If my PCP got interrupted with the frequency that many radiologists get interrupted, do you know what I would do? I would walk out and take my business elsewhere.

Why do radiologists not demand fewer interruptions for themselves and the patients they serve? One reason might be about the nature of our work. We don't have an "actual" patient right in front of us. The patient is not there to see firsthand how our work is conducted or how long it takes. So it's not a "big deal" to interrupt us, apparently. The patient is not there to get upset, and it doesn't matter if the radiologist is upset.

Another reason may be that, because we are dealing with images rather than patients, a radiologist's time is somehow seen as less valuable than another physician's. We are not clinicians, i.e. not "real doctors", so our work is "less important" and it's easy to justify all sorts of impositions on our time. But image interpretation is our "patient encounter equivalent" and it makes no more sense to interrupt one patient's "radiology clinic visit" to ask a radiologist mid-interpretation to review another patient's imaging study than it is to interrupt a PCP examining one patient to get an antibiotic prescription for another patient. Image interpretation time is not actually "ours." That time belongs to the "patient" we see right in front of us in the form of their imaging study. Patients would almost certainly prefer that radiologists be focused and work uninterrupted, unless the interruption is related to their care, such as consulting a colleague or an evidence-based resource when encountering a challenging finding on imaging.

A third reason for justifying (or more correctly, excusing) the interruption of radiologist work is that although diagnostic radiologists are working just as hard as and for as many hours as a "real doctor," each discrete task of a radiologist is relatively brief. Depending on the type of imaging studies we are reviewing, we may be performing interpretations on a dozen or more studies every hour, punctuated by variable amounts of other, often even faster, tasks, such as providing a protocol to a technologist. Our "task volume per unit time" is very high. We are used to starting and completing new items on work queues quickly. But given interruptions during even brief tasks, whatever speed we go at may be insufficiently fast to consistently start and complete only one discrete task at a time.

To date, the "value" of a diagnostic radiologist to an institution has been image interpretation because it is measurable (in RVUs) and is billable. More recently, radiologists are hearing from the ACR and others, though not necessarily from their institutional leaders, that radiologists need to "add value" by engaging in more non-interpretive facets of radiology, such as consultation, protocolling, and technologist interaction. But we are already engaged in those activities. It's just that data regarding non-interpretive activities are not being captured and documented. And as we all know, if you can't measure it, then it doesn't count, it doesn't exist, and it doesn't have value, right? Wrong.

The admonishment that radiologists need to add value ignores the important primary work diagnostic radiologists engage in because it sounds like value is missing, that value is not already intrinsic to the interpretive service we provide. The interpretation of clinically-indicated diagnostic imaging studies has tremendous value in health care. For example, instead of saying "mammograms save lives," the ACR should have ad campaigns with wording like: "Radiologists who interpret mammograms save lives." Not simply because it's good public relations, but because it's true. After all, mammograms don't interpret themselves.

How bad is the state of interruption for diagnostic radiologists? As described in a recently-published JACR® article, co-lead authors Andrew Schemmel and Matthew Lee, along with their colleagues, conducted a detailed time study looking at numerous types of interruptions during a neuroradiology fellow's workflow. They separated interpretive and non-interpretive functions, the latter including teaching, consultation, protocoling, and technologist interactions.

What was "more remarkable" to the authors than the actual amount of time spent on non-interpretive tasks was the frequency of task switching between interpretive and non-interpretive tasks, more than 11 times per hour. How can anyone expect a radiologist to stay focused on task but do so in the context of a workflow which repeatedly derails focus? This article should be required reading for every radiologist.

What about the idea that in order to be a radiologist one must be able to handle multitasking? The concept of multitasking is pure fallacy. Our brains can actually engage in only one focus-requiring activity at a time. If we are engaging in multiple "simultaneous" tasks (like texting and driving a car), we are actually not doing both those tasks at once. Our brains, our focus, and our energy quickly switch between the tasks, and you do not complete these tasks as efficiently or completely as you would focusing on one at a time. In other words, you may think you're multitasking and even be proud of your ability to do so, but you're not fooling your cerebral cortex.

Radiologists are often the first physicians to interact with a patient (indirectly) during a health care encounter. For example, I often make a diagnosis on imaging, only to call the ordering provider with the result, who then says "Who? Is that my patient? I haven't seen that patient yet." I am not saying that radiologists are actually primary care providers, but maybe I am saying that. And just like PCPs, radiologists should expect minimal interruptions when involved with their main patient care tasks. Radiologists should insist upon a re-tooling of their work environments to minimize task-switching . For example, in Schemmel and Lee's article, based on the results of the time study, the authors report that they plan on creating a "consulting" radiologist workflow to handle non-interpretive tasks, freeing others to focus on interpretation. Like these authors, radiologists can creatively find ways to incorporate more "value-added" non-interpretive tasks to their work. If radiologists can successfully implement effective means of minimizing workflow interruptions while also providing, measuring, and documenting non-interpretive tasks, then the ACR can adopt a new mantra: "Radiologists are adding EVEN MORE value than before."

Radiology Firing Line - Chargemaster
Creativity: The Radiologist as Author

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Wednesday, 28 June 2017

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