Quite fascinating Paul. Yes, I never quite understand the "gatekeeper"
mentality ingrained into imaging practice in this country. As Rowley points
out, we don't find the same attitudes in pathology services, even though the
risks are far greater. And I disagree that the Australian comparison is not
valid (because of differences in radiation protection legislation) as I've
noted the same obstructive behaviour with my radiology colleagues for many
years, long before IRMER regulations came into force.
As for a "fee per service" approach, I doubt the conflict that Philip
suggests would prove unworkable; there are many safety-versus-finance
conflicts in society which work well, probably the best example being in the
field of civil aviation. In other words, I doubt there is any problems
getting a scan in the private sector in this country. Which comes back to my
original argument, that obstructive behaviour has little to do with
radiation protection and much more to do with work avoidance.
Speaking of risks, Philip is correct, although may even have overstated the
risk. As far as I'm aware, there have been no proven cases of harm to any
patient undergoing diagnostic imaging (notwithstanding the argument that
angioplasty with stenting is not really diagnostic). Perhaps there are a few
case study exceptions which no doubt Philip can share with us. And although
individual cases are difficult to "prove" one way or the other, it is widely
accepted that the radiation doses involved in routine diagnostic imaging are
vastly overshadowed by background radiation.
Coming back to Paul, yes, I'm not at all worried about threats, veiled or
otherwise. As you say, everything we say on this List is in the public
domain, and yes, my radiology colleagues are well aware of my views!
AF
----- Original Message -----
From: "Paul Bailey" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, December 12, 2006 1:28 PM
Subject: Re: alleged drug ingestion
> Totally.
>
> I work in what could best be described as an urban general hospital.
>
> Our ED sees in the order of 50k / year.
>
> We have "no questions asked" access to plain films 24/7; CT from 0800-2300
> each day "no questions asked" other than talking to the booking clerk.
> Access after midnight more problematic, and straightforward access to MRI
> 0800-1700 M-F.
>
> We get 'hot' CT reporting ie contemporaneous.
>
> Our radiology colleagues are very happy for us to judge the
> appropriateness
> of imaging according to the patients needs, and we really never get
> knocked
> back.
>
> We certainly operate in a CT rich environment, and the English RMOs who
> come
> across to work with us for a year or so can't believe the contrast to the
> situation "back home".
>
> PB
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
> Sent: Tuesday, 12 December 2006 9:11 PM
> To: [log in to unmask]
> Subject: Re: alleged drug ingestion
>
> Well, you've hit the nail on the head Paul. I think the level of poor
> cooperation we find from radiologists in this country has nothing to do
> with
>
> IRMER or radiation exposure. It's just plain "work avoidance" if you ask
> me.
>
> AF
>
>
> ----- Original Message -----
> From: "Paul Bailey" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Tuesday, December 12, 2006 12:36 PM
> Subject: Re: alleged drug ingestion
>
>
>> Here we go again.....
>>
>>
>> From an Australian perspective, it's amazing when you start working with
>> a
>> "fee for service" (ie paid for each individual test) radiology department
>> how these concerns seem to evaporate.
>>
>>
>> Paul Bailey
>>
>>
>> _____
>>
>> From: Accident and Emergency Academic List
>> [mailto:[log in to unmask]] On Behalf Of Vallis, Jacquie
>> Sent: Tuesday, 12 December 2006 8:30 PM
>> To: [log in to unmask]
>> Subject: Re: alleged drug ingestion
>>
>>
>> Whether or not you can abide it, under IR(ME)R, radiology still has the
>> ultimate responsibility for justifying the use of radiation to patients.
>> As
>> I have said already, the main problem is the minimal information on the
>> request in the first place. If there can be no justification made from
>> the
>> information on the request, then radiology will just keep bouncing it
>> back.
>>
>>
>>
>> At the end of the day, it should all be centred around what is best for
>> the
>> patient, and that is why everyone should work together as a team in the
>> hospital. The lack of respect for other specialities such as radiology
>> is
>> astounding, and I'm sure that my radiologist colleagues would be
>> interested
>> to hear your views.
>>
>>
>>
>> Jacquie Vallis
>>
>>
>>
>>
>>
>>
>>
>> _____
>>
>> From: Accident and Emergency Academic List on behalf of Adrian Fogarty
>> Sent: Mon 11/12/2006 23:49
>> To: [log in to unmask]
>> Subject: Re: alleged drug ingestion
>>
>> ----- Original Message -----
>>
>> From: "Vallis, Jacquie"
>> I do dispute the comment from someone that radiology has no clinical
>> responsibility for the patients, as that was a completely unfounded
>> comment.
>> Radiology sees patients from the entire hospital, not just the A&E
>> department. [Jacquie Vallis]
>>
>> What I actually said was "radiologists don't have primary responsibility
>> for
>> patients" but since you brought it up I'm happy to clarify, and maintain
>> they have no direct clinical responsibility. They do have responsibility
>> for
>> their reporting decisions, and can be held liable for reporting errors,
>> but
>> that is not the same thing as direct clinical responsibility.
>>
>>
>>
>> And it has nothing to do with patients from other parts of the hospital
>> as
>> you suggest. The same thing applies: all patients who undergo imaging are
>> referred from direct-care clinicians, who take ultimate responsibility
>> for
>> their patients' management. Radiologists don't, and what I can't abide is
>> radiologists - or radiographers for that matter - trying to impose their
>> views on patient management on to referring clinicians, particularly
>> since
>> the former (i.e. radiologists) are no longer in clinical practice.
>>
>>
>>
>> Adrian Fogarty
>>
>>
>>
>>> No, it is the concept of "refusing" that does not facilitate good
>>> relationships between departments. Fine, I don't mind a radiologist
>>> (or radiographer) suggesting a different imaging strategy, or I don't
>>> mind a radiologist (or radiographer) asking for more detail on a
>>> request form, but I don't accept a radiologist (or radiographer)
>>> refusing a request because they don't believe it's indicated.
>>>
>>> That's my job, to decide if someone has sufficient clinical evidence
>>> to warrant imaging, not the radiologist's job. Just this week a
>>> radiology reg tried to persuade my reg that a CT head was not
>>> indicated. Fine, it was a very borderline request and both registrars
>>> suspected it would be negative, but ultimately it's my registrar's
>>> call, not the radiologist's. My registrar has ultimate responsibility
>>> for the patient, not the radiology registrar.
>>>
>>> Put it this way, when the debate had reached an "impasse", my
>>> registrar - rather than simply accept the radiologist's advice not to
>>> scan - held firm in his request for a scan. The impasse was finally
>>> broken when my registrar calmly suggested that since he still wanted
>>> the scan then he would have to document that the radiologist had
>>> refused the scan. The radiologist immediately then acceded to my
>>> registrar's request.
>>>
>>> The bottom line was, that once we record that the radiologist has
>>> refused the scan, then they have to accept a share of the
>>> responsibility for the patient, and they were not prepared to do
>>> that. I thought this was quite illustrative. Radiologists are happy
>>> to try to persuade us that the scan's not needed, but only insofar as
>>> we change our mind and so we take responsibility. But if you ask the
>>> radiologist to share some of the responsibility, then they're not so
>>> keen to refuse to scan.
>>>
>>> At the end of the day, radiology is a "service" specialty, not much
>>> different from pathology or neurophysiology or any other service
>>> specialty. By that I mean that radiologists' workload is determined
>>> by referring specialists who in turn have primary responsibility for
>>> patients. Radiologists don't have primary responsibility for
>>> patients; their only responsibility relates to the exigencies of the
>>> imaging modality itself.
>>>
>>> So, at the end of the day, you may feel more comfortable making a
>>> distinction between "requesting" and "ordering" but I can tell you
>>> now, when a senior clinician "requests" an image, it's a lot stronger
>>> than a polite "request", and more often than not for practical
>>> purposes he's "ordering" it. I know you folk aren't comfortable with
>>> that concept, but that's the reality of the situation.
>>>
>>> I suspect a lot of this has got to do with semantics: "request"
>>> suggests subservience while "order" suggests dominance. Perhaps we
>>> should use the more neutral phrase "to book a scan" which more
>>> realistically describes what's going on.
>>>
>>> Adrian Fogarty
>>>
>>> --
>>> *Included Files:*
>>> am2file:001-HTML_Message.html
>>
>>
>> /Rowley./
>>
>>
>>
>>
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