Why some Radiologists Say ‘No’ and some say ‘Yes’

I was working with someone quite junior recently and noticed they were refusing a lot of scans that I would have said ‘yes’ to…Thinking back I used to say ‘no’ a lot too. What changed? Here are some of my musings:

ST1 to ST2 — Trust No one, say ‘no’ to as much as possible!

I remember this stage as though it was yesterday (sounding very old now). I used to reject a lot of scans back then…and I still feel a little embarrassed by it. I think it was mainly based on my own insecurities and what I felt comfortable doing. I was scared to do scans as I had no confidence in my ability to get it right. The overwhelming fear of getting it wrong and something bad happening to the patient was a big burden. I still remember the first time a surgeon walked into the reporting room and said:

‘Based on what you have written I have to take this patient to theatre…are you sure you are right?’

It was daunting, so back then I used to try and limit the number of scans that were coming my way. I used to insist on registrar level referrals despite the referral actually being pretty good. I refused things that didn’t need to be done ‘out of hours’ and stuck to the guidelines like glue. If anyone tried an ‘according to the guideline’ referral and got the guideline wrong…BOOOOM….computer says NO!

(by the way, if you are an ST1 and are about to go on call soonish then think to yourself…is my opinion on the scan going to be better than the person making the referral. The answer is almost always ‘yes’ so don’t sell yourself short…you can do this!)

ST3–4

By now I have had a few unsavory encounters and started to notice that my consultants would always ‘cave in’ to do scans that I felt clearly did not need to be done. I never really understood why. Was it the all-important PP?

They seemed to agree to the most ridiculous things and pander to whatever the clinicians wanted. Maybe they had been beaten down by the system? I couldn’t tell…yet.

Anyway, by now I noticed that I was saying ‘yes’ to a lot more. I had seen things that did not ‘fit the guidelines’ that ended up being a scan that probably should have been done… they are ‘guidelines’ after all.

I noticed a few clinical presentations that made no sense that ended up being ‘weird and wonderful’. On the whole, the scans I was getting were never completely normal. There was always something interesting going on, be it a completely horrible post surgical abdomen or an anatomical variant of some sort….gotta love the arteria lusoria anyone? No? Maybe just me?

More importantly, I was a lot more confident that I could offer an opinion that mattered and could be helpful. By now I had come to know a few of the clinicians and their pattern of referrals which helped too. I also noticed that the way I was rejecting scans was different. I would discuss things a lot more, tell them my reasoning and then tell them to get back to me. It seemed to work. People were more pleasant on the phone, as the whole thing was a discussion. I had gained the ability to say ‘no’ without actually saying ‘no’.

ST5 and beyond…?

This might be controversial but I have become a lot like those consultants that I felt caved in way too easy. It’s because in honesty it takes seconds to say ‘yes’ and a lot longer to say ‘no’. Often the scan will get done at a later date anyway and if things get escalated the scan is happening immediately. Too many times I have found myself ‘debating’ only to find myself overridden. In my experience (and it may be skewed) the vast majority of scans out of hours are not normal. There is usually something up. Also having seen a lot of ‘weird and wonderful’ over the years, I take the view that if it is in the realms of possibility and if a clinician is asking for the scan then I just do it. For example:

‘Is it in the realms of possibility that this patient with good going consolidation could have a PE?’.

The answer is yes…it is in the realms of possibility. Scan gets done.

The other principle I have adopted is:

‘Will this be beneficial to the patient regardless of what time of day it is done?’ (By this I don’t just mean immediate management — it could help with being teed up for a procedure as soon as possible or even being referred to the correct clinical team sooner)

If the answer is ‘yes’. Scan gets done. Can you imagine being told that you have a mass in your brain, it could be cancer and you will need a full-body scan to help find out…but that can’t happen till after the weekend? If that was you or someone you loved you would want to know as soon as possible. Maybe my own personal experience has changed my outlook with this kind of thing, but being the patient and waiting must be horrible…bring on those staging scans… 🙁

Saying ‘no’ to a scan can sometimes be like a surgeon refusing to review a patient. Why do this job, if you don’t like doing this job?! I honestly like scans and the more I see the better I become. On a shift, there is usually a scan or two that will have me stumped and I end up having to go to Google for the answer (what did anyone do before Google?!). If I’m stumped then there’s good reason to be stumped.

I take it all as a learning experience. By now I am confident I can give an opinion that is helpful and accurate to the best of my ability.

So now I barely ever say ‘no’, and if I am going to say ‘no’ it’s because I can offer something better or nothing at all from doing the scan…or maybe I’ve been beaten down by the system :-)