Clinical indication: Patient tripped over red wagon walking to Walmart

Why isn’t it mandatory within the certification requirements of The Joint Commission that requests for all diagnostic studies be accompanied by the current clinical signs and symptoms that prompted the study to be obtained? There are a zillion (or some other really big number) rules about how far boxes need to be from automatic sprinklers, how bottled gases need to be arranged, and so on. What is it about requiring meaningful clinical information on imaging tests that makes it forbidden territory for mandatory oversight?

Picture yourself as an internist (nothing personal against internists; some of my best friends are internists) who is seeing a patient with abdominal pain. You have several potential approaches to deal with the situation.

By the way, why is it that someone would want to “rule out” their primary diagnosis? I would think you would want to verify it. Having it ruled out all the time would force you to question your diagnostic skills. But I digress.

Of course the entire scenario described above is hyperbole. I hope.

So why is it that expensive imaging studies, which require patients to be injected with contrast materials—or swallow obnoxious liquids or perhaps even get these liquids instilled from the opposite direction—in preparation to receive a walloping dose of ionizing radiation on the order of a smallish solar-mass ejection get requested with missing or misleading information? Performing these studies is serious business and should be requested with some consideration for cost, appropriateness and the risk-benefit ratio. Of course, pertinent and factual clinical information should be provided to the interpreting physician. Some nonradiologists interpret studies quite well, but I would never bet on one over a board-certified radiologist, not for any patient I cared about.

When the topic of useful clinical information came up recently with some visiting radiology residents to my program (of course no resident from my institution was present) I heard some interesting examples of the less than in-depth clinical information provided on requests. Here are just a few:

I’m certain the reader can supply many more such examples. Please send them my way as I am trying to build a world-class collection. Information technologists tell me that newer order-entry systems require clinical information before an imaging study is “ordered.” Fine, except someone who actually knows the patient should enter that information. It must be accurate and, even better, should ask a specific question for the study to resolve. One begins to doubt concurrent requests on 30 intensive care unit patients who all have “atelectasis” for their clinical information. All such foolproof systems have workarounds anyway. It’s sad that such measures are needed.

OK, now all you hospital regulators and risk managers out there get cracking on this problem! We have all seen more than a few imaging study interpretations messed up as a result of missing or misleading indications. If the study is important enough to perform, it’s important enough to be requested correctly. After all, we’re here to help the patient, not challenge the radiologist to read shadows in a clinical vacuum.

By the way, it might not be such a bad idea to leave this editorial lying around where your referring docs just might happen to run across it.