Moving Past Bargaining in Radiology QA Reviews

I dabble in many roles at vRad including study interpretation, client services, site visits, CME presentations, and quality assurance (QA) review. It is this last that I have chosen as the topic for my first blog. I, as all vRad radiologists, have felt the painful sting of a QA submission on more than one occasion and know that the awful experience has a powerful effect on both personal and professional pride.  The fact that our red RIS indicator is the same color as my early teachers' corrective pens helps to lessen the impact not at all.  I well remember my own response to my early QAs, and I have noticed a similar pattern in many colleagues in my years of QA review.  I have at last achieved some measure of peace with my own fallibility as well as a significant reduction in my own error rate and I would like to share the insight I believe is most responsible for that state.

Radiologist’s QA Response

Anyone who was even so much as awake in medical school remembers the five stages of grief:  denial, anger, bargaining, depression, and acceptance.  Interestingly, but actually not surprisingly, these stages also apply to a radiologist's response to QA as well.  A radiologist will first argue with QA committee members or the impassive images themselves, move then to irritation and a paranoid sense of unwarranted persecution, and finally come to rest at the bargaining stage with rationalizations minimizing the clinical significance of the acknowledged error.  What I would like to encourage is objectivity that will allow a radiologist to move past this point, hopefully with only a brief period of depression, to the acceptance that creates a real change in practice patterns.  The mental trick I use here is simply an objective recounting of those steps leading to medical imaging that we all know take place but from which we are distanced, in light of which it becomes impossible to minimize the impact of any error:

1.       The patient develops escalating symptoms of a condition and endures them for anywhere from hours to years.

2.       The patient finally resolves to make an appointment, take time off from work, arrange transportation, and stews for hours in a waiting room.

3.       The patient endures the indignity of probing questions and physical exam from a hurried stranger with a cold, impersonal demeanor.

4.       The clinician with years of training and experience compiles this data, orders several hundred dollars of laboratory tests, and determines that medical imaging is required for accurate diagnosis.

5.       The patient is referred to an imaging facility, often at a different time and place resulting in a repetition of step 2.

6.       A multimillion dollar machine, often requiring specific facility construction, is then operated by a technologist with years of training following painful IV placement and the injection of hundreds of dollars of contrast material that carries its own not-insubstantial health risks.

7.       The images thus created are transferred over the country's largest WAN through a series of servers and by virtue of expensive proprietary software developed over years are placed on a radiologist's worklist to be interpreted using more expensive software and hardware.

Accepting the QA Review

I have found that a mental review of these expensive, time-consuming steps in the diagnostic process is all that is required to eradicate the rationalizations that can so easily derail this particular professional grief process.  I have found that my own acknowledgement of the expense, professional time, patient inconvenience, and general effort underlying any imaging study makes it utterly impossible for me to shrug off any error of any severity as "clinically insignificant" and I believe this objectivity has had a very real effect on the way in which I discharge my professional obligations.  While it is hard to uncover a truly original thought in dealing with such an erudite group as radiologists, I fervently hope this reminder of our role helps at least a few move past the bargaining stage and attain that peaceful and objective state of acceptance.

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