Ordering x-rays

I just don’t understand the way we order radiologic tests and procedures. 


If I discover skin cancer during an office visit, I refer the patient to the dermatologist or surgeon for evaluation and treatment. I don’t have to order the specific procedure they will do, or fill out a prior authorization form for their biopsy or excision.

If I diagnose symptomatic gall stones or an incarcerated hernia, I refer the patient to the surgeon. I don’t pick the procedure the surgeon will do. My office and I don’t schedule the operating room time and notify the patient.

If my patient needs anesthesia for a procedure,  I don’t tell the anesthetist or anesthesiologist what medications or doses to use, or what size tube to intubate with.

If after my initial evaluation, I am uncertain about the cause of a patient’s cough or dyspnea and I refer to the pulmonologist for further evaluation. I don’t decide for the pulmonologist what tests she will do.

But if I want a CT scan or an ultrasound or MRI, I am forced to pretend I am a radiologist and determine how the study is to be done, such as whether or not to use contrast. I am expected to do the prior authorization to ensure that the radiologist is paid by the insurer. This routinely involves a series of phone calls between my office and the radiology department. It often involves my having to reach a radiologist, interrupting them and disrupting my day, present the case and my clinical question, so the radiologist can tell me what test he wants me to do and how, after which I start the order and my staff does the prior authorization.

It would be better care for the patient, more efficient for my office, and better billing for the radiologist if I ordered a radiologic evaluation of abdominal pain or hemoptysis or thyroid nodule with weight loss and tachycardia, included a copy of my note or a summary of the relevant clinical information, and then let the radiologist determine how best to proceed.

The radiologist knows far more than I do about which is the best radiologic study in a given clinical setting. The best test in the wrong setting gives the wrong answer 100% of the time.



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